Running head: EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

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Effects of an Education Presentation for Hospital Providers on Heart Failure and Core Measures
Beth Conway
Arizona State University

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE
Abstract
Purpose: To evaluate the effectiveness of providing education on current heart failure (HF)
guidelines and core measures documentation (CMD) for healthcare providers to improve
implementation of HF guidelines.
Background and Significance: HF affects over 5.1 million people in the United States, costing
$31 billion a year; $1.7 billion spent on Medicare readmissions within 30 days of
discharge. Guidelines and care coordination prevent expenses related to hospital readmissions
and improve quality of life for adults with HF.
Methods: Healthcare providers (HCPs) at a metropolitan hospital participated in an education
session reviewing HF treatment and CMD. Thirty participants completed the single five-point
Likert scale pre/post surveys evaluating their opinions of knowledge and behaviors toward
implementation of guidelines and CMD. Patient outcome data was abstracted measuring
pre/post education compliance for ejection fraction, ACE/ARB, beta-blocker, HF education,
follow-up appointments, aldosterone antagonist, anticoagulation, hydralazine nitrate, and CMD
30-45 day’s pre/post education. Analyses included descriptive statistics of participants and
pre/post surveys using a paired t-test. Percentage of compliance for quality measures was
completed on patients from September through December.
Results: Providers post intervention showed improved knowledge and behaviors toward
implementation of guidelines and CMD, including reconciliation of medications to statistical
significance. However, the demographics showed the majority of participants were non-cardiac
specialties. Improved compliance for outcome data of quality measures was insignificant over
time. The non-cardiac demographic may have contributed to this result.
Conclusion: The surveys did not correlate with the patient outcome data. Recommendations
would include targeting cardiac focused HCPs for future education sessions.

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Effects of an Education Presentation for Hospital Providers on Heart Failure and Core Measures
Chapter 1 Introduction
Heart failure (HF) is a common condition that develops and worsens over time. As HF
progresses, it can become more complicated and difficult for patients and providers to manage
resulting in frequent hospital admissions, which can result in high medical costs. Methods to
improve quality of care, reduce readmission rates, and reduce costs for HF patients has been
linked to implementing certain changes within the plan of care for patients. Implementing
certain changes within the plan of care could improve quality of patient care, reduce readmission
rates, and reduce costs for HF patients.
Problem Statement
HF affects approximately 5.1 million people in the United States (US) and is one of the
largest financial drains on the healthcare system (Centers for Disease Control and Prevention
[CDC], 2013). In patients 65 and older, HF is responsible for 80% of the hospital admissions,
which makes it one of the top diagnoses for hospitalizations (McClintock, Mose, & Smith,
2014). Hospital readmission within 30-days of discharge is one of the major areas where
healthcare money is spent. It is estimated that nearly 25% of patients discharged from the
hospital will be readmitted within 30-days (Feltner et al., 2014). Perceivably, part of the
readmission problem is due to poor compliance with implementing EBGs for HF related to
resistance to change (RTC) by HCPs. This inquiry has lead to the clinically relevant PICOT
question, in healthcare providers (P), how does an interprofessional (IP) collaborative approach
to implementing a HF clinical pathway (CP) (I), compared to imposed OC (C), affect RCT (O)?

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Background and Significance
Heart Failure is a highly prevalent condition associated with increased mortality,
morbidity, and healthcare costs (Heidenreich et al., 2013). Patterns of inconsistencies and
deviations in the use of evidenced based practice (EBP) for HF are responsible for increased
hospitalizations and fatal outcomes (Fonarow et al., 2011). The estimated national cost for HF
was approximately $31 billion in 2012 and is projected to cost $70 billion a year by 2030
(Heidenreich et al., 2013). In 2011, according to the Healthcare Cost and Utilization Project
(HCUP) the 30-day readmission rate for Medicare patients was approximately 134,500 for a total
cost of over $1.7 billion. Hence, evidence based strategies must be employed to safely and
effectively transition patients from the hospital back into the community to reduce the risk of
hospital readmissions.
Current practice at St. Joseph’s Hospital (SJH) implies poor compliance following the
2014 ACCF/AHA Get with the Guidelines for HF. There is approximately an 80% total
compliance rate with implementing the eight quality measures for HF throughout the hospital
and only 26% compliance completing the CMD for HF (Flynn, 2015). In effort to improve the
quality of care for HF patients and reduce the risk for hospital readmission within 30-days, SJH
implemented a HF clinical pathway (CP) based on the 2014 ACCF/AHA Get with the Guidelines
for HF, which can be found within the Cerner electronic medical record (EMR) system under
CMD.
Several individual and combined methods to reduce hospital readmission rates and
improve the quality of care for patients have been reported. Fleming and Kocioal (2014) found
through a systematic review that using evidence based guidelines (EBGs) such as those
established by the American Heart Association (AHA) in conjunction with a transitional care

