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Chapters
Introduction- Innovation & Application of Nursing Dashboards | Innovation and Application of Real Time Nursing Dashboards
Introduction- Innovation & Application of Nursing Dashboards | Innovation and Application of Real Time Nursing Dashboards
chapterdatainterventionaljeannejourneylearnmammographymanagermeaningfulmultidisciplinaryNonenurseobjectiveoperationsradiologystoriesstrategy
Organizational Strategy | Innovation and Application of Real Time Nursing Dashboards
Organizational Strategy | Innovation and Application of Real Time Nursing Dashboards
alignchapterdailydartmouthdatadevelopfrontleadersmeaningfulmetricsNoneorganizationalorganizationspacemakerspatientsradiologyseniorstaffstrategiesstrategytranslate
Data- The Story Behind the Numbers | Innovation and Application of Real Time Nursing Dashboards
Data- The Story Behind the Numbers | Innovation and Application of Real Time Nursing Dashboards
bridgingcapacitychapterchrisdatahelpedjeannejourneyleadersmetricsNoneorganizationradiologyreviewseniorstaffstartstrategicsustainableunderstandworkflow
Building the Radiology Nurse Dashboard | Innovation and Application of Real Time Nursing Dashboards
Building the Radiology Nurse Dashboard | Innovation and Application of Real Time Nursing Dashboards
accomplishalignbuildbuiltcapturecategorychaptercovercreatedatadesigneddisplayeddocumentationengagementintentjeannejourneymeasuresmetricsmodalitiesmultipleNonenursenursesnursingpendingproductradiologyrealrelevantselectedstaffingsystemteamunderstandworkflow
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
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Dashboard Component- Nursing Case Volume per Hour | Innovation and Application of Real Time Nursing Dashboards
Dashboard Component- Nursing Case Volume per Hour | Innovation and Application of Real Time Nursing Dashboards
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Dashboard Drill Down Report | Innovation and Application of Real Time Nursing Dashboards
Dashboard Drill Down Report | Innovation and Application of Real Time Nursing Dashboards
chaptercomponentdatademonstratedinterpretNonenursingpatientreporttimeline
Q&A- Success, Case Add-Ons | Innovation and Application of Real Time Nursing Dashboards
Q&A- Success, Case Add-Ons | Innovation and Application of Real Time Nursing Dashboards
capacitychapterdecisionsdrivenjourneymodalitiesNonenursesnursingobjectivestartedteamworktechsutilization
Q&A- Documentation, Before and After results, Leadership, Culture | Innovation and Application of Real Time Nursing Dashboards
Q&A- Documentation, Before and After results, Leadership, Culture | Innovation and Application of Real Time Nursing Dashboards
accomplishchapterculturedatadocumentationdocumentinginterventionalleadershipmanagermodalityNonenursenursesnursingpatientphysiciansprojectprojectsradiologyroundingteamtechnologisttechnologists
Transcript

good morning everyone my name is Jeanne Bulger and I'm the interventional nurse manager at dartmouth-hitchcock Medical Center and also the section supervisor of ultrasound and mammography I've been dartmouth-hitchcock about eight years four of which has been in my

current role hi everyone I am Tomi ocean Koya I am the service line quality specialist in radiology I've been with dartmouth-hitchcock for about six years I started out as a performance

improvement consultant at our Valley Institute and over the about the last three years I've been working in radiology managing a quality program across the multiple sites for our service line good morning I'm Chris

Kevin Logue I'm the operations manager at dartmouth-hitchcock for those of you don't know we're in Lebanon New Hampshire and we came from snow so we're very happy to be here I have been the operations manager for about eight or

nine years I was also the IR interventional nurse manager supervisor I was an interventional nurse and a critical care nurse so I'm very old I've been doing this for a long time so very happy to be here so let's start on

our journey in the innovation and application of real-time nursing dashboards so when I think about my journey I became a nurse to take care of people and with people there are always stories but typically data doesn't

always connect to those stories so today we are hoping to take you on a journey to understand how we've been able to use data to tell meaningful stories that show how our staff and patients are linked to organizational strategy we

have four objectives for you today the first one is to learn how to align strategy and data across all levels of the organization application of dashboards of the frontline would not be effective without this alignment second

numbers have feelings and tell their story we hope that you will learn as nurses that we can tell stories behind the numbers that can help us take better care of our patients the third objective

building and designing a nursing dashboard we hope that you will learn that we at dartmouth-hitchcock embarked on this journey to build meaningful dashboards using multidisciplinary team work and the last objective our

dashboard look interpret apply and assess model is to hope that you have learned how to apply the dashboards in real time to translate the numbers into meaning and purpose for the frontline staff everyday work the diagram on the

Left represents the amount of time it took for us to complete each objective in this project now hands off to Chris to talk about strategy Thank You Jeanne

so before we get into the dashboards which I know you're all interested in

hearing about I'm going to talk a little bit about organizational strategy and how it really does align with our frontline workers so we all know that senior leaders have a responsibility to create a vision and a strategy for our

organizations they do this using benchmarks cost margins revenue in order to position our organizations to deliver high-quality care but also to position ourselves in ever-growing markets which I'm sure you're all aware of so as

organizational leaders develop these strategies for future development it is really important that the front line that the mid-level leaders are able to take these strategies and translate them down to the front lines so when you read

a story or you watch a movie you just assume that the cast of characters and the plot are going to follow along and if they don't we lose interest or we become disengaged so in this case can you trace the CEOs sorry can you trace

the CEOs vision for his strategy and how he asks the mid-level leaders to take down to the front line probably not and this is what all organizations struggle with because we know that the whole is always greater than the sum of all the

parts so now we're going to show you some boxes and these boxes represent the front line the mid-level and the senior leaders let's have a show of hands today for how many of you in the audience consider yourself to be frontline staff

do we have any mid-level leaders great how about senior leaders great well today our dashboard presentation is going to mostly apply to the frontline staff so we know that when organizations build strategies and they ask our

mid-level leaders to take them down to the frontline staff that sometimes the translation of that information creates chaos and disruption at the front lines and an example of that is at Dartmouth our senior leaders had a strategy for

improving access for care for an underserved population of patients that had pacemakers and needed MRIs Fordyce diagnostic studies we felt we could take the volume so we embarked on imaging patients with pacemakers and what we

found is that the number of patients that had pacemakers was outpacing the resources that we had at the frontline and this created chaos and it made the good intention of the strategy lost on the frontline nurses so it's really

important that we not only take strategy down to the frontline but that the mid-level leaders take the reaction of the staff and how it affected their work back to the senior leaders so in 2013 at Dartmouth we began our journey to bridge

this gap and we did some process improvement projects and we soon found that the data that we were presenting wasn't really accepted or understood or trusted by the staff that we were working with we discovered

that at the front lines that sometimes perception is not always reality so our job was to help the staff objectively understand how to work on a daily basis how their work on a daily basis impacted our organizational strategy in 2015

you'll see we went live with the radiant product that epic has for radiology and when I began looking at the reporting metrics that epic presented I saw that it didn't really translate into radiology language and it really didn't

translate into nursing language at all so we needed some metrics and we needed a way to be able to give the nurses meaningful actionable information that they would be able to work on and that we could really turn them into

data-driven problem solvers so this is when I engaged with Thome our quality specialist and I asked her to help us develop a strategy for how we could empower the staff to become more data-driven problem solvers what we

decided was that we first had to build build competencies and understanding around data and how Thome decided to do this was to develop these monthly scorecards the scorecards our performance scorecards that the leaders

in the organization in our department can use to kind of measure their success so we first met with the leaders in each modality and this was the radiology directors it was our technologists lead our nurse's leads and Thome sat down and

said what would be meaningful for you to understand so that you can talk to your staff about the business that you are running so this is an example of one of the scorecards that Thome built and at the same time we decided that we would

align our organizational strategies and our department strategies with these scorecards this is an example of an IR scorecard and you'll see that they chose quality and safety operational excellence and

sustainability this was a way to look at what their monthly volumes were and when we were asking them maybe to move that needle a little bit and give us some more and they felt maybe that they couldn't because the staff was saying

that they were too busy we could show them that the utilization in one of their rooms was 65% and maybe there was indeed some opportunity to move that number a little bit after we were successful with the scorecards and we

felt we had built the competency on the department the section director level Thome began working on dashboards and these are real-time metrics that our frontline staff can use every day to see how well they're processing their

patients through our system we also developed daily Huddle's where they take these dashboards the charge tech nurse tech the radiologists staff if they're interested and we talk about what went well what maybe didn't go so well we

talked about action items opportunities for improvement and maybe some projects that we could start around things that they identify that are impacting their workflow so now I'm gonna turn this over to Tommy who's gonna talk to you about

how she used that data to get us to our dashboards thank you Chris all right so

as Chris described to you we really walked this journey around bridging the data gap from our front lines all the way to our senior leaders and we thought

this was very important because we didn't think we could drive a sustainable organization if everyone was not on the same page or even in the same book so we had to start helping the staff understand the story behind the

numbers and help them understand that every number actually has a story and is connected to their work it's not just random numbers these are things that also define patient care and can help us improve the way that we take care of our

patients and so the scorecards were really key in creating that alignment across the organization because as you can see on this chart here the senior leaders the radiology mid-level leaders and the

frontline staff all review the scorecards so AB monthly staff meetings the radio radiology leaders review the scorecards with the frontline staff and then we have our radiology director and our clinical chair review the scorecards

with the institutional senior leaders as well so all across the organization everyone had the same understanding around performance and if there was a strategy strategic vision that our senior leaders had they could easily see

how we could accomplish that based on the numbers that we had on our scorecard and then when it came to the dashboards these were as Chris mentioned more real-time frontline tools that were applied by our staff and but the metrics

on the dashboards were also included on the scorecards as well so when we designed the dashboard we pulled some metrics from the scorecards and thought about which which of these metrics would be more relevant in real time for our

frontline staff and so that way we restraints where we were continuing to build that competency for our frontline staff to help them to understand how to use data to drive decision-making in real-time and finally when it came to

the strategic plan we still have our senior leaders design strategic plans but our radiology leaders were able to move that strategic plan through our strategy to deployment program to define more specific strategies for radiology

and then roll that down to our frontline staff through their one on one performance management goals so this really helped us to start to create the same level of expectation across the organization as Chris mentioned we might

have senior leaders say well we have our strategic vision of increasing or falling by 10 percent over the next year and for our frontline staff that might be difficult because if they to them their work might be chaotic and they

think they cannot possibly do any more volume but when we presented the scorecard for example on s Chris showed in I arm at a 65 percent utilization everyone could see that if our benchmark was 80 to 85 percent we still had more

capacity in our rooms to be able to service more patients and on the same scorecard we could see our on-time start rate which was actually kind of low around 50% and so that helped us engage in conversation

with our frontline staff to help them understand that our issue was not necessarily a capacity issue we had the capacity to increase volume but the way that we were managing our workflow as you can see from an on-time start was

not great and so this helped them to start to identify projects that they could lead to help to manage their workflow better and with the dashboards they could actually see real-time improvement or real-time changes as they

made decisions around their workflows so again our goal to this journey or our journey to this one box was around bridging the data gap and to really create a sustainable organization where each frontline staff was empowered to

solve problems and have the data that they needed to do that objectively so now Jeanne will go over the current state of our nurses as we embark on that next steps of up - specific dashboards for them thanks to me

so what is it like to be a nurse in radiology all four of these boxes represent the essential part of radiology nursing workload and staffing speaks to how our rit nurses cover all seven modalities in radiology in a

variety of functions these functions include but are not limited to sedation IV therapy triage recovery education and emotional support for our patients regarding staffing this requires deploying nurses in multiple locations

at one time to ensure that the patients are receiving the best care at the right time for us the challenge was how do we adequately deploy the staff to multiple areas while being efficient fiscally responsible but continue to provide

compassionate care the next box epic which is our electronic medical record centers around orders and documentation as Cris mentioned earlier in 2015 we went live with radiant and epic plugin specific

for radiology workflow the radiant functionality was exam specific and less patient flow specific this presented a problem for nurses who cover patients and all modalities and had more documentation requirements than the

technologist did and the last box engagement as we know is so important our nurses felt like they were getting pulled in multiple directions and often time misunderstood by the other modalities and radiology that really are

just focused on their modality and it risks nursing job satisfaction and increased our burnout rate right so as Jeannie described to you that was the current state that our nurses we're facing and as we designed or created the

dashboards we had to understand how we could create meaningful metrics for the nurses to address all these different issues that they were facing our nurses and dartmouth-hitchcock radiology did not just cover interventional radiology

so they were covering MRI CT fluoro so they were all over at the department and it was really hard to capture all of that work and really help them understand how to align their staffing to cover all these multiple modalities

and that also made it difficult for engagement sometimes as they interacted with different staff across the department so we have to consider all of this on top of the complexity with documentation in our EMR system we had

to combine all of these factors as we designed the dashboard so fortunately for us we did not follow Dilbert's boss's philosophy we had much more intent international intent as we design our dashboards so when it came to build

in the radiology nurse dashboard if we could sort of break down the steps we took we would go over these three categories the first category is identifying what measures were relevant for the nurses given the current

situation that they were facing the second category was where that information lived and how we could pull this in to the dashboards meaningfully and the last is how that data needs to be

displayed on the dashboard so going to our first category here which is what measures are relevant we have two main goals the first goal was to select measures that could help our nurses monitor their performance in real-time

so again this was part of our journey around competency building and sustainability across the department and we knew that for our frontline staff including our nurses they were not used to looking at data especially data in

real-time to make decisions and a lot of their description about their day was very variable and really driven by perception of what they were feeling at any given moment so our objective or our goal around monitoring real time for

performance was to create an objective understanding across the board around how the day went so if someone said that they were really busy what did that actually mean so trying to make sure everyone speak in the same language

using data and objectively understanding their performance the second goal around our measures was to help the nurses be more proactive around decision making so as a part of this journey we wanted our frontline

staff to be better problem solvers and be empowered to make decisions around their workflow and so we wanted the measures to be relevant around helping them make more proactive decisions to be more efficient around their daily work

to the left here as an example of some of the metrics that we selected Gina will go into more details around to the dashboard but that's just a real quick snap short of some of the metrics that we selected and a lot of those metrics

are showing pending work for our nurses and a lot of what that does for them is decide how they can align their staffing on a daily basis to accomplish a lot of the pending work that they have so that's just an example of some of the

measures that we selected to accomplish those goals so moving on to the second category here which is where the information lives as Chris and Jeannie both mentioned and I'll mention it again because it was a real pain when we went

live with radiance in 2015 it wasn't great for nursing it didn't capture a lot of the nursing work accurately and because our nurses covered so many different modalities it was difficult for them to see all of their work in one

place in a way that made sense so part of our journey or one of the biggest things as we built the dashboard was to create nurse resources within radiance that helped us accurately capture all of the nursing work and described it in a

way that was easy for them to understand and differentiate between the different kinds of work that they did in radiology and then we am partnered with epic to participate in a cojito project cojito is a branch of epic which builds

dashboards almond does analytic reporting so this was a paid engagement where we told them what we wanted and they had their analytic team built and designed the dashboards within the epic system the engagement took about 12

weeks to complete and that was not just for the nursing dashboard we had about 17 different dashboards that we were building across radiology and so all that entire engagement took about 12 weeks to complete and so that was how we

partnered or that was where we partnered with the epic cojito team to actually build those dashboards within the EMR system and then finally in our process of building the radiology nursing dashboard we had to figure out how the

data needs to be displayed so again we were dealing with frontline nurses who are not used to looking at data and at first we're really opposed to looking at it because they didn't really understand what it meant to them and so we had to

make sure that the data was simple and easy for them to to understand especially in real time for the dashboards it has to be something that they would look at it would be visually appealing and they could really get

enough context in real time to make a decision around their workflow so we had to juggle all of these different pieces as we built and design our radiology nurse dashboard and in a minute you will go over what that actually looked like

when we're done but before that I wanted to show you a prototype of what we started with as we embarked on the cojito project so this is just a PowerPoint template or design that we shared with the Epico hero

team when we started this was our way of sharing or showing our vision of what we wanted on the dashboard we knew that there were a team of analytic people who didn't necessarily understand our operations of workflow so we wanted to

make it easy for them to understand what we needed and we also had to do some shadowing and training in real time with the analytics team as they embarked on this project to build our dashboard but of course when we presented this to them

we knew that our actual product would would the result of the final product would be constrained by what they had in the system so for example they did not have as many callers in their color palette to create a dashboard and so as

Jeanne goes over our final product you might not see as many beautiful colors in there that was their upgrading to more colors and that was great but we knew that as we move forward we would have to be restricted by what they

actually had in the system for a final product or outlook but I just wanted to share this just to give you if you're thinking of embarking on their journey to build dashboards you can start simple just create a wait just have a way to

share your vision with the with whoever the Analects analytics team is that is built in the dashboard you don't have to know what it would look like exactly on the system itself so now Jeanne is gonna walk you through

our actual dashboards and how we apply them in real time thanks to me

so are you ready here's the final project product tada that's what our d-h radiology nursing dashboard looks like today so as Tommy mentioned the goal of

our dashboard is to help the frontline objectively understand their performance and be proactive about making decisions to help their run day their day run smoothly all of these metrics on the dashboard work together to achieve those

goals so for example at the top right here the procedural workup pending and calls pending help to see the volume of pending workup and phone calls that need to be completed over the next few days another exam

well here on the bottom left the nursing case volume that's another it helps us to sort of see the different levels of nursing resources needed by hours of the day the dashboard is not just for nurse managers and for supervisors but for the

frontline users as well we had to teach your nurses how to use this information in real time what we have learned that by using actual data to drive decision-making nurses are able to deliver patient care more consistently

and in compliance with standard practice they are also able to manage variation and optimize utilization of resources the dashboard proves to be an easy tool to apply and capture meaningful metrics around the radiology nursing workflow

this is the framework we use to educate the frontline nurses on the real-time application of the dashboards we broke it down into four simple steps look so looking at the data interpret and gain insight 3 apply and maybe take action

and for what are the results and how are we assessing those results the next few slides will look at some specific components of the indicators on the dashboard and demonstrate how we use this model look interpret apply and

assess to increase the utilization of the frontline staff in their everyday work this is one of the dashboard components that you saw on the dashboard called buffer time the buffer time is the amount of time left till the patient

scheduled appointment time so for example the patient's appointment time is at 12:00 you can see the check-in time generally what we have found that it takes about 60 minutes from the time the patient checks in to get them into

the procedural room so based on that we have the appointment time at 12 12 o'clock the patient checked in at 10 11 and we have a buffer time you have 21 more minutes to go until there a scheduled appointment

time so let's use the look interpret apply and assess model to help better understand how this dish board indicator works so look as you can see we have multiple patients that have checked in interpret we have three patients

highlighted in red that indicates their past their appointment time and then we have four patients in green indicating time left till scheduled appointment time so what action can we take on this well first I'd look at the red patients

since they're late and I would determine next steps there's an ir case in room two that's nine minutes late and then we have an MRI our nurse that is also nine minutes late and it looks like we have a CT case that has nineteen minutes late

oftentimes I know this just because it's our area but if I was to look at this in our nurses too we would confirm that the CT three case really needed a nurse and generally we don't do procedures in our CT room three as far as the green

patients are concerned we would look at the we'd look at both these two twenty one minute buffer times and say and confirm that the pre-work is on track that we're ready to go and we're going to be able to get those patients in as

far as these two patients you can see they checked in way early then there's 60-minute time and at this point I wouldn't do anything else for that and then as far as assessing generally that's done sort of like later in the

day to discuss in the huddle future actions that needed to be taken maybe to prevent this okay let's try another component of it of our dashboard this here is our procedural patient workup turnaround time so here the first box is

the time in which it takes the RN to do her workup so that might be checking the patient in verifying labs vital signs placing an IV etc and then this middle box is the total workup time which includes the fizz

since time as well so a si and Malley mallampati assessment consent that kind of thing and then the third box is the total time the patient was in the pre room so let's apply our model again so as we can look the RN pre workup is

taking 22 minutes on average the pre procedural workup time total is taking 39 and the total patient time 65 so what can we gather from that as I mentioned earlier we give about us it's about 50 minutes generally when we've done a lot

of audits but we give a 60 minute window so that's why we asked our patients to come in 60 minutes before their before their actual scheduled appointment time so what can we interpret from this so as I'm looking the RN process time is

within 30 minutes so we're good there the total workup time was is in within the 50 minute expectation and we still have our 10 minute buffer remember however the total time in pre exceeds the 60 minute expectation so what action

might we take as a frontline either charge nurse or the any of the nurses say what should we do next so here what I might do is talk to the charge tech who sort of does all the orchestrating of the rooms and say so what's the

possible bottleneck because we've got our patients ready to go within 39 minutes to gain on time start but however it looks like we're stuck I will tell you that there is some of those variations like we had a stroke come in

or a trauma that actually bumps cases we get that piece but why are the rooms running what can we do can we maybe make a person that was scheduled going to room to go into our overflow room in five if say a power authorities like are

less acuity room so those are type of things that we can talk about in real time to get patients moving and so we don't continue to have late start delay so we'll move on to the next one

this is nursing case volume per hour so

staffing is a consistent challenge as I mentioned before having dashboards helps to make real-time decisions to help allocate nursing resources during high-volume times so this dashboard indicator

identifies the distribution of nursing workload over the course of the day I love this one for me especially as a nurse manager especially since me knows Tommy says they they feel like oh my god it's so busy it's so busy it's so

chaotic and you're trying to help them you know well of course I understand why it is now so I actually have data to understand their story and help them to see the data and why they feel it's chaotic so again with the help of color

coding the ability to look and interpret the data is simple so here since I've taken you through a few I thought I'd throw it out to everybody and see what if you wanted to kind of take a stab at using our model so if showing or if

anyone wants to raise their hand so what are you seeing here in this dashboard a lot of what you owe to our cases yeah anything else are you seeing yes correct there's nothing happen at 8 o'clock anything else right yep

sort of a lull here correct so what might you interpret from that in other words so what would you kind of see your say about this I'm sorry can be allowed a long time oh yes yep exactly right and so so then

what action might we take here to help sort of get rid of sort of the high volume times yes exactly so here's where you would shift the staffing to help cover the high volume areas and so I'll just take you through what how since

it's what we do at D H I'll take you through so exactly right I think someone pointed out that you have nurse cases except for say at 8 and at 6 and 6 generally we're just doing recovery at that point we don't need any more cases

going through interpret wise so we have this Pio nurse as you can see in the magenta and I'll tell you a little that's our MRI nurse to specific for MRI doing Pio sedates as Chris mentioned we have an MRI nurse there and we also do

cover pacemakers as well and those that's her caseload as far as non sedation we actually just have we sort of as people aren't busier in between rooms is when they might go you know give lasix for a year gram or you know

port access or what have you so what I'm looking as interpret I have a Pio nurse available seven several times a day so only in the magenta is she busy or he and then the best times may be for IR addons is between like say 11 and 12

here I would potentially my action would be to say hey this pio nerves could actually come and help get cases started and get them on time and then also come and maybe relieve lunches that's another I'm sure probably an issue for everyone

is like you're down a couple staff during that time but we're still running our rooms great that was a great job very good okay so a couple more to just kind of quickly show the pending patient workup documentation so this gives the

ability of the frontline RN to have instant visuals of the electronic medical records documentation that needs workup and phone calls that are needed to be completed for future patients so again let's use our model

so look there are a lot of workup phone calls pending and remember this is real time so in this case if you were looking this is just a snapshot but say today is March 4th okay going around so the first thing I'm saying yep there's a lot of

cases I've got 14 here and it shows a couple of days worth obviously you can see how the numbers add up I'm looking at the high number of same-day pending work for procedures so you can see here three four five six work ups and I have

nine phone calls to be made and I'm looking at the MRI work up calls and right now there are a couple days out so I'm opening less concerned about that so how would I apply and what action would I take well first I would clarify that

these same day workup and phone calls are actually pending sometimes they might have been done or someone missed hitting the icon on our computer and then I would prioritize completion of pending work so I might say to a couple

nurses that are in between rooms or whatever can you make a couple of phone calls we've missed this and we need to get contact with the patient and then of course I would obviously prioritize the I our work ups before the MRI ones

because there are a couple days out okay

so last is a drill down report so as Tommy mentioned we've kept the dashboard simple for the nurses to easily interpret the data so we really we needed it to be like a quick visual

however there are times when nurses might need more context in detail behind what they are seeing in the dashboard this shows a drill down report as you can see behind each dashboard component that we just spoke about that can

provide some additional details so example this report shows the actual time stamps and it's a little squished because it's a long thing but these are the actual time stamps and that's how we generated the data for the scorecard and

this is a great tool during huddle time to quickly investigate and answer more specific questions about the patient timeline so remember when the first one I showed you with the red boxes and for like nine minutes late or whatever

well with this drill down you're able to kind of see whether the patient got there on time so where they the patient might came thirty minutes before their appointment said a sixty or what was the holdup and you can actually see was it

the nursing that's running behind or or the physician or whatever so it really helps to drill it down so you can get to this drill down report by clicking on this icon on each dashboard component so this was the nurse casing buffer time

indicator and as you can see there's a couple of tabs up here and this right here can get you down to this drill down report one things I wanted to mention is that this report can also be manipulated to run data historically and over larger

timeframes it's sort of how Tommy got the information for the scorecards by using this drill down report and then she could also pull it for like I said daily Huddle's at the end of the day we can look at a particular case and say

why was it late and what do we r and so really fixing things in real time so this completes the formal part of our presentation on our journey to create meaningful nursing dashboards at D H and just to review our objectives so we hope

that you were able to make the connection that Chris spoke about between the different leadership boxes and the importance of lining across aligning across different levels of the organization remember

strategy is ineffective if you can't be rolled down to the front lines second Tommy discussed and we demonstrated how data is an important part of driving high quality patient care and that behind every number there is a story and

every story there is a number thirdly we hope you learn some useful ideas for building and designing your own nursing dashboard and lastly we demonstrated the practical application of the dashboard for the frontline staff using the look

interpret apply and assess model so

we're happy to open up the floor for questions you want to use it maybe a mic for them yeah sorry oh let's use a microphone then everyone can hear Thanks

can you hear me on this one yeah so I think your question was how successful were we thank you for this presentation so I used to be six feet tall so I will tell you that the journey was very difficult and it's not for the faint of

heart it takes a lot of people to really make this happen and as I mentioned in 2013 we were working with the value Institute and that's where I grabbed Thome from I stole her shamelessly and you know we did some projects and I'll

say the first few were not successful and what we learned from that and I mentioned in my speech is that they don't understand data unless you put it and you present it in a way that's meaningful and that was hard for us and

and so yes it was hard so my so my point is that that this is really incredible and how I would use this and based on your experience how helpful was this to to increase your efficiency and for the nurses to actually look at this and say

oh my god you know this is what we have to meet and we're not meeting it so yeah so I will tell you and the journey was real I mean the perseverance was I mean it really was driven by Chris and Tomi they didn't give up and we met like even

when we started with the scorecards we met weekly with all of the supervisors in all modalities because we didn't just do this for IR Nursing we did it for all modalities and it was it was really hard in the beginning because I kind of felt

like that's where we talked about stories and numbers you know and I I talked about Nursing being a very story driven you know the frontline nurses want to help for their patients and when you show them numbers they start telling

you that all you care about is your volume and your data and you're just going to keep driving us until we get driven down into the ground and so it's no honestly and so it was how do we make that connection and I think to your

question we started with the scorecards as those were less impactful to the frontline staff but once we started using the dashboards and we just we slowly like rolled it out we started with

Huddle's first and we had like the charge check and the charge nurse talked about it and then other nurses and text would be around in the core and they would sort of listen in and maybe chime in about why a case was laid and what

have you and so we started doing the Huddle's and then once we rolled out the dashboards now we have actually a big screen up that runs the dashboard is visual um in the core of the IR a suite and it's really great we have there

actually it's so funny we have them an on-time start like glitter posters so it's on your like it gets posted on the outside of your door and everyone's involved before it was like the techs were much more driven about getting the

cases on time the nurses were less but now we've really actually the teamwork the competition of it and the teamwork it's hilarious I love seeing it they're like yes I've got like all my cases were on time today and they ran like room to

like a clock and so it's it's been very good and they've really utilized that the other thing I love is you know the work up stuff so after the day sort of you know winds down and they're trying to figure out like what were cups they

have to do or whatever I watched the charger she'll put up on there and say like we need you know we need to get this done or whatever so it's really helping to to show them like what work they still have to do so no

one's just standing around going I'm not sure what I'm supposed to do now you know the other thing I'll mention though that was important to getting there was so we took all the lead techs in every modality we call them education

coordinators in our modalities and Tommy did classroom work with them so they would come they would come every two weeks and sit in a classroom and Tommy would speak specifically to the reporting metrics and what it meant and

it did two things it not only taught them how to read data it also engaged them with each other and we cross kind of crossed the modalities where they were siloed in their work before it really built some teams among the

technologists and the nurses and Tommy spent a lot of time teaching them and it it it was very impactful so I would I would absolutely recommend that you have to have some kind of classroom work for this do you want

I think she um great presentation like this is quite inspiring you know it's really nice to see that you've able to build this up in accomplished and everything you did my question is more on a Don cases so when

it's scheduled its predictable you can try and work work things so that you hit everything on target but how do you deal with a Don cases cuz we I feel like in our in our area ninety percent of the cases I add ons so how do you how have

you been dealing with it are important and that was a lot of why we started this journey because a lot of what we would get is oh we have another add-on case and now the world and the sky's fallen over it was a lot of that

reaction to everything that was thrown on a frontline staff so I'll start from the scorecard let me start from the scorecards so on the scorecards we have the utilization numbers which shows how much of our

capacity were using and that was the first step for the team or for everyone to start to understand how much work can we actually do and how much of it have we and how much over that we utilize in today so if we are at a 50 or 60 percent

utilization we're not really at a high capacity utilization rate but then who still had frontline staff who thought add-ons were very chaotic and so it wasn't necessarily about the volume of work it was how we were managing it so

starting to break it down in this way helped everyone start to understand okay maybe it's not that we're doing too much it's how are we managing what we have so that was why the numbers were important to set that objective level of

understanding in the first place and then when it comes to the stat to the dashboards which is more frontline information because they have so we don't have the I our interventional radiology dashboard here

on that dashboard we can see the utilization in each room so we can see how much how much capacity there is to actually manage to add on more cases into each room so that's something that when they make decisions on add-ons they

look at each room and say what is the utilization currently do we have enough time to actually add on one or two more cases and then as Jeanne showed you in the nursing on the nursing dashboard with the caseload by hour of day they

can make decisions around what time of day is the best time to add on this case because we see we already have five at 8:00 a.m. maybe we should add this case on at 1:00 p.m. so it's really helping people make more objective objective

decisions around the add-ons or around their workload vs. reacting to everything that comes up so you talked

about you rolled out the radiant in 2015 and all of this data is great but it's reliant on the nurses documenting it in

all their different areas so how did you did you actually when you built this dashboard did you leave blanks because you just didn't have the data available or did you circle back around and hold the nurses accountable how did you do

that trying to motivate them and engage them rather than it looking like a disciplinary action because you're showing that they're not documenting appropriately yes and that's part of our journey from 2013 we started all these

projects it became evident that document documentation was important when it came to the data and so we actually started training from our technologists and and then to our nurses we created standard work for how they documented time stamps

I'm at different points in the process we audit we audited that for a while to make sure that they were compliant with that documentation so so we embarked on a lot of projects and I did a to greenbelt projects I did one in

interventional radiology and I did one on beginning complete because you really have to start at the ground and if people's reporting is not good you have to fix it so we have a definition for beginning complete for our

technologists which cleaned their data up then we did a project with Jeannie's nurses around and Tommy did some auditing around the time stamps in their system and that took a long time so yes you have to clean your data up first

and that takes projects in order and we also did Tommy led all of us to look at our data and a data validate sort of like Gilbert's thing you know so is it really valid and so we did a lot of work around that as well

the nurses do with themselves and the nursing supervisor did it as well to make sure and the technologists help you with that because what we found is when we handed the data to the nurses and we had them do their audits it was more

impactful than when we did it how would you say your start times improved from pre project pre dashboard to current how did you measure that was the time yes so that was actually interesting especially in interventional radiology because it

it when we started rolling off the Huddle's and the dashboards we had some participation in the with the technologists and the nurses and the providers doing their Huddle's and looking at the information and then

there was a period of time when they stopped doing that and they actually and they actually saw a drop in there on time starts so when we started up they were around maybe 40% on-time start and then when they consistently did their

Huddle's and looked at the - would I use the information they quickly jumped to 60 65 percent so and when they stopped dropped again so it was sort of it proved that that the tools actually worked and now they're actually going

back and owning the work of their own to continue T their Huddle's and use the dashboards in real time yeah rome wasn't built in a day and would you say that this is significantly impacted employee engagement yes I will definitely say it

has previously we had a real sort of segmented nursing work you know silo's and now we have like this cohesive team of nursing and and physicians and technologists working together in IR I will say also part of

our leadership team crisp as part of this as well our senior leaders we did a job we did a change in sort of our leadership structure so before it was like the physicians they led their physicians the technologists led their

technician technologists and the nurses led theirs well we in got a team together so we have a nurse manager the chair of interventional radiology the nursing supervisor and the nursing technologist

and supervisor and we lead as a team now and so we look at volumes together we look at budgets together we look at staffing together so it's not no longer just leading in silos so with that consistency in that that that sort of

got them all together and then so then they see that you can't hit a technologist against a nurse in a physician against a nurse or a technologist because we're all one team and that was a big part of helping this

out yeah sorry before that I was just going to talk about how important leadership was in this so Chris is our operations manager and I would say she made all of this perseverance tommy's the brains I'm the Brawn so I

would like to ask you give more details on the culture like what you were just describing about becoming a multidisciplinary team sure um that's a good vision but practically how did you accomplish so the culture was really

really hard and my Greenbelt project that I did back in 2013 was not successful because of the culture and what we learned was that we had to do something about the culture Jeannie alluded to the fact that our our

department chair dr. chair Toth and our administrative director Karen Buttrey talked to me about this and and they decided it was important that they had leadership teams in each modality so every modality and radiology has a

leader it is the division director the technologists lead and if there's a nurse a nursing lead they meet once a month tommy's does the score cards for them they bring their score cards they bring their a3 reports on

their strategic plan and they sit as a group I sit with them as well and we talk about how they're aligning their strategy to their work what the culture is like and do we need help sometimes we bring HR in if we think we need help

and geney's done a lot of leadership training with the nurses she's very good at it we have Conaty so we've partnered with Dartmouth and we send different teams to Conaty to learn leadership training this

has been really this all started really in 2013 and it continues today and we work just as hard on it as we did in 2013 Neverending yeah and I was part of that Conaty training and it was phenomenal so

it was two of the IR physicians myself the business manager and another radiology technologist supervisor and so really we had to work on a project together and it really brought us together to understand each other's work

and for um I feel like probably the strongest you know asset I have is relationships and and making those connections and nursing wasn't my first career I did practice management and so I worked for a doctor's office and I

kind of know that you have to sort of make sure that everyone understands that we're all trying to get we're all trying to take care of the patient and we all have different responsibilities to do so and there's a crossover if we fight

against each other then nothing's going to work and so that was where I I feel like I probably did the best these again you know brains and brawn and I was just sort of like let's make it all work together people with it so

was that something that you had to work into the amount of hours that it takes to maintain the new task that was being asked for yes so the documentation is part of their work to take care of the patient so for a technologist for

example when they go get the patient from the waiting room they start the beginning the exam in Radian those are things they need to do - as part of the EMR to actually accomplish their work so that was by design already part of their

workflow we just had to make sure that they were all doing it at the same point in time so for example before we standardized the definitions we would have some technologists who would begin the exam when they went to go again the

patient some will do it after they had set up the rooms so we have to standardize all of it so the data was measuring at the same points and for the nurses as well as part of their documentation as they work up the

patient so it's all part of the flow the other thing we do that I want to mention quickly because we're out of time is rounding so rounding is really important so I am the operations manager I probably around three times a day in

every modality and as an example I was just in mr and I saw a red button on their dashboard and I said why aren't we 19 minutes behind and somebody had forgot to complete the exam and everybody was there and they were

talking to me about it and they said yep and they ran back and they you know so I stay engaged the supervisors Jeanne I have two other supervisors tomy rounds you have to keep the conversation going you can't just build these and think

they're gonna take care of themselves because they're not you have to really do that disciplined rounding work so thank you everyone very much yeah thank you and just some related articles that

other other institutions have used for healthcare dashboards I found really really great so I don't know if this is true but I think they're going to send the slides after yeah conference oh yeah yeah afterwards we're happy to stay here

thank you

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