1
Focus Group Facilitation Guide
Community Hospital
CH Focus Group Guide
Mention that this is a two-way needs assessment: data is being gathered from both RH and CH about their perception of both sites and the collaboration between them.
•Introductions
•Objectives
•Discuss the ICU
•Discuss patients and staff
•Explore two case scenarios
15 minute break at mid point Agenda
•To work together to help you meet mutual goals in caring for patients
•Explore the current practices
•Explore areas of strengths and potential improvements
•Identify potential solutions and strategies for change
•To learn from your experiences, which can also help other hospitals
Needs Assessment Objectives
Community Critical Care Performance and Inter- Hospital Relations Improvement Initiative
Focus Group Session
•Collaborative partners
• Input partners Introduction
2 Consent form will be discussed at this time and completed by participants.
•Part of larger REACHout needs assessment
•Who are the investigators
•Recording & transcript only available to study investigators
•Recording & transcript are confidential; not shared with anyone at CH
•Will be anonymized by person who transcribes
•Final report may quote discussion, but will identify speaker only as “nurse from CH”
•Aggregate data may be submitted for publication Disclose project funding sources
Very briefly summarize all the sources of data that will be triangulated in this needs assessment. The focus group is one of many sources.
Your role as Participants
• Highlight the importance of the participants.
• Their feedback and ideas are essential to improving patient care.
• We are excited to learn from their experiences.
• We are here to work together and to learn from each other.
Our commitment
• The results will be compiled and available
• The next step will be to work together to develop a program for improvement
• The results will also help other hospitals to learn from the experiences in CH/RH and also improve their units
Your Role as Participants Our Commitment
•Institutional Review Board
•IRB approval -Audio taping -Confidentiality -Informed consent
•Project Funding
•
Disclosures
•Data Collection
•Interviews
•Focus groups –at CH and RH
•Family questionnaires
•On-site walk through
•Simulations
•Database
•Chart Audits
Needs Assessment Methodology
3 For group discussion. Ensure the group does NOT equate
‘critically ill’ with code blue!
Should not take long.
Probes:
• Do the same people work in the ICU every day?
• How much time does each specialty member spend in the ICU?
• How do members of the team interact? Differences during crises than normally?
• How do care team members communicate (verbal and written)?
For the Discipline Specific focus groups:
• can also explore unperceived needs of other groups (i.e., asking the nurse group to identify areas of strength and challenges working with physicians)
For group discussion. Ensure the opinions reflect the group overall (i.e. no participant dominates or responds on behalf of the group).
Who do you interact with at The Referral Hospital? i.e. which professions, not specific people.
What is the nature of the interaction?
Probe: If only mention transfers, ask anything else? Education, questions/consultation on patient care without transfer? Etc.
Contact via CritiCall or direct?
How do you interact with them?
Probe – telephone, email, face to face Any problems with communication?
E.g. Accessing someone to talk to? Do they understand the CH context?
If so, how could communication be improved?
•What is your definition of a critically ill patient?
Critical Illness
•Who works in the ICU?
Social/Professional Roles
•Who do you interact with at The Referral Hospital?
•What is the nature of the interaction
•How do you interact with them?
•Any problems with communication?
•If so, how could communication be improved?
The Referral Hospital
4 For group discussion – NOT for one participant to answer on behalf of the group!
(If asked, no history of COPD or heart disease)
The case will be explored by the participants and subsequent flow mapping will be completed on large paper board with markers. The goal of this process is to be led by the
participants from to final outcomes in the ICU and/or transfer.
Following the cases, questions will be asked to identify strengths and weakness of the process, barriers to KT, and identify potential solutions (use a different coloured marker to identify these points). Gaps in the system, knowledge,
attitudes and behavior will be explored.
Probing:
Who meets the patient ?
What happens next (go through each step)?
In the ICU on arrival, what happens, who meets the patient During the day what happens? At night?
What resources are required? Are any available but not used?
Are any needed but not available?
Some areas to discuss:
What works well in this process?
What are challenges you face caring for these patients?
For the challenges identified:
What could be potential solutions?
How do you see these changes being made?
Case 1
•An elderly female with Parkinson’s disease presented to the emergency with pneumonia and required intubation.
•CXR shows diffuse bilateral infiltrates. She is hemodynamically stable.
•Ventilation parameters are: Volume A/C, Vt 600 cc, RR 12, PEEP 5, FiO20.5
•ABG on this ventilation: pH 7.4 / PCO240 / PO2140 / HCO324
•What would happen with this patient?
14
Case 1
5 When there is disagreement about who should occupy beds (example using this case, you could say that the ICU is full) how does this get resolved? Who has ultimate decision power (days, evenings, nights)?
What factors determine if a patient is transferred or cared for here?
e.g. Severity of illness? Staff competence? Staff confidence?
Beds available? Specific equipment needed?
Do you feel pressure to transfer or keep patients?
Probe:
? by patients and families
? by other staff or administration
? by tertiary hospitals
? Is the pressure to transfer patients or not to transfer
Do you have the opportunity to discuss cases or debrief crises with your colleagues?
Probe: Within the hospital i.e., interprofessional rounds?
With colleagues at tertiary site/RH?
Would this be valuable to you?
•Any differences during day/evening/night?
•Would this patient be transferred?
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•Who gets admitted to the ICU?
•Is there criteria you use for admission?
•Who gets transferred to a tertiary hospital?
•Is there criteria you use for transfer?
Patient Flow
•Do you feel pressure to transfer or keep patients?
•Describe your interaction with referring hospital
•Describe this interaction
•Strengths and areas for improvement
•What reactions from RH intensivists/nurses have you come to expect when you contact them?
•Are there other ways that you would like to see the tertiary hospital supporting you in caring for critically ill patients?
Patients
•Do you have the opportunity to discuss cases or debrief crises with your colleagues?
•Within CH
•Between CH & RH?
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6 For group discussion – NOT for one participant to answer on behalf of the group!
(If asked, no history of COPD or heart disease) Description
The case will be explored by the participants and subsequent flow mapping will be completed on large paper board with markers (a second person will be marking down the points while the facilitator guides the discussion). The goal of this process is to be led by the participants from to final outcomes in the ICU/transfer. Following the cases, questions will be asked to identify strengths and weakness of the process, barriers to KT, and identify potential solutions (use a different coloured marker to identify these points). Gaps in the system, knowledge, attitudes and behavior will be explored.
Probing:
Who meets the patient ?
What happens next (go through each step)?
In the ICU on arrival, what happens, who meets the patient During the day what happens? At night?
What resources are required? Are any available but not used?
Are any needed but not available?
If giving antibiotics are mentioned, verify how easily antibiotics can be accessed.
Some areas to discuss:
What works well in this process?
What are challenges you face caring for these patients?
For the challenges identified:
What could be potential solutions?
How do you see these changes being made?
Case 2
•A 48-year-old female is admitted to the ward with community-acquired pneumonia (CAP).
•On the ward the nurse noticed that her oxygen demands were increasing and her BP had dropped to 80/35.
•Past medical history is unremarkable.
•What would you do with this patient?
•Differences during day/evening/night?
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Case 2
7 Probes:
How would you get in contact with a tertiary intensivist?
What would the conversation be like?
The intensivist recommends an epinephrine infusion; is this available at your site? If the drug is available, do staff know how to mix it and is there a titration protocol? In general, how are vasopressors prepared, administered and titrated?
Are there tools to facilitate this?
Would this patient likely be transferred? If not, what if the patient developed the need for hemodialysis?
In other words, patients that staff would like to be able to keep at CH (and that it would be appropriate to keep at CH) if only staff had more training and/or confidence.
Do not spend time having staff think of and list all the tools – we will collect them during the site walkthrough. Focus on whether the tools are up-to-date, accessible and actually used.
Types of tools:
• medical directives / standing orders
• Policies & procedures
• Admission checklists
• Treatment checklists
• Decision aids
• Dose calculation sheets, etc.
Not a priority – can skip this if time is short.
•She is transferred to the ICU - on arrival, she is intubated, and again becomes hypotensive (the effect of fluid boluses on the ward was transient). Her skin is warm and pulses bounding. Pulse is 120-125.
•She remains hypotensive despite the use of a vasopressor
•What would you do next?
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Case 2
•Are there any patient types that could be cared for at the CH given its resources, but that are transferred because of lack of confidence or familiarity?
Patients in the ICU
•Are there any clinical tools available at CH to help as memory aids or with clinical decisions?
Standing order sets?
•If so, are they used? If not, what kinds would be most useful?
Clinical Tools
•Who discusses goals of care with patients and their families?
•Where do these discussions take place?
•Who provides palliative care to patients at CH?
•What are the strengths and areas of improvement?
•What barriers exist to improving this care?
Goals of Care / End of Life
8 Ensure discussion stays within the scope of critical care.
Probes
•For topics – ask about specific topics, refer to areas discussed during the focus group.
• Can have the group rank the top 3 learning topics they would like to have
• For method – can probe if would prefer lectures, groups sessions, hands-on activities, online, interprofessional, etc.
Quality improvement:
• Any current QI processes underway?
• Any experience with past QI interventions – what worked and didn’t?
Ensure scope is limited to care of critically ill patients.
•How do you determine who is discharged from the ICU and when to discharge them?
•Where do these patients go?
•Any follow up?
Discharge
•What methods do you use for ongoing education?
•Attend conferences, read, working environment, journal club, online, none…
•What educational activities are currently available to you?
•What type of education would you be excited about adding?
Education
Any issues or topics that we have missed?
Thank you for your participation!
9
Focus Group Facilitation Guide
The Referral Hospital
RH Guide
Mention that this is a two-way needs assessment: data is being gathered from both RH and CH about their perception of both sites and the collaboration between them.
•Introductions
•Objectives
•Discuss the ICU
•Discuss patients and staff
•Explore a case scenario
15 minute break at mid point Agenda
•To work together to improve care of patients in the Champlain LHIN
•Explore the current practices
•Explore areas of strengths and potential improvements
•Identify potential solutions and strategies for change
•To learn from your experiences, which can also help other hospitals
Needs Assessment Objectives
Community Critical Care Performance and Inter- Hospital Relations Improvement Initiative
Focus Group Session
•Collaborative partners
•Input partners Introduction
10 Consent form will be discussed at this time and completed by
participants.
•Part of larger REACHout needs assessment
•Who are the investigators
•Recording & transcript only available to study investigators
•Recording & transcript are confidential; not shared with anyone at RH
•Will be anonymized by person who transcribes
•Final report may quote discussion, but will identify speaker only as “nurse from RH”
•Aggregate data may be submitted for publication Disclose funding source(s)
Very briefly summarize all the sources of data that will be triangulated in this needs assessment. The focus group is one of many sources.
Your role as Participants
• Highlight the importance of the participants.
• Their feedback and ideas are essential to improving patient care.
• We are excited to learn from their experiences.
• We are here to work together and to learn from each other.
Our commitment
• The results will be compiled and available
• The next step will be to work together to develop a program for improvement
• The results will also help other hospitals to learn from the experiences in CH/RH and also improve their units
Your Role as Participants Our Commitment
•Institutional Review Board
•IRB approval -Audio taping -Confidentiality -Informed consent
•Project Funding Disclosures
•Data Collection
•Interviews
•Focus groups –at CH and RH
•Family questionnaires
•On-site walk through
•Simulations
•Database
•Chart Audits
Needs Assessment Methodology
11 For group discussion.
Probes:
When does interaction occur? Only for transfers? For advice as well? For education?
How is interaction achieved? Call direct? CritiCall?
Is it easy to reach someone?
Are interactions amicable and collaborative?
Do staff from each organization understand the roles and limitations of the other?
What would need to change to improve the relationship?
Any ideas of how this could be done?
Describe how an ideal relationship would work. How is this different than present state?
What barriers to achieving this exist at each site? Regionally?
What past QI efforts have there been that involved CH and RH? Were they effective? Why or why not? What can we learn from past successes/failures?
How would group members envision an educational program for RH and/or CH? What professions would be targeted?
What would the education involve (i.e. what topics/issues?) If staff at CH require education, what role do you see RH staff playing? What would be required for you to be able to provide just-in-time education?
•What is your definition of a critically ill patient?
Critical Illness
•Could you please describe the interaction between CH and RH?
•What are the strengths of this relationship?
•Do you feel that enhancing this relationship could improve the care of patients at CH? At RH?
•If so how?
•What main challenges/barriers do you see to implementing these changes?
•Has there been any collaborative educational or quality improvement initiatives with RH and CH?
•If so, who was the target, how was the education accomplished? What kind of feedback was received?
•If you were to create a program for education of professionals at CH, who would you target?
•Who would you like to have facilitate?
•If you were to create a program for education of professionals at RH, who would you target?
12 Description
The case will be created by the participants and subsequent flow mapping will be completed on large paper board with markers. The goal of this process is to be led by the
participants from presentation/recognition to final outcomes in the ICU/transfer. Following the cases, questions will be asked to identify strengths and weakness of the process, barriers to KT, and identify potential solutions (use a different coloured marker to identify these points). Gaps in the system, knowledge, attitudes and behavior will be explored.
Probing:
Typical patient presentations (may ask to list 3-5) Please tell me about the patient at CH ?
When would RH become involved ? How would this interaction occur?
Describe the nature of your interaction / collaboration?
What happens next (go through each step)?
What if the patient is transferred?
What if the patient is not transferred?
Some areas to discuss:
What works well with this interaction?
What are challenges you face caring for these patients?
For the challenges identified:
What could be potential solutions?
How do you see these changes being made?
Case
•Can you please describe a typical patient for whom you would provide collaborate care.
15
Case 1
•Any differences during day/evening/night?
16
13 Probe - What factors determine if a patient is transferred or
cared for at CH?
e.g. Severity of illness? Staff competence? Staff confidence?
Beds available? Specific equipment needed?
RH: Do you feel pressure to accept transfer or refuse patients?
Probe:
? by patients and families
? by other staff or administration
? by tertiary hospitals
? By community hospitals
? Pressure to transfer patients or not to transfer?
Emphasis on providing feedback to colleagues at CH when a patient is transferred.
In other words, patients that staff would like to be able to keep at CH (and that it would be appropriate to keep at CH) if only staff had more training and/or confidence.
•Do you feel pressure to accept transfer or refuse patients?
•What factors determine if a patient is transferred to RH or remains at CH?
•Is there criteria you use for transfer?
Patient Flow
•Do you have the opportunity to discuss cases or debrief crises with your colleagues at CH and RH?
•Would this be valuable to you?
19
•Are there any patient types that could be cared for at CH given its resources, but that are transferred because of lack of confidence or familiarity?
Patient in CH’s ICU
14 This slide is optional depending on what comes out of the
earlier parts of the needs assessment.
Ensure scope is limited to care of critically ill patients.
Any issues or topics that we have missed?
Thank you for your participation!
•Are there any clinical tools available at CH to help as memory aids or with clinical decisions?
Standing order sets?
•If so, are they used? If not, what kinds would be most useful?
•Are there any tools at RH to help clinicians understand the context or resources at CH?
•If so, are they used? If not, what kinds would be most useful?
Clinical Tools
•Have you come across difficult situations around end of life care at CH for which you think solutions can be considered through this initiative?
•What barriers exist to improving this care?
Goals of Care / End of Life
Focus Group Facilitation Guide
Interhospital
Inter-hospital Guide
•Introductions
•Objectives
•Discuss the ICU
•Discuss patients and staff
•Explore a case scenario
15 minute break at mid point Agenda
Community Critical Care Performance and Inter- Hospital Relations Improvement Initiative
Focus Group Session
•Collaborative partners
•Input partners Introduction
Mention that this is a two-way needs assessment: data is being gathered from both RH and CH about their perception of both sites and the collaboration between them.
Consent form will be discussed at this time and completed by participants.
•Part of larger REACHout needs assessment
•Who are the investigators
•Recording & transcript only available to study investigators
•Recording & transcript are confidential; not shared with anyone at RH/CH
•Will be anonymized by person who transcribes
•Final report may quote discussion, but will identify speaker only as “nurse from RH/CH”
•Aggregate data may be submitted for publication Disclose project funding source (s)
Very briefly summarize all the sources of data that will be triangulated in this needs assessment. The focus group is one of many sources.
•To work together to improve care of patients in the Champlain LHIN
•Explore the current practices
•Explore areas of strengths and potential improvements
•Identify potential solutions and strategies for change
•To learn from your experiences, which can also help other hospitals
Needs Assessment Objectives
•Institutional Review Board
•IRB approval -Audio taping -Confidentiality -Informed consent
•Project Funding Disclosures
•Data Collection
•Interviews
•Focus groups –at CH and RH
•Family questionnaires
•On-site walk through
•Simulations
•Database
•Chart Audits
Needs Assessment Methodology
Your role as Participants
• Highlight the importance of the participants.
• Their feedback and ideas are essential to improving patient care.
• We are excited to learn from their experiences.
• We are here to work together and to learn from each other.
Our commitment
• The results will be compiled and available
• The next step will be to work together to develop a program for improvement
• The results will also help other hospitals to learn from the experiences in CH/RH and also improve their units
For group discussion.
Probes:
When does interaction occur? Only for transfers? For advice as well? For education?
How is interaction achieved? Call direct? CritiCall?
Is it easy to reach someone?
Are interactions amicable and collaborative?
Do staff from each organization understand the roles and limitations of the other?
Your Role as Participants Our Commitment
•What is your definition of a critically ill patient?
Critical Illness
•Could you please describe the interactions between CH and RH ?
•What are the strengths of this relationship?
What would need to change to improve the relationship?
Any ideas of how this could be done?
Describe how an ideal relationship would work. How is this different than present state?
What barriers to achieving this exist at each site? Regionally?
What past QI efforts have there been that involved CH and RH? Were they effective? Why or why not? What can we learn from past successes/failures?
How would group members envision an educational program for RH and/or CH? What professions would be targeted?
What would the education involve (i.e. what topics/issues?)
Case
•Do you feel that enhancing this relationship could improve the care of patients at CH? At RH?
•If so how?
•What main challenges/barriers do you see to implementing these changes?
•Has there been any collaborative educational or quality improvement initiatives with RH and CH?
•If so, who was the target, how was the education accomplished? What kind of feedback was received?
•If you were to create a program for education of professionals at CH, who would you target?
•Who would you like to have facilitate?
•If you were to create a program for education of professionals at RH, who would you target?
Description
The case will be created by the participants and subsequent flow mapping will be completed on large paper board with markers (a second person will be marking down the points while the facilitator guides the discussion). The goal of this process is to be led by the participants from
presentation/recognition to final outcomes in the
ICU/transfer. Following the cases, questions will be asked to identify strengths and weakness of the process, barriers to KT, and identify potential solutions (use a different coloured marker to identify these points). Gaps in the system, knowledge, attitudes and behavior will be explored.
Probing:
Typical patient presentations (may ask to list 3-5) Please tell me about the patient at CH?
When would RH become involved ? How would this interaction occur?
Describe the nature of your interaction / collaboration?
What happens next (go through each step)?
What if the patient is transferred?
What if the patient is not transferred?
Some areas to discuss:
What works well with this interaction?
What are challenges you face caring for these patients?
For the challenges identified:
What could be potential solutions?
How do you see these changes being made?
•Can you please describe a typical patient for whom you would provide collaborate care.
15
Case 1
•Any differences during day/evening/night?
16
Probe - What factors determine if a patient is transferred or cared for at CH?
e.g. Severity of illness? Staff competence? Staff confidence?
Beds available? Specific equipment needed?
Probe:
? by patients and families
? by other staff or adminstration
? by tertiary hospitals
? By community hospitals
? Pressure to transfer patients or not to transfer?
Emphasis on providing feedback to colleagues at CH when a patient is transferred.
In other words, patients that staff would like to be able to keep at CH (and that it would be appropriate to keep at CH) if only staff had more training and/or confidence.
•What factors determine if a patient is transferred to RH or remains at CH?
•Is there criteria you use for transfer?
Patient Flow
•CH : Do you feel pressure to transfer or keep patients?
•RH : Do you feel pressure to accept transfer or refuse patients?
•Do you have the opportunity to discuss cases or debrief crises with your colleagues at CH and RH?
•Would this be valuable to you?
19
•Are there any patient types that could be cared for at CH given its resources, but that are transferred because of lack of confidence or familiarity?
Patient in CH’s ICU
This slide is optional depending on what comes out of the earlier parts of the needs assessment.
Ensure scope is limited to care of critically ill patients.
•Have you come across difficult situations around end of life care for which you think solutions can be considered through this initiative?
•What barriers exist to improving this care?
Goals of Care / End of Life
Any issues or topics that we have missed?
Thank you for your participation!
•Are there any clinical tools available at CH to help as memory aids or with clinical decisions?
Standing order sets?
•If so, are they used? If not, what kinds would be most useful?
•Are there any tools at RH to help clinicians understand the context or resources at CH?
•If so, are they used? If not, what kinds would be most useful?
Clinical Tools
