Facilitating gthe Nursing 

Transformation in PAC

Lisa Meredith, PhD 

RAND Corporation RAND Corporation 

VA HSR&D Center for the Study of Healthcare Provid

PACT Demo Lab Cybersemin

Aug , ust 15, 2012

Sensitive Information – Please do not cite or circ

VAIL-PACT VISN22 
Patient Surveys Patient Surveys 

Practice ElectronicSurveys measures

VAIL 

Evaluation Teamle

effectiven

evaluatio

Implementation

Evaluation 

Clinician & Staff 

S 

Economic 

E l ti Evaluation Surveys

8/14/2012 
PACT Clinician and Staff Surv

• Track changes in clinician and staff 

knowledge, attitudes, and reported brelated to PACT and VAIL implement

–Important for efficient redesign of car

processes, identification of 

“best pra

• Early and later 18-month follow-up su

–First wave replaced last VOVA First wave replaced last VOVA –Formative feedback, pre-post chang

vs no VAIL factors associated with vs. no VAIL, factors associated with 

VAIL-PACT VISN22 
PACT Clinician and Staff Surv

• VISN22 health professionals 

–primary care clinicians (MDs, NPs, P

excluding residents) 

–other clinical staff based in primary c

(RNs, LVNs, MH professionals, phar

health educators, and dietitians) 

• First wave 11/29/11-3/9/12 • Median completion time 20-22 minut

VAIL-PACT VISN22 
Response Rates 

• Overall: 63% 

p 

– Primary care clinicians (PCCs): 54% 

– Other primary care staff: 70% 

• Other staff by job category: 

– RN: 79% – NBHD: 76% – LPN/LVN: 68% – Clerk/HT/MA/NA: 64% 

VAIL-PACT VISN22 
t

Ch t i ti (N 132) (N 55) (N 10

Demogp ra hics and Years in Cli

Provider Characteristic 

MD 

(N=132) 

NP 

(N=55) 

RN 

(N=10

% Female 37 86 83 %L i atno 5 6 10 % Non-White 50 48 56 

Mean Age 49 52 49 

Mean Years in Clinic 12 10 6 

VAIL-PACT VISN22 
Members of a Teamlet 

100% 

Yes No Don't know 

70% 80% 90% 50% 60% 20% 30% 40% 

0% 

10% 

MD NP RN 

VAIL-PACT VISN22 
Number of Teamlets You Supp

100% 

pp 

60% 80% 40% 

0% 

20% 

RN LPN/LV

1 2 3 4 5 to 9 5 to 9 

VAIL-PACT VISN22 
Team Perceptions Differ by Job 

Everyone in this team has the special ski

are needed for team work 

RN 

Strongly Agree Agree Neither Disagree Stro

LPN/LVN 

mean=4.3 mean=4.1 

NP 

mean=3.8 

MD 

mean=3.8 

Sig across jobs above, p<.05; no sig diff between RNs and LPN/LVNs 

0% 20% 40% 60% 80
Readiness for PACT Differs by Job 

There are some tasks expected of my ro

PACT that I don’t have time for 

RN 

Strongly Agree Agree Neither Disagree Stro

LPN/LVN 

mean=3.6 mean=4.0 

NP 

mean=3.6 

MD 

mean=3.5 

RNs sig. higher than other jobs above, p<.05 

0% 20% 40% 60% 80
f

Emotionally drained from work

Feel used up at end of workday

Doubt significance

of work

Exhilaraccom

Working Working w/people w/people all day is a strainBurned out from work

Fatigued Fatigued when get up in morning morning to

face another day at job

Less enthusiastic

about work

Just want to do

sometHaveaccom

face another another day at job

Frustrated by jobWorking too hard on jobWorking with people directly is too

Just want to do

job and not bebotheredbothered

many 

things Good a

Working with people directly is too

stressful

Components Components of Burnout Burnout

α=.90 (total scale) 

