In this section, we describe how to plan your project with a focus on developing a sustainable infrastructure, pieces of which include governance, communication, utilization of resources, and incentives for participation. We also describe structural elements of a pediatric congenital heart surgery program as recommended by the Society for Thoracic Surgeons (STS). When you start your project, your institution may be missing some of these elements, as we were. Therefore, it is important to remember that, although the program structure elements are presented at the beginning of the toolkit, you will develop these pieces as you work throughout your project.
Because teamwork is fundamental to supporting efforts of implementing any changes in practice, it is critical that you start by assessing your organization’s readiness for TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety is described in “Teamwork”). The national TeamSTEPPS Web site provides valuable tools and guidelines for this process – the Organizational Readiness Assessment Checklist and Tips and Suggestions for Enhancing Organizational Readiness. With these tools, you will address topics such as culture change, time and resources needed, and sustainment in a step-by-step fashion. If barriers are too great to begin an organization-wide effort, then you can use the suggested tools to start on a smaller scale.
In addition to the organizational readiness assessment, you will want to examine the various clinical areas along the pathway for pediatric congenital heart surgery patients and assess each unit itself. TeamSTEPPS at UNC Health Care has developed a readiness checklist for this purpose. This unit-based assessment can usually be accomplished in one half-hour meeting with the lead physician and nurse manager, and will enable your understanding of what is already in place and what challenges and barriers you may face.
As part of this critical assessment process, you will need to ensure buy-in (agreement to support your project) from at least one of the cardiothoracic surgeons. In discussions with surgeons about the project, it is important to emphasize the benefits of increased communication between the surgical and anesthesia teams, better handoffs to the ICU, and standardization of care. You should also listen to their concerns and discuss how the project team could address those concerns throughout the project.
The Advisory Council is a key ingredient for a multidisciplinary, cross-unit effort such as Project TICKER. The Advisory Council should have members representing all areas involved and include clinical and administrative leaders as well as frontline clinical staff and families. You might already have a group or committee that can function in this role with some additional members. For Project TICKER, this meant hospital and service line directors, medical and nursing staff from service units (pediatric intensive care unit/cardiac intensive care unit, children’s cardiac intermediate care unit, operating room, neonatal intensive care unit), diagnostic and therapeutic teams focusing in pediatrics (respiratory therapy, nutrition, pharmacy, patient- and family-centered care specialists, chaplain, etc.), surgeons and providers from various medical teams (cardiothoracic surgery, cardiology, anesthesiology, pediatric/cardiac critical care, neonatology), and families of congenital heart patients. The Advisory Council will likely need to meet monthly for the first 1 or 2 quarters of the project and then quarterly or bi-annually for the rest of the project. The frequency of meetings in the beginning is based on the importance of agreeing on goals and execution of the project and removing any initial barriers.
The responsibilities of the Advisory Council include:
- Establishing the project charter,
- Providing input for the timing and phasing of the project,
- Serving as communication liaisons for their clinical areas,
- Assessing progress on a regular basis,
- Reporting and removing barriers,
- Working in small groups to address specific processes, such as unit handoffs, and
- Determining incentives for participation, such as continuing education credits for teamwork training and maintenance of certification for physicians.
Along with the Advisory Council, there are several key roles that should be considered critical for this effort. In most cases, the project leader will be a physician leader (such as a medical or surgical director) within the pediatric congenital heart surgery service line, and he or she will work with a small core team to run the project. The main functions of this core team are project management, process improvement support, data management, quality analysis, and communication. Depending on the size and complexity of your program and the resources available, you might have 3-6 people on this core team fulfilling these functions (see the project charter for more details regarding roles and time commitments). In addition, the TeamSTEPPS facilitator (described in Teamwork) is a member of the core team.
Family advisors are another key resource that might or might not be a regular part of teams within your institution. For Project TICKER, we recruited parents of children who had been cardiac surgery patients at our hospital to be part of the Advisory Council. We also held separate discussions with them to address topics such as communication between provider and family, unit transitions, orientation materials, and facilities. The feedback from these discussions was used in two ways: 1) incorporation directly into ICP materials and 2) initiation of side projects.
In addition to personnel, we found that some non-personnel resources were critical to project success. For example, our training supplies included TeamSTEPPS pocket guides and ID badges that identify staff as TeamSTEPPS coaches or as having completed TeamSTEPPS training. Inclusion of family advisors meant that we had to budget for tele- or web-conferencing equipment, printing and postage for recruitment materials, and parking vouchers and amenities for attending meetings at the hospital. Another budget consideration might be expenses for patient- and family-centered care training for one or more project team members.
With a project’s communication plan, the goal is to reach all stakeholders in a way that will speak to them. First, list all stakeholders (anyone who will be impacted in any way by the project) and then, for each stakeholder, think about communication goals, what type of information to communicate, when, how, and which core team member is responsible. You can include this information in your project charter and/or create a separate document for communication planning. Some of the communication methods recommended are:
- Progress reports presented at in-person meetings,
- Quarterly newsletters distributed via email,
- Web site to post announcements and updates as well as draft tools,
- Feedback surveys regarding project activities like cardiac rounds and peer review conferences, and
- Informal one-on-one meetings.
The following structure elements, with the exception of teamwork training, were recommended by STS for consideration in the recent National Voluntary Consensus Standards for Pediatric Cardiac Surgery. However, in the final report, only the cardiac surgery registry participation and surgical volume were endorsed by the consensus recommendations as structure measures. The others listed below were withdrawn to be considered at a later date due to several issues including poor documentation and exclusion criteria, evidence required for structural measures, and lack of specificity. We believe structure and process measures are important in moving toward optimal quality outcomes, and therefore, we recommend all of the following structure elements. In “Measurement”, we describe how to measure progress related to partial or full implementation of each element.
- Cardiac Surgery Registry (Now Endorsed by NQF Measure 0734): The purpose is to have your program’s data for quality performance measures compared to national participants. The STS National Database is a systematic multi-institutional database for cardiac surgery. At our institution, all pediatric congenital heart surgery patients are entered into the database by the cardiothoracic team’s nurse practitioner; these data are uploaded from the institutional site to the national database twice per year.
- Pre-operative Multidisciplinary Conference (STS recommendation): The purpose is to plan surgical cases with representatives from cardiology, cardiac surgery, anesthesia, and critical care. Our program holds a weekly meeting with participation from all groups.
- Multidisciplinary Rounds (STS recommendation): The purpose is to review the status and care plan for each cardiac surgery patient with representatives from cardiology, cardiac surgery, and critical care. We made changes to our timing of ICU rounds (which were already in a standardized format1) in order to have participation from all teams.
- Peer Review Conference (STS recommendation): The purpose is a regularly scheduled multidisciplinary quality improvement conference. We held these meetings following one of the weekly pre-operative conferences every other month. The agenda consisted of reviewing mortalities since the last meeting, reviewing STS data and dashboards, and discussing topics related to standardized care and prevention and treatment of complications.
- Teamwork Training & Coaching (UNC Project TICKER recommendation): The purpose is to create an infrastructure to support training in teamwork and ongoing coaching for continued development of teamwork skills. We have a TeamSTEPPS® training program with Master Trainers throughout the organization (visit TeamSTEPPS at UNC Health Care for more information).
- Transesophageal Echocardiography (TTE) & Extracorporeal Life Support (ECLS) (STS recommendation): These were both available at our institution at the start of the project.
- Surgical Volume for Pediatric and Congenital Heart Surgery (Now part of Endorsed NQF Measure 1815 Pediatric Cardiac Surgery Stratified Mortality & Volume Measure Pair): The purpose is to know the numbers and size category for your institution and understand how your volume might affect your outcomes.2,3
Tools & Resources for Getting Started
1 Whalen L et al. Herding Cats: The Successful Implementation of Standardized Multidisciplinary Bedside Rounds Including the Use of Pediatric ICU Daily Goals submitted for publication 2012
2 Pasquali SK, Jacobs JP, He X, et al. The Complex Relationship Between Center Volume and Outcome in Patients Undergoing the Norwood Operation. The Annals of Thoracic Surgery 2012;93(5):1556-1562.
3 Welke, KF. Interpreting Congenital Heart Disease Outcomes: What Do Available Metrics Really Tell Us? World Journal for Pediatric and Congenital Heart Surgery 2010;1(2): 194-198.