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system appeared to be the most effective interventions. The use of EBGs for development of a
CP is a method used to standardize care, which promotes less variation along with transparency
for the plan of care and can be utilized in a multidisciplinary model (Vanhaecht, De Witte,
Panella, & Sermeus, 2009). Although a CP can be beneficial in reducing costs related to
variations in care, it is crucial to have the support of the providers for successful implementation
(Feinberg et al., 2012).
Search Strategy
Evidence pertaining to the proposed PICOT question was obtained by performing an
exhaustive search of the following databases: PubMed, CINAHL, Academic Search Premier,
and The Cochrane Library. Medical subject heading (MeSH) terms included: HF, healthcare,
healthcare providers, IP, multidisciplinary, collaboration, CP, critical pathway, RTC, imposed
change, and implementation. Searches were conducted breaking down the areas of the PICOT
question and combining the relative MeSH terms to gather the best data including use of the
Boolean connectors “AND” and “OR” within the search items. A five-year publication
limitation was applied to each of the databases and terms and limits were then combined pulling
the best search terms together to fulfill the entire PICOT question. In addition to the databases
used, an ancestry search was performed from some of the key articles that had a strong
correlation with the PICOT question.
PubMed
A PubMed search using the MeSH terms of HF “AND” CP “AND” healthcare providers
“AND” implementation was completed yielded 15 studies. Limits were placed on the search,
which included data within the last five years. This yielded two studies, one of which was
relevant and retained. Changing the MeSH term from healthcare providers to healthcare in

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addition to adding CP “OR” critical pathway yielded 11 studies. Finally, the Mesh terms
healthcare “OR” healthcare providers “AND” IP “OR” multidisciplinary “AND” collaboration
“AND” RTC produced 12 studies. One study was appropriate and kept.
CINAHL
The search strategy for CINAHL using the same limits with the MeSH terms healthcare
“OR” healthcare provider “AND” IP “OR” multidisciplinary “AND” collaboration yielded 326
studies. However, with the addition of HF it produced only two studies. One of those studies
was applicable and held. The MeSH term RTC required a narrower search using healthcare
“OR” healthcare provider “AND” RTC yielding 18 studies. One of the 18 studies was pertinent
and obtained.
Academic Search Premier
An exhaustive search was conducted in the Academic Search Premier database using the
keywords and limitations of articles written from 2009 to 2015. Combining the MeSH terms HF
“AND” CP “OR” critical pathway “AND” implementation “AND” healthcare yielded 11 studies.
Only one study was fitting and saved. Eliminating HF from that search and including “AND”
healthcare provider “AND” collaboration yielded six studies. Searching with the MeSH terms
healthcare “OR” healthcare provider “AND” IP “OR” multidisciplinary “AND” collaboration
produced 979 studies, which was significantly reduced with the addition of the MeSH term
“AND” shared decision making to yield 14 studies. Two studies were relevant and kept for use.
To evaluate the area of RTC, healthcare “OR” healthcare provider “AND” RTC produced 114
studies but when the additional MeSH term of collaboration was introduced, no studies were
yielded. However, RTC “AND” collaboration yielded 22 studies, which had two relevant