Emotional Exhaustion Cynicism Profess

Emotionally drained from work

Feel used up at end of workday

Doubt significanceof work

Exhilaraccom

Less enthusiasticabout work

Just want to do

sometHaveaccom

Working Working w/people w/people all day is a strain

Burned out from work

Fatigued Fatigued when get up in morning morning toface another another another day at jobFrustrated by job

Working too hard on job

Working Working with people directly directly is too

stressful

Just want to do

job and not bebotheredbothered

many things Good a

α=.92 α=.68 α=
Burnout Differs By Job Type 

35 40 

y yp 

(Total burnout scores can range from 0 

20 25 30 35 10 15 20 

0 5 

VAIL-PACT VISN22 

p<.001 
Emotional Exhaustion Differs B

y Jo

30 

y 

(Scores can range from 0 to 54) 

1 20 25 

5 

10 15 

0 

VAIL-PACT VISN22 

p<.001 *adjusted, based on normative sample of healthcare workers, Maslach 
Cynicism Differs By Job Type 

7 

y y yp 

(Scores can range from 0 to 18) 

4 5 6 2 3 4 0 1 

VAIL-PACT VISN22 

p<.01 *adjusted, based on normative sample of healthcare workers, Maslach 
Professional Efficac

y Differs B

y Job 

6 

y y 

(Scores can range from 0 to 18; High scores indicate 

4 5 2 3 0 1 

VAIL-PACT VISN22 

P<.001 *adjusted, based on normative sample of healthcare workers, Maslach 
Job Satisfaction Differs Across Job 

Overall, I am satisfied with my job 

Strongly Agree Agree Neither Disagree Stro

RN 

mean=3.8 

LPN/LVN 

mean=4.0 

NP 

mean=3.6 

MD 

mean=3.5 

Sig across jobs above, p<.05; no sig diff between RNs and LPN/LVNs 

0% 20% 40% 60% 80
No Differences in Teamlet Satisfac

Overall, I am satisfied with how my teamle

members work together. 

Strongly Agree 

Agree Neither Disagree Stro

RN 

mean=3.9 

LPN/LVN 

mean=3.9 

No sig diffs; no comparisons with MD and NP since question wording differs 

0% 20% 40% 60% 8
–

PACT Activities: RNs and LPN/LV

• Exposure 

RNs less likely less likely to be using new measur

to be using new measur

tools to assess teamlet performance (p<

– RNs more likely more likely to be in clinic using info

to be in clinic using info

systems to provide PACT feedback to s(p<.01) 

• Perceived helpfulness 

– No differences between RNs and LPN/L

No differences between RNs and LPN/L

– LPN/LVNs and RNs report new schedu

approaches as more helpful than report

pp p p 

PCCs (p=.058) 
RN: Exposure to PACT activities 

Team performance measures 

Yes No Don't kn

Teamlet huddles 

Team performance measures 

Info systems, feedback to staff 

New schedulin

g approaches 

Reports on your performance 

Small tests of change 

g pp 

0% 20% 40% 60% 
LPN/LVN: Exposure to PACT activ

Team performance measures 

Yes No Don't kn

Teamlet huddles 

Team performance measures 

Info systems, feedback to staff 

New schedulin

g approaches 

Reports on your performance 

Small tests of change 

g pp 

0% 20% 40% 60% 
RN: Perceived Helpfulness of PAC

Team performance measures 

Very helpful Somewhat helpful Not he

Teamlet huddles 

Team performance measures 

Info systems, feedback to staff 

New schedulin

g approaches 

Reports on your performance 

Small tests of change 

g pp 

0% 20% 40% 60% 
LPN/LVN: Perceived Helpfulness o

Team performance measures 

Very helpful Somewhat helpful Not he

Teamlet huddles 

Team performance measures 

Info systems, feedback to staff 

New schedulin

g approaches 

Reports on your performance 

Small tests of change 

g pp 

0% 20% 40% 60% 
Comments 

• Generally, “vision of PACT is understood” and supp

“PACT training has been a huge help for our clinic PACT training has been a huge help for our clinic, ” 

