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PTOS

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PTOS

  1. 1. Physical Therapy at Orthopedic Sarcoma (PTOS) DIGANT SHAH 12/8/2016
  2. 2. Vision  The UT Health Innovation Hospital will consistently transform healthcare utilizing cutting-edge technology to improve patient safety and quality each day."
  3. 3. Problem  Sarcomas are a diverse and relatively rare group of malignant tumors that develop in soft tissue and bone.  According to NIH in 2014 in the US, 1. 15,000 cases of sarcomas. 2. Approximately 6,200 people had died [1].  The 5-year relative survival rate for both bone and soft tissue sarcoma was approximately 65 percent [1].
  4. 4. But is Survival everything?
  5. 5.  The duration of the entire treatment process takes 1-3 months and often involves a combination of surgery, chemotherapy and/or radiotherapy.  Studies have shown: 1. Relation between survival and outcomes to having an increased diagnosis-treatment interval [2, 3]. 2. Patients often become disillusioned and frequently depressed during the process [4]. 3. Other comorbidities such has hypertension, diabetes, poor physical function, etc. have an effect on the post-surgical outcome and patient health.
  6. 6. http://drugabuse.com/wp-content/uploads/xdrugabuse_shutterstock-243591463-sad-teen-couch-flakka-CTA.jpg.pagespeed.ic.Uv4YcEWuLF.jpg https://t4.ftcdn.net/jpg/00/87/22/77/240_F_87227731_OdTkoeZJZsl5m8fzkdTHIYiMu1OEpLQ4.jpg Preparing the patient for the surgery both mentally and physically is the need of the hour.
  7. 7. PTOS team  Alexander Penny - Project Leader and Head physical therapist  Dr. Justin Bird and Dr. Ann Ngo - Physicians  Digant Shah – Clinical Informaticist and Change Agent  James Wang - EHR IT representative
  8. 8. Project Governance Division of Surgery Chair Department of Orthopedic Sarcoma Chair PTOS team Physicians Communication Head Physical Therapist Support EHR IT representative Software Technology Change Agent Process Deployment
  9. 9. Project Plan  Goal of the project: 1. Improve outcomes. 2. Reduce length of stay. 3. Generate revenue for the department.  Identify the factors that can have an impact on the patient’s outcome by using the “Shah screening tool” and determine the type of pre-surgical intervention required.  The interventions are: 1. Physical therapy and counselling. 2. Prehabilitation.
  10. 10. What is the Shah screening tool?  It is a 10 question survey  Developed at UTHealth Innovation Hospital.  Evidence based [5-7].  Relying on questions that are routinely asked during h&p but may not be usually recorded in patient notes.  Created in RedCap and will be available in the EHR as a button.  Total of 30 possible points.
  11. 11. Distribution of points  10 points: No intervention.  11-24 points: Physical therapy and counselling.  24-30points: Prehabilitation.
  12. 12. Advantages of using a screening tool  Identifying vulnerable population.  Improving quality metrics for the institute.  More data to draw information.  Can serve as a database to carry out cross comparative research on having an intervention.
  13. 13. How will the process change? Sr. No. Current Process Future Process Gap analysis Individuals involved 1. No prehabilitation protocol present at the department. Assessment tool developed which will assist in judging if the patient requires prehabilitation. Develop 10 point questionnaire which can be completed in less than 5 minutes based on the information collected from the patient. Informaticist, senior physical therapist and orthopedic surgeon. 2. No questionnaire is used for presurgical physical therapy. The physician assistant/resident will complete a presurgical questionnaire for the attending physician. Training provided to the staff on the use of the questionnaire. Informaticist, physician assistant, resident and orthopedic surgeon. 3. Patient is in the waiting room where the physician assistant/resident takes the h/p. The physician assistant/resident along with taking the h/p completes the questionnaire based on the patient responses. Altering the workflow to incorporate the time required to fill the survey. Informaticist, physician assistant and resident. 4. Attending physician sees the patient in the clinic, takes h/p and performs required clinical tests. Attending physician sees the patient in the clinic, takes h/p and performs required clinical tests and based on the questionnaire score recommends intervention. Getting the attending physician to use the scoring tool. Informaticist and orthopedic surgeon. 5. Post-surgically the patient is seen by the orthopedic rehab team in the clinic. The orthopedic rehab team will see the patient pre-surgically and post- surgically. Modifying orthopedic rehab team workflow to incorporate the influx of patient for pre-surgical physical therapy Informaticist and orthopedic rehab team. 6. No billing for prehabilitation in orthopedics Patient or patient’s insurance billed for prehabilitation in orthopedics Need the billing team involved to clear the patient prior to providing prehabilitation Informaticist, physical therapist and institutional billing team.
  14. 14. How will it work in the EHR? Source: http://twimgs.com/informationweek/galleries/automated/755/01_EpicResolutescreen_full.jpg http://cdn2.hubspot.net/hubfs/150313/make-medical-charting-easier.jpg http://orig13.deviantart.net/f5ed/f/2010/108/c/5/green_submit_button_by_rukiaxichigo15.jpg http://img.medscape.com/thumbnail_library/is_160224_doctor_computer_800x600.jpg
  15. 15. Types of Users  Nurses  Resident Assistants/Physician Assistants  Physicians
  16. 16. Stakeholders Stakeholder group Role in Charge Opinion leader Level of commitment needed to succeed Barriers to change Initial contact Attending Physician Team Directly Affected Dr. Justin Bird Internalization Always apprehensive about using a new tool. Skeptic about spending additional time. Resident Assistant Team Directly Affected Internalization Busy with patients. Additional work to answer the screening tool. February – 2nd week Physician Assistant Team Directly Affected Internalization Busy with patients. Additional work to answer the screening tool. February – 2nd week Nursing Team Directly affected Internalization Busy with patients. Additional work to answer the screening tool. February – 2nd week Physical Therapist Team Directly Affected Alexander Penny Internalization Needs assistance with patient scheduling. February – 2nd week EHR Informatics Team Indirectly Affected James Wong Busy due a different system Go-Live. Have drained existing resources. February – 1st week Insurance verification Team Indirectly Affected March – 1st week Patients Directly affected
  17. 17. Stakeholder individual Position Barriers to change Initial contact Dr. Valerie Lewis Ortho Dept. Chair – Champion Extremely busy with patient, other on-going projects and meetings January – 2nd week Naruto Uzumaki Graduate Research Assistant January – 2nd week Dr. Tyler Who Surgery Division head – Champion, Opinion leader Extremely busy with patient, other on-going projects and meetings January – 4th week Steve Martin Rehab department chair Receives incentives based on the number of patients being treated in the department February – 2nd week Megan Taylor Patient Scheduler for PT Additional workload. March – 1st week
  18. 18. Communication Plan Who? What? When? Where? How? Target Audience Communicator Stage Message Timing Location Type Specific tools or approaches Dr. Ino Yamanaka Dr. Justin Bird Knowledge and persuasion Need for the change and “Go Ahead”. January – 2nd week Personal office Interpersonal Naruto Uzumaki Graduate Research Assistant Knowledge January – 2nd week January – 2nd week Personal cubicle Interpersonal Provision of Shah scoring tool and access to RedCap Dr. Tyler Who Dr. Valerie Lewis Knowledge Need for the change and “Go Ahead”. January – 4th week Personal office Interpersonal EHR Informatics Team James Wong and Digant Shah Knowledge and persuasion Proposed plan and expectations February – 1st week Conference room Interpersonal Attending physician team Dr. Justin Bird Knowledge Sense of urgency and proposed plan February – 2nd week Email Mass media Email – which includes the proposed plan and links to hospitals having prehab care. Physical therapist team Alexander Penny Knowledge Sense of urgency and proposed plan February – 2nd week Email Mass media Email with the proposed plan and links to hospitals having prehab care. Physician Assistant team, Resident assistant team, nursing team Digant Shah Knowledge Sense of urgency and proposed plan February – 2nd week Email Mass media Email with the proposed plan and links to hospitals having prehab care. Steve Martin Dr. Valerie Lewis Knowledge and persuasion Sense of urgency, proposed plan, expectations. February 2nd week Office Interpersonal Ortho department meeting Alexander Penny, Dr. Justin Bird and Digant Shah Persuasion Proposed plan, and communicating vision and strategy. February – 4th week. Conference room Interpersonal Visual aids and copy of the questionnaire.