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studies. Finally, RTC “AND” imposed change produced 17 studies with one pertinent study
obtained.
The Cochrane Library
The Cochrane library was searched using the keywords with limits applied for methods
studies between the date ranges of 2009 to 2015. However, there were limited relative studies
retrieved. The final yields for the Cochrane library include 11 studies on HF, five for CP, and
four IP studies with the removal of the methods studies limit. Additional keywords did not yield
any relative studies. However, none of the Cochrane studies that were yielded were deemed
appropriate for use.
Based on the results from the search strategy 10 key articles were retained for critical
evaluation. Of these 10 articles, five were cross sectional studies (CSS), three case studies (CS),
one descriptive study (DS), and one was a systematic review and meta-analysis RCT, which
were placed in an evaluation table (Appendix A).
Evidence Synthesis
There were 10 articles retained for review related to this project (Appendix A & B). Of
these 10 articles, five were cross sectional studies (CSS), three case studies (CS), one descriptive
study (DS), and one was a systematic review and meta-analysis random control trial (RCT)
(Appendix B). Five of the 10 studies demonstrated level III evidence with only one study that
was level I. Three of the remaining four studies were level four and the final study was a level
six (Appendix B). The overall focus of the majority of the studies is related to OC, which was
found in eight of studies, disease and non-health related (Appendix B). The strongest of those
studies by Feltner et al. (2014), concluded that home-visiting programs and multidisciplinary HF
clinics are supported with the highest evidence for reducing readmission rates, which warrants

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significant evidence for the benefit of OC. Bias was apparent in all the US related publications,
which was most commonly related to publication or financial benefit with the exception of
Feinberg et al. (2012). The additional studies that were completed outside of the US were level
three and four CS or CSS, which had little to no bias (Appendix B).
The study populations and interventions were diverse in age, race, sex, health status, and
OC. The majority of the studies had significant heterogeneity of the demographics and
interventions (Appendix B). Only Manning et al. (2013) and Feinberg et al. (2012) were mildly
structured to a degree of homogeneity based on demographic for disease and specific
interventions. However, it is difficult to declare the validity of either of those studies because of
the lack of information on sample size and specifics regarding the studies used.
Collaboration was the strongest correlation to the desired outcomes in nine of the 10
studies, particularly when measuring RTC and patient or professional satisfaction (Appendix B).
Only half of the studies measured RTC, but all five studies found a decrease in resistance with a
collaborative team approach (Appendix B). In addition to collaboration, the use of a
multidisciplinary or IP approach in the health care setting improved outcomes for patient or
professional satisfaction and decreased RTC (Appendix B). There were limitations in measuring
the effects of OC because the 10 studies varied grossly in the nature of the demographics,
interventions, and outcomes. The majority of the measurements used were generalized surveys
or questioners, which can result in opinion, bias, and be less reliable. Statistical measurements
were generated using t-tests, Chi square test, syntagmatic analysis, realist synthesis, and
descriptive analysis.

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Purpose and Rational
The burdensome nature of HF continues to plague the healthcare system. In order to
reduce the mortality and morbidity of HF patients as well as reduce costs related to hospital
readmissions, it is imperative to make changes with patients care before they are discharged.
Change needs to begin with implementation of all the appropriate EBGs for HF including
completing documentation regarding treatment and education while the patient is still in the
acute care setting.
To have a successful organizational change, all relative parties that will be involved with
the transition process need to be aware of the purpose and benefit for the change and their role as
key stakeholders through this collaborative interaction. Enhancing the provider’s awareness
through education and collaboration can decrease RTC with compliance for implementation and
documentation. In addition, if compliance with EBGs improves it is conceivable there will be a
reduction in the 30-day readmission rates and overall healthcare costs for HF patients,
consequently improving the quality of care and life for the patient. Therefore, the purpose of this
EBP project is to evaluate the effectiveness of providing an educational presentation for HCPs on
current EBGs for HF as indicated by the AHA and completing the CMD for HF patients prior to
discharge from the acute-care setting.
Chapter 2 Applied Clinical Project: Methods & Results
This chapter will discuss the EBP model that was used to guide the project and the
Conceptual/Theoretical Model used to guide the intervention. In addition, the project methods
describing the setting, intervention, data collected, and results will be reviewed.