• “System is overloaded”: insufficient staffing for PAC

lack of clerical support, schedules more inflexible, reover increased responsibilities 

• “Performance measures have become more importa

patient care”

• Leadership is disconnected/inconsistent (e.g., MD, 

and administrative); line staff concerns are not addrand administrative); line staff concerns are not addr

VAIL-PACT VISN22 
RN Comments 

• “[I] am impressed with how nursing leadership has s

the drastic culture and operational change [PACT ]b

the VA The largest obstacle to being able to comthe VA. ...The largest obstacle to being able to com

implement PACT and have nurses function at their level is the lack of clerical support. ...I believe the 

th ll t h littl di l t i i d the call center have little or no medical training and 

root cause for clinical staff having to do their work oover on a day to day basis.”

• “The biggest issue I see with PACT is the lack of cl

support support. We have worked very hard to get our team

We have worked very hard to get our team

functional, but without this piece it takes away from medical care as issues often are interrupted by nee

copying records faxing things making routine appocopying records, faxing things, making routine appo

and non-clinical calls. Once this problem is rectifiedshould work smoothly.”
LPN/LVN Comments 

• 

“No time or consideration has been placed in staffinnumber of providers assigned to have a successful 

t l team

e

t. T l team

e

ts are set b t d t k t th 

t up 

b

ut 

do no

t work 

togeth

staffing issues. Performance measures have bec

important than PACT.

”

• 

“As long as there is walk-in in the clinic, PACT team 

fully successful since it fully successful since it takes a lot of time seeing m

takes a lot of time seeing m

walk-in patients.”

• 

“Need help in this clinic implementing PACT due to number of attendings & residents... Nursing manag

not able to tackle this not able to tackle this scheduling challenge scheduling challenge! ”
Facilitating the

Nurse Role

Transformationin PACT

Greg L. Stewart, PhDBonnie J. Wakefield, PhD, RN, FAANVISN 23 PACT Demonstration Demonstration Lab,

Iowa City VA Health Care System
VISN 23 Demonstration Demonstration L

• L ba L d ea ership:

– Gary Rosenthal, MD, PhD, Director– D id av Katz, MD MS , c, Co‐Director

– Bonnie Wakefield, PhD, RN, Co‐Director

• Evaluation includes 5 states in VISN 23

– 30 PACT Teams in VAMCs and CBOCs

o 22 Teams in VISN 23 Learning Collaborative

o 8 Teams in C t en ral R i eg on C ll o aborative
’

VISN 23 Demo Lab Main Areas of 

• Ongoing Ongoing formative formative evaluation evaluation of barriers barriers to P

implementation, interdisciplinary team funct

and work role transitions transitions

• Evaluation of the impact of PACT implementa

quality quality of care, patient patient outcomes outcomes, patient patient pe

pe

of care, and provider satisfaction

• Support nurse care managers’ roles in PACT t

the development of a ‘Community of Practice

• Development and testing of interventions to 

chronic disease management and care of dua

managed veterans in rural CBOCs
E l va uation of the Nurse R 

Transformation During PA

Implementation

Greg L. Stewart, Stewart, PhD, Core Leade

Leade

Formative and Team Evaluation
Team and Formative Formative Evalua

Evalua

material

culture

f db k

interviews focus

groups

feedback

to teams

and VISN

leadership

observation work role

survey

site visits

1. Quantitative Quantitative W

with Two Data Year 1)

2. Focus Group F

Separated by 

• Writing E

• What ca

you do y

3. Open‐ended q

• What iss

creating 

• What fac

facilitate 

• What fee

to guide 
Series1 

Series2Series3Series4

General General Work Perception

Perception

5

ProviderClinicalRNCMClerical

5

4 4

3 32 21 1

2010 2011 2010 20

Job Satisfaction Empowerment

General level of satisfaction with Psychological feeling that w

getting getting what is wanted out of job meaningful meaningful and significant significant & a

a

Overall negative trend, p < .05 Overall negative trend, 
Series1 

Series2Series3Series4

Challenging Challenging Role Character

Character

54321

ProviderClinicalRNCMClerical

54321

2010 2011 2010 2

Role Overload Role Conflict

Feeling of being asked to do too much Feeling of having incomp

requirements and poor gu

Overall upward trend, p 
,

Nurse Care Managers Managers Sa

Clerical Associates

You help when you take care of reminders

before the patient arrives, schedule

appointments and handle related calls,

route alerts, route Veteran questions

Clinical Associates

You help when you do pre‐ca

beyond reminders, take initiativ

needs and act on them, and 

appropriately, and pull data for PACT reports

or schedule scrubbing.

patient care over teamlet au

As an RN I can do more than scrub

schedules and answer phones.

Providers

You help when you use secure messaging or

call patients, delegate work across the

Neighbors

You help when you offer me

reconciliation, chronic disease m

p g mange specialized clinics (e.g. li

entire team, use group visits, and take an

active leadership role.

g p ( g 

coag), maintain same day access

if we have time before you assu

take on more work.

N t o e. This i f n ormation is wh t a NCMs want to communi t ca e t 

o oth
Clinical Clinical Associates Associates Say

Clerical Clerical Associates Associates Nurse Care Manage

You help when you participate in team

projects, route incoming calls

correctly, try asking me before the RN,

Nurse Care Manage

You help when you lend 

during busy times, delegate 

y, y g , others work on teamlet pro

and fax for outside notes.

p 

you, and coordinate with n

I am licensed to do more.

If I am an integral team member, why

am I “floating” to other teams?

Provider

You help when you delegate work

throughout the team, ask me about

h t I li d t d d d l t

Neighbors

You help when you stay con

what I am licensed to do and delegate th t d d t 

that work to me, and take a strong

leadership role in our PACT team.

the team and understan

teamlet’s aims.

N t o e. This i f n ormation is wh t a Clinical Associ t t ates want to communi t ca e 
Empowerment Paradox

Clerical Associates Say

You help when you keep an open mind,

participate in the teamlet’s activities, delegate

to NCMs so you aren’t overbooked, and treat

d d l h

h “ l

k

”

Clinical Associates Say

You help me when you delega

throughout the team, ask me abo

licensed to do and delegate that w

me as an in

divi

dual rat

her than

a

“

cler

k.” an

d ta

k

e

a strong l d ea

ders

hip role 

Providers Say

I could d l e egate more if you could ta

k

e more

initiative. I want to work with neighbors but

wonder how they can do more when they

aren’t covering what I feel are the “basics.”

Nurse Care Managers Say

You help when you use secure messaging or call

patients, delegate work across the entire team,

Neighbors Say

You help by sharing the respon

patient care with us and allowing u

use group visits, and take an active leadership

role.

patient care with us and allowing u

you by providing the service we s

N t o

te. Thi

s i f n

formation is

w

h t a

t

Team

Mem

bers

have

t

o say

a

b t ou

t

Pr
Questionnaire Data

• Participants completing a Learning Collabor

completed a questionnaire (14 RN Care Ma

LPN Clinical Associates)

• Questions included

– What factors have you observed that have help

PACT?

– What feedback can you provide to help leaders

successfully guide PACT in the future?

• Responses were coded for themes
Barriers Barriers to PACT Identified Identified by N

Top 5 Rank Order By Frequency

RN Care LPN

Manager A

Roles 1 Delegation 3 (tie) Implementation 2 

Staffing 3 (tie) 

Team 5 
Identified Identified Barriers Barriers to Role Develop

Develop

• RN Perspective

– Staffing – PACT RNs and LPNs pulled to work in 

– Unclear role expectations

• LPN Perspective

– The VA does not [allow] LPNs to function as nu– Clerical associates are not able to function to th

due to different role alignment – sharing lab an

responsibilities.
What Has Facilitated Facilitated Role Develop

Develop

• RN Perspective

– Finally getting some policies so you can write 

when needed rather than ask MD to do all.

– Two providers in our CBOC that haven’t partic

learning sessions have embraced PACT & are 

th i e r own style wi ht regard to role functions o

members, nurse f/u visits, telephone appts, e

• LPN Perspective

– Open mindedness, trying new ideas, willing to w

team treating each member as they sh ld ou be. 

is valuable no matter what letters are behind yo
Suggestions for Improving

Role Development

• RN Perspective

– Allow ideas to be brought forth and listen to rationa

deny g in teams opportunity to try things

– Listen to what the front line staff is saying – we are 

with the information. Don’t design PACT around wh

leadership thinks.

• LPN Perspective

– Continue Continue training training seminars seminars and realize realize for this to su

su

acknowledgement of needed staff and the willingne

adapt is necessary

– Allow st ff a to function at f ll u pot ti en al, support st f

a 

out the bad eggs in the bunch, listen and actually im

change.
Identified Identified Barriers Barriers to Delega

Delega

• RN Perspective

– Provider’s boss is not RN’s boss, and clerks also 

different boss.

– Employees not wanting to step up and do differ

that are within their role.

• LPN Perspective

– A few people in clinic doing all jobs/depts. And 

maybe 2 jobs/tasks.

– Other departments make the teamlets the “dum

grounds”
What Has Facilitated Facilitated Delega

Delega

• RN Perspective

– More outpatient nurse visits creating open acce

provider

– Providers like having the same RN to go to

• LPN Perspective

– We have been able to do a “few more” things t

were not allowed to do before

– Needed staff are in place. We are at full staff fo

PACT teams. It helps to have people who are o

change and are willing to put in the extra work.
Suggestions Suggestions for Improving Improving Deleg

Deleg

• RN Perspective

– Oftentimes we feel left in dark or uncertain – y

have opinions but we want to be included in de

changes

– R i ev ew Administration Processes and eliminate 

requirement

• LPN Perspective

– Support us not hinder us
VISN 23 Nurse Care Mana

Mana

Community of Practice

Bonnie J. Wakefield, Wakefield, PhD, RN, FAA

Lab Co‐Director
Background

• ~250 RNs in VISN 23 PACT teams transitioning to n

Nurse Care Managers (NCM)

• VA has care managers in some settings, PACT role i

• Role definition of care & case management lacks c

• FE Core findings: negative perceptions of role chan

pronounced in NCM

• NCM expressed an interest in connecting with othe

gain role clarity and definition

• In response, the VISN 23 Demo Lab initiated a PACT 

Community of Practice (CoP)
Community Community of Practice Practice

“Communities of practice are groups of peopl

share a concern, a set of problems, or a pas

about a topic, and who deepen their knowlexpertise in this area by interacting on an o

basis.”

Wenger E, McDermott R, Snyder WM: Cultivating communities o

Boston, Harvard Business School Press 2002.
CoP Characteristics

• Members Members have overlapping overlapping expertise expertise• Concern about a common topic• Collaborate Collaborate to solve problems problems relating relating to the topic• Members learn from peers and through practice

• V l a ue b th o t it ac and expli it c knowledge

• Safe to speak the truth and ask hard questions• Consult each other for h l e p

• Strong sense of identity and belonging

• Devel i op ng and sh i ar ng knowledge

Bentley, C, Browman, GP, & Poole, B. (2010). Conceptual and practical challenges for implementing the com

model on a national national scale – a Canadian Canadian cancer control control initiative initiative. BMC Health Services Services Research Research, 10:3
‐

Goals of VISN 23 CoP

1. Support NCM during transition to PA

model

2. Standardize NCM work processes ac

VISN 23

3. Better align NCM practice with PACT 

of care

4. Promote Promote use of evidence evidence‐based prac

prac

improve patient outcomes in primar
CoP Formation

• Primary care service line nursing directors identifie

nurses from each VISN 23 healthcare systems to se

advisory advisory group (1 main facility facility, 1 CBOC)

• 17 NCMs representing all healthcare systems

• First meeting meeting (7/11) – developed objectives

• COP purpose is to support and empower nurse car

to:

– Increase their voice in the PACT implementation process– Define nurse care management management practice practice– Develop and share expertise

– Facilitate alignment of practice with the PACT model of ca
Goals

• Share information, insight, and advice

– Engage with other practitioners who face similar situation

• Develop expertise from each other

– Multiple perspectives for complex problems/issues– Challenge our thinking

• Serve as a living repository of knowledge

– Stay abr teas of current curr en knowledge knowledge– Establish and standardize baseline knowledge; focus on a

issues

• Empower the members to be heard

• Engage in specific sub‐projects of interest

– Action learning/practice development/EBP projects/Rese
–

CoP Formation

• Second meeting (11/11) focused on lack of clarity a

NCM role and task delineation and delegation

• N dd ee e to identify WHAT t k as s the NCMs were act 

and what the frequency of their time devoted to th

• Survey process

– Small group work to compile a list of all NCM tasks

CBOCs worked separately separately as their tasks are somewhat somewhat dif

dif

– As a group categorized tasks in the CBOC list as CBOC only 

and CBOC

– NCMs reviewed list to clarify or add to the list

– Categorized interventions into NIC Domains

• Surveyed i W nter 2012
Task Frequency Survey Responses: Comparison of CBOC (n=9) and Main Facility 

Winter 2012

5

4.5

4

3.5

3

2.5

2

1.5

1

0.5 

0

5

4.5

4

3.5

3

2.5

2

1.5 

1

0 5. 

0
CoP Formation

• Third meeting (3/12)

– Results from task survey– U dp ate on FE findings

– Computer lab work for PACT tools

• Next meeting – Sept 2012

– Expanding beyond the initial 17 nurses– PC Almanac and Disease Registry training

– Shared Medical Appointments

– Care Coordination for complex patients

– Obstacles to role implementation
Summary Summary of Work to Da

• Three face‐to‐face meetings of the core gro

• Communication methods established withi

(Sharepoint, Yammer site)

• Monthly Monthly phone call for core group of 17

• Transitioning to VISN‐wide participation

Acknowledgements

VI

S

N 23 Patient

Ali d gne

d

Care Team Demonstrati b on La

boratory, Departm

Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA

Gary Rosenthal, MD, PhD, DirectorDavid Katz, MD, MSc, Co‐Director DirectorBonnie Wakefield, PhD, RN, Co‐Director

Michelle Lampman, MA, Associate Director of Operations

Samantha Solimeo, MPH, PhD, Qualitative InvestigatorMonica Paez, BA, Qualitative Core Coordinator

Marsha Cheyney, MPH, Research Coordinator

VISN 23 Primary Primary and Specialty Specialty Medicine Medicine Service Service Line (PSM SL)Jaime Bland, MS, RN, HPDP/PACT Coordinator, VISN 23 PSM SL, Omaha, NE

Sally Frohn, RN, BSN, CPHQ Administrative Officer, VISN 23 PSM SL, Lincoln, NE

Marsha Herke, MPH, RD, Asst. Administrative Officer, VISN 23 PSM SL, Minnea

p

Michael Koopmeiners, MD, Medical Director, VISN 23 PSM SL, Minneapolis, MNVISN 23 PACT Collaborative team members

C t en

ter

f C or

Compre

hensive

Access

&

D li e very

Researc

h an

d

E l va uation (

(

Department of Veterans Affairs, Iowa City VA Health Care System, Io
Disclaimer

The views expressed in this presentatithose of the authors authors and do not neces

neces

reflect the position or policy of the

Department Department of Veterans Veterans Affairs Affairs or the 

States government.