  19. 19. Target Audience Communicator Stage Message Timing Location Type Specific tools or approaches Megan taylor Alexander Penny Knowledge and persuasion Proposed plan and expectations March – 1st week Email Interpersonal Needs for the modified patient scheduling template. Insurance verification Team Alexander Penny Knowledge and persuasion Proposed plan and expectations March – 1st week Email Interpersonal as only 2 members are involved Ortho department Alexander Penny Persuasion Results of the pilot April – beginning of 3rd week Email Mass media Ortho department Persuasion Modifications required or not Monthly meeting – April 3rd week Conference room Interpersonal Ortho department PTOS team Decision “Go” or “No Go” May - 1st week Conference room Interpersonal Poll Ortho department and Dr. Tyler Who PTOS team Implementation Notification of implementation May – end of 1st week Email Mass media Ortho department and Dr. Tyler Who Dr. Valerie Lewis Implementation One month update June – 2nd week Email Mass media Ortho department and Dr. Tyler Who Dr. Valerie Lewis Confirmation 6 month update successful completion of project November Email Mass media
  20. 20. Readiness Assessment  Before the Go-Live, users and department leaders will be asked to complete a survey to assess their readiness for the implementation.  The criteria for this is 100% user training being completed.
  21. 21. Questionnaire [8] Disagree  Agree 1. People who work here are committed to implementing this change. 1 2 3 4 5 2. People who work here will do whatever it takes to implement this change. 1 2 3 4 5 3. People who work here want to implement this change. 1 2 3 4 5 4. People who work here are determined to implement this change. 1 2 3 4 5 6. People who work here feel confident that they can handle the challenges that might arise in implementing this change. 1 2 3 4 5 7. People who work here feel confident that they can keep track of progress in implementing this change. 1 2 3 4 5 8. People who work here feel confident that they can coordinate tasks so that implementation goes smoothly. 1 2 3 4 5 9. People who work here feel confident that the organization can support people as they adjust to this change. 1 2 3 4 5 10. People who work here feel confident that they can manage the politics of implementing this change. 1 2 3 4 5
  22. 22. Time frame Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Nov 2017 Shah scoring tool created in RedCap Communication Integration of Redcap tool in EHR Pilot Modification of tool or system is required Departmental implementation Monitoring
  23. 23. Project Charter  Timeframe – January, 2017 – November, 2017.  Focus: 1. Pilot testing from March 2017 - April 2017 in Dr. Bird’s clinic. 2. Communication.  Proposed budget - $50,000.  Fund allocation: 1. Graduate Research Assistant (GRA). 2. Training. 3. Overtime.
  24. 24. Expected outcome  Reduced length of stay.  Decreased recovery time.  Improved patient satisfaction.  Happy patients.
  25. 25. Challenges  Non compliance by the user.  Delay in getting the button the EHR.  Training everyone before the Go-Live.
  26. 26. Factors needed for success  Support from leadership.  Support from the user community.  Timely delivery of the EHR button from the IT department.  Feedback from the patient population on the effectiveness of this intervention.
  27. 27. References 1. https://www.cancer.gov/research/progress/snapshots/sarcoma. 2. McLaughlin, J. M., Anderson, R. T., Ferketich, A. K., Seiber, E. E., Balkrishnan, R., & Paskett, E. D. (2012). Effect on survival of longer intervals between confirmed diagnosis and treatment initiation among low-income women with breast cancer. Journal of Clinical Oncology, 30(36), 4493-4500. 3. Sandar, M., Hsiang, L. G., Yew, C. K., & Guat, L. B. (2014). Use of Population-Based Cancer Registry Data to Determine the Effect of Timely Treatment on the Survival of Colorectal Cancer Patients. Journal of registry management, 41(4), 130-138. 4. http://www.cancer.org/treatment/treatmentsandsideeffects/emotionalsideeffects/anxiety-fear- depression-and-cancer 5. Arshi, A., Sharim, J., Park, D. Y., Park, H. Y., Yazdanshenas, H., Bernthal, N. M., & Shamie, A. N. (2016). Prognostic Determinants and Treatment Outcomes Analysis of Osteosarcoma and Ewing Sarcoma of the Spine. The Spine Journal. 6. May, P., Garrido, M. M., Cassel, J. B., Kelley, A. S., Meier, D. E., Normand, C., ... & Morrison, R. S. (2016). Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers of comorbidities. Health Affairs, 35(1), 44-53. 7. Houdek, M. T., Beahrs, T. R., Wyles, C. C., Rose, P. S., Sim, F. H., & Turner, N. S. (2016). What Factors Are Predictive of Outcome in the Treatment of Soft Tissue Sarcomas of the Foot and Ankle?. Foot & Ankle Specialist, 1938640016666925. 8. Shea CM, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational readiness for implementing change: a psychometric assessment of a new measure. Implement Sci. 2014 Jan 10;9(1):7. PMCID: PMC3904699.
  28. 28. Source: http://il9.picdn.net/shutterstock/videos/4388282/thumb/1.jpg
  29. 29.  Source: http://il5.picdn.net/shutterstock/videos/15802915/thumb/6.jpg

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