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EBP Model and Conceptual/Theoretical Model
EBP Model
The Model for Change to Evidence-Based Practice (MCEBP) by Rosswurm and Larrabee
(1999) was chosen to guide a scholarly project (Appendix C). This model is based on theory and
research, which is designed to direct healthcare professionals through an organized process for
change based on EBP, application of research, standardized language, and the change theory
(Rosswurm & Larrabee, 1999). The model has six components (a) assess the need for change in
practice, (b) link problem interventions and outcomes, (c) synthesize best evidence, (d) design
practice change, (e) implement and evaluate change in practice, and (f) integrate and maintain
change in practice (Rosswurm & Larrabee, 1999) (Appendix C).
Conceptual/Theoretical Model
The conceptual framework of the transitional care model (TCM) is a comprehensive inhospital and post-acute health care model utilizing a multidisciplinary team to support a smooth
transition of care from an acute care setting to their home or other care setting while promoting
positive patient outcomes and reducing health care costs (University of Pennsylvania [UP], n.d.).
The TCM incorporates 10 essential elements involving specific components relative to the care
of the patient with specific focus on collaborative and comprehensive holistic multidisciplinary
care, continuity of care, along with communication and active engagement of patients, family,
caregivers, and providers (UP, n.d.) (Appendix D). In addition, specific focus for successful use
of the TCM for this project will include (a) collaboration implementing an EBP plan of care with
the patient, family, caregivers, and HPCs, (b) education for the patient, family, and caregivers
regarding medications, and (c) scheduling a follow-up appointment prior to discharge and within
seven days of release from the hospital (Appendix D). The TCM promotes guidance for HCPs to

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follow current HF EBGs and CMD during the transitioning discharge process of HF patients.
Thus, reducing the complications post-discharge, thereby enhancing patient outcomes and
reducing the 30-day readmission rates.
Methods
Ethics and Setting
The Arizona State University IRB approved this EBP scholarly project as an expedited
review based on all of the data, documents, and records submitted (Appendix E). The setting for
this EBP project is an in-patient environment at a Level 1 metropolitan hospital in Phoenix
Arizona, which was approved by the hospital’s Chief Physician Executive (Appendix F). The
organizational culture at St. Joseph’s Hospital and Medical Center is committed to excellence by
fostering the healing ministry of Jesus, and providing compassionate, high-quality, affordable
healthcare to all patients through collaborative practice (Dignity Health website, n.d.).
Participants
The participants consisted of physician level HCPs managing HF patients in the inpatient setting. The population for the demographics included attending physicians, residents,
medical students, nurse practitioners (NPs) and physician assistants (PAs).
Intervention and Outcomes Measured
In September 2015 de-identified data was abstracted using a retrospective chart review on
in-patients with a HF diagnosis. This was performed to establish HCP compliance with
implementing eight HF quality measures as well as compliance numbers for completing the HF
CMD prior to the educational intervention. The eight quality measure outcomes that were
abstracted for assessing the pre/post intervention compliance included (a) ejection fraction, (b)
ACE/ARB, (c) beta-blocker, (d) 60-minutes of HF education, (e) follow-up appointments within

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seven days of discharge, (f) aldosterone antagonist, (g) anticoagulation, and (h) hydralazine
nitrate (Appendix G). The reliability and validity of the eight quality measure outcomes were in
accordance with the 2014 ACCF/AHA Get with the Guidelines for HF (AHA, 2014).
Staff from St. Joseph’s Hospital created an education presentation in the form of a
PowerPoint presentation on the Get with the Guidelines for Heart Failure and HF CMD, which
was designed to be a brief overview of HF and how to use the CMD (AHA, 2014) (Appendix H).
The presentation was delivered on two different occasions for the HCPs in a 60-minute
educational discussion setting. The first education session was presented in a conference room at
the Family Practice building on St. Joseph’s Hospital campus October 16, 2015 and the second
was delivered on November 17, 2015 in a conference room at St. Joseph’s Hospital. The cardiac
rehab nurse educators and the cardiology medical director conducted the presentations. A brief
personal introduction, summary about this scholarly project, and instructions regarding
participation was provided (Appendix I). This was followed by submission of a paper form
demographic sheet attached to one pre and one post education survey for the HCPs. It was
expressed that participation was completely voluntary and anonymous. The demographic
information consisted of questions regarding gender, age, employee status at the affiliated
hospital and length of employment, employee title and specialty, as well as years of practice
(Appendix J). The pre and post education surveys measuring the HCPs outcomes consisted of
seven questions and were designed to be identical. The surveys were created as a single fivepoint Likert scale evaluating the HCP’s self reported opinions of knowledge, confidence, and
behaviors toward implementation of HF guidelines and CMD (Appendix K). The surveys were
determined to have face validity as reported by two clinical experts in the field who were not
previously associated with this project.

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The demographic forms and pre-education surveys were completed prior to the
educational review, followed by the post-education surveys at the end of the presentation. The
surveys were passed to the end of each table and collected upon completion of the meeting. Deidentified data from retrospective chart reviews were continued in October and November to
assess for changes with implementation of the guidelines and CMD from the first and second
educational presentations. The final retrospective chart review was concluded December 31,
2015, which was approximately 30-45 days after the second education session.
Data Analysis
The data analysis and statistical tests were completed using IBM SPSS 22 and Excel.
Descriptive and inferential statistics were used to describe the sample and the outcome variables.
A paired t-test was used to analyze the score difference between the seven pre-post education
survey questions among the HCPs. Standard frequency analysis was performed to describe and
compare the demographics for the HCPs completing the surveys. The eight quality measure
outcomes, which included ejection fraction, ACE/ARB, beta-blocker, HF education, follow-up
appointments, aldosterone antagonist, anticoagulation, hydralazine nitrate, and CMD was
evaluated from each retrospective chart review. They were further categorized by the month
identified and imputed using Excel. The data was converted to percent values and measured for
outcome compliance and totals (Appendix G). The critical value was set at p<0.05 and a two
tailed test was used to analyze the data.
Proposed Budget
The proposed budget for implementation of this project will result in very little out of
pocket expenses to facilitate. The actual personal expense implementing this project consists of
a small amount of money to pay for printer paper to be used for the provider demographic sheet,

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surveys, and quality measures. The hospital staff has already designed the education
presentation, which resulted in no additional costs. The presentation will take less than an hour
and is to be conducted in a hospital conference room and may or may not include lunch or snacks
provided by the hospital. There will be two sessions held approximately a month apart during
normal business working hours. Having the meeting at the end of the day or lunchtime reduces
the likelihood that providers are being pulled away from seeing patients, therefore costing them
and the hospital time or money. The nurse educators are currently tracking the same pre/post
quality measure outcomes data that was used for this project daily. Hence, there will be no
additional cost for this process.
Results
Thirty HCPs (n=30) completed the surveys (Appendix J & Appendix L). Of these, 13
(43.3%) were male and 17 (56.7%) were female (Appendix L). The majority of group, 25 (83%)
was 25 to 35 years of age, 3 (10%) were less than 25 years, and 2 were 36 to 45 years of age
(Appendix L). Employment titles/positions included 0 (0%) attending physicians, 25 (83.3%)
residents, and 5 (16.7%) medical students (Appendix L). Employment specialty varied with the
highest group being Family Medicine 14 (46.7%), followed by Internal Medicine 9 (30%), 1
Hospitalist (3.3%), and other 6 (20%), which included the 5 medical students and 1 from
neurology. Finally, there were 17 (56.7%) in practice for less than a year and 13 (43.3%) from 1
to 5 years (Appendix L).
The pre and post surveys signified the HCPs (n=30) knowledge about the guidelines,
confidence to implement them, understanding the importance for completing the CMD, and
comfort level for completing CMD (Appendix K). A paired-samples t test was calculated to
compare the mean pre-test scores to the mean post-test scores. Statistically significant results

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were seen in the overall knowledge level (p=<0.001), implementation of EBGs recommendations
(p=<0.001), understanding importance of completing CMD (p=<0.001), how to access CMD in
the EMR (p=<0.001), and how to reconcile medications in the EMR (p=0.005) (Appendix M).
The eight quality measures and CMD compliance by the HCPs had the most unexpected
results with significant decline in total compliance from 80% in September, 76% in October,
73% for November, and only 68% in December (Appendix N). The worst compliance rate was
with HCPs implementing hydralazine nitrate at discharge, which had a 0% compliance rate in
September, October, and December but a 20% compliance rate for November (Appendix N).
Interestingly, the CMD compliance rates increased from 26% to 40% (Appendix N). These
overall results were lower than published statistics (Vanhaecht et al., 2009). However, an
inferential analysis was not performed on this data.
Discussion
This evidence based project evaluated if providing an educational presentation on the
current EBGs for HF and CMD would impact compliance rates with implementation of the HF
guidelines and completion of CMD in the EMR. The target populations for the educational
intervention were HCPs of HF in-patients but it was not limited to specific specialty groups,
provider level of practice, nor was it mandatory for attendance. Due to these non-specific
requirements a few barriers were met with this scholarly project. Since the sessions were not
mandatory, it was not possible to control attendance of key HCPs that would typically have the
greatest amount of interaction with HF in-patients. In addition, because participation was
voluntary and anonymous, it is not possible to decipher whom or what levels the other providers
were that attended the sessions. For this project, the information and results are based on the 30
HCPs (n=30) that attended the sessions and elected to complete in the surveys. However, there

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were approximately 30 HCPs that attended the first session with a return of 22 completed
surveys and around 15 HCPs that attended the second session in which eight surveys were
returned. It was also noted that there were no attending physicians that completed the surveys.
Perhaps this could be considered another barrier because the residents and medical students
follow by the example and leadership of the attending or higher level resident physician.
Preparation and execution of the presentation also encountered a couple barriers for both
scheduled sessions. The first barrier was met when the dates and times required changing from
the initial planning, which pushed the presentation session out by a couple months. Secondly,
when the new date and time was sent out for the first education session to the people in charge of
organizing it including the Cardiology Medical Director, the time was listed 1 hour later than the
actual scheduled time. The Cardiology Medical Director arrived at the “sent” time, which
delayed and rushed the presentation to stay on track within the time allowed. The second session
also was delayed due to technical difficulties. The disorganization for both sessions may have
caused some items to not be discussed in as much detail as was necessary and lack of focus from
the audience.
On the other hand, several things assisted with facilitating the intervention. The
presentation was put together well with excellent bullet points to focus on the main concerns and
included nice visual aids for assisting how to use and access the CMD. The Cardiology Medical
Director and nurse educators were very knowledgeable about the topic and process, which
provided a nice flow when discussing the information and answering questions from the HCPs.
In addition, there were several nice color handouts that were given to the HCPs including a
reminder card that could be attached to their badge holder for them to take and use as a prompt,
emphasizing specific important guidelines or actions.

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Changes that would be advised for use in this setting or a different setting in the future
would include mandatory attendance of one of the live sessions or creating an on-line education
tutorial. Having a tutorial might be an easy addition for the hospital because they already have
on-line education modules that are mandatory for HCPs to complete throughout the year.
Unfortunately, the results of this scholarly project did not correlate with the
literature/evidence synthesis. Specifically, the design of this project was similar to Vanhaecht et
al., (2009), which recommended using EBGs to develop a CP to standardize care and promote
less variation within a multidisciplinary model. The EBGs from the AHA was used to design the
CMD. Despite a notable 14% increase rate for completing CMD from September 2015 to
December 2015, the actual compliance implementing the guidelines into practice significantly
decreased from 80% to 68% total compliance from September 2015 to December 2015. These
results could be related to some of the barriers met with the implementation process.
Limitations
This project had a number of limitations, which may have contributed to the inconsistent
quality measure and CMD outcomes when compared to the pre/post survey and literature results.
First, the education sessions were offered as an open invitation to all levels of providers from
select specialty groups. Although there was a sign-in sheet for attendance, the sign-in sheet was
not included for this project to assist with maintaining an unidentified structure. Moreover, the
surveys were also completed anonymously. Consequently, this resulted in no definitive way to
know if the HCPs that attended and responded to the surveys were the primary providers on
admission or discharge for the HF patients whom the outcomes were measured on. In addition,
the only providers that participated were residents or medical students from non-cardiac
specialties.

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In order to capture all of key HCPs, the sessions should be mandatory for the providers
that are most frequently involved with admitting and discharging HF patients. Secondly, HCPs
that admitted and discharged the HF patients were not identified. Identifying the HCPs
associated with the care for each patient would provide transparency regarding patterns in
compliance, which would allow appropriate education interventions. Fourth, the sample size for
HCPs was fairly small with only 30 participants. Ideally, having a sample size greater than 100
would provide more strength and validity to the results (Kellar & Kelvin, 2013). Finally, the
surveys used for the pre/post test were designed to obtain the HCPs opinion. The surveys were
created using face validity for assessing measurement, which is a weaker form of measurement
because it is subjective judgment.
Chapter 3 Organizational/Health Policy Impact & Sustainability
The final chapter will discuss the impact this evidence-based scholarly project had on the
organization and the probability for sustainability of the intervention in the future.
Impact of the Project
The educational session was perceived well from the resident and student medical
providers, although there were no attending physicians or cardiac specialty providers that
participated. Although the paired-samples t test did not indicate statistical significance
(p=<0.182) in the pre/post surveys by the HCPs (n=30) for the education session being helpful, it
did imply there was some benefit (Appendix M). However, the HCPs that participated reported
improved knowledge and understanding regarding the importance of HF guidelines as well as
enhanced comprehension of how to document HF management in the EMR to statistical
significance. Interestingly, despite the results from the areas of improvement, patient quality
measures recorded during the period of the intervention trended toward worsening guideline

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compliance with improved CMD. The decline in guideline compliance by the HCPs could
potentially have impacted the health outcomes for the patients, which may have put them at risk
for hospital readmission. While follow-up data on these patients is not available for this project,
if failure to adhere to the EBGs did result in readmissions, the hospital may writhe the financial
burden associated with the this finding.
Cost/Benefit Analysis
The cost/benefit for implementation of this project had minimal out of pocket cost and
would likely result in little financial costs to another individual or the facility if the project was
replicated in a similar fashion (Appendix O). The personal expenses implementing this project
consisted of a small amount of money to pay for printer paper. This covered making the
demographic sheets and surveys for the providers along with the instruments used for the
retrospective chart reviews. The education presentation in this case was already designed by the
hospital staff but could be created at nearly no cost using PowerPoint. The presentation took less
than an hour and was completed during regular business hours for all staff. Thus, it should not
have generated additional overtime pay. The sessions were conducted in a hospital conference
room, which also did not require additional expenses to be paid out. The first session was at the
end of the workday and did not include any food. However, lunch was provided by the hospital
for the second one. Although the exact cost for lunch is not known, it could be estimated to cost
approximately $350.00 for 30 people (Appendix O). It should be noted that offering “free
lunch” did not increase attendance compared to the first session without food. In this particular
case the nurse educators track the same pre/post quality measure outcomes data that was used for
this project daily. Therefore, no additional expenses were added related to the nurse educators

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recording the quality measures data. At the end of the month, one of the educators de-identified
that data for that month and sent it for use in this project.
Impact of Current Policy
There is no specific policy at St. Joseph’s hospital regarding HCPs practice. However, it
is expected that they will follow the most current EBGs as appropriate to deliver the highest
quality of care and excellence for patients. This project promotes current EBP, which is
congruent with the expectations of the hospital. Thus, it is not expected that the results of this
project will hinder future implementation of educating HCPs. In addition, the foundation of this
project is in alignment with the expectations of the Affordable Care Act (ACA). Hospital
readmission within 30 days of discharge is one of the major areas where money is spent.
Medicaid reported 18,800 readmissions at a cost of $273 million, and approximately 3,600
uninsured people were re-hospitalized costing about $43 million (HCUP, 2011). In an effort to
improve quality of care and reduce the costs of preventable medical expenses, incentives to
reduce high hospital readmission rates have been set under the ACA (U.S. Department of Health
& Human Services [HHS], 2010). Under the ACA incentives, hospitals with Medicare patients
that have high readmission rates can lose up to 3% of their Medicare reimbursement (HHS,
2010). As a result, it is imperative for hospitals to work on reducing readmission rates to prevent
loss in hospital Medicare reimbursement.
Personal Role as Project Leader and Innovator
As the project leader, it was imperative to follow and respect the current plan of
execution for the education presentation because the key cardiac team members from the hospital
already designed it. A collaborative effort was established particularly with the cardiac rehab
nurses to assure the project would measure objectives of interest for the hospital. During this

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

21

process vigilant attention was placed on not breaching the Health Insurance Portability and
Accountability Act (HIPPA) during the course of disseminating the outcomes measures.
Moreover, it was also decided the identity of the providers that participated would remain
anonymous for this project trial. The highlighted interest for the cardiac team was to see if the
presentation would improve CMD. The theory being, if CMD improved the implementation of
current HF guidelines would also improve.
Barriers were minimal once the plan of action for the project was outlined. However,
there were two obstacles that occurred after the agreed plan for the project. First, coordinating
dates and times that worked for all parties was tricky, but fortunately as project leader being
flexible in this area was not a problem. Secondly, the key person that was providing the deidentified data for the project left the position prior to the completion of the project. After a
short exchange with the cardiac rehab nurse requesting help with what was needed to complete
the project, she was gracious enough to assist with providing the information. The role of
leadership and innovation for the success of this project was surely a collaborative effort between
all parties.
Sustainability
Moving forward this project is sustainable and has the opportunity to expand, which
would make it more accessible to all providers. The cost effectiveness of the current project
design makes it easy to continue or replicate. The presentation created by the staff was put
together exceptionally well, while maintaining focus on the major concerns and including visual
aids for assisting how to use and access the CMD. Since all the information on that PowerPoint
is the most current information, it can be reused for future sessions. Since Cardiology Medical

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

22

Director and nurse educators were primary stakeholders and champions of change for this
project, it can be expected they will be open to improving the intervention for future use.
Minor adjustment could be made to enhance the impact of the material presented to
produce more profound outcomes from the providers. Ensuring the providers that are
responsible for managing HF inpatients are present for one of the education sessions is essential
for positive results. When tracking compliance outcomes, making note of the discharging HCP
will assist with improving the outcomes. First, this information is vital for knowing the target
audience. Second, it allows for opportunities to share current AHA or CMD information with
the HCPs if compliance areas are not met. Conversely, it is an admirable way to acknowledge
the HCPs for delivering excellence in quality patient care. Finally, making the quality measure
compliance results transparent to the HCPs monthly or quarterly is a great reminder to keep up
the good work and shows areas needed for improvement.
Implications for Further Application
Implications to improve educational opportunities and outcomes would include
consideration to require mandatory attendance for the live sessions or creating an on-line
education tutorial. It is imperative to have the key HCPs that are managing the inpatient HF
patients to be fluently knowledgeable with the current HF EBGs to increase compliance rates and
ultimately to improve patient outcomes. Having an on-line option would assist in capturing all
of the necessary HCPs and could be offered to any other groups deemed appropriate. The online tutorial should be an easy addition for the hospital because they already have on-line
education modules that are mandatory for HCPs to complete throughout the year. Although
there may be an initial expense to implement the new module, they will be easy to disseminate
once in place to the appropriate HCPs annually.

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

23

Implications for future practice should include consideration of adding an NP to the HF
team to assist in providing continuing education to all HCPs and patients. A collaborative effort
from NP with the HF nurse educators and cardiology medical director would be feasible to
facilitate more latitude of leadership and educational opportunities. This joint collaboration for
care coordination of HF patients could lead to significant improvement in quality of care and
patient outcomes.
Gaps Identified
There were a few major gaps identified in this project that may have been critical to the
outcome results. First, the population of HCPs was not well controlled. It is vital to for the data
to be considered accurate to be sure the demographic population being taught the intervention
and surveyed are truly the same as the HCP population managing the patients for which the
outcomes are being measured. This was not possible to identified secondary to the unknown
identity of the attendees. In addition to an uncontrolled population receiving the intervention it
was impossible to identify if any of the attendees provided care for the HF in-patients. Again,
this addresses the importance of knowing the target population.
It is interesting that compliance completing the CMD improved overall yet the total
compliance implementing the EBGs dropped. Considering if the HCP did not go to the
education session, but they reviewed the questions in the CMD, it would have prompted the
provider to assess or deliver specific AHA EBGs for the patient. It is uncertain why this did not
occur. However, it is possible the HCPs simply did not pay attention to the questions asked and
simply completed the expected checks-offs from in the CMD. This is relevant to the work by
Feinberg et al, (2012) who noted a CP would only be useful and prevent variations in care if the
HCPs are open and supportive the change.

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

24

Conclusion
This project was an excellent start to evaluate the effectiveness of a currently in place
EBG intervention to assess areas of strength, weakness, and potential for changes. Current
recommendations and EBGs from the AHA were used to create the education presentation that
was used for the teaching intervention. The educational PowerPoint and presentation was
organized and delivered by compassionate, knowledgeable, and well-respected experts from the
field. Areas of weakness were found in the target populations that were present for the education
session. Particularly, there were no clearly identified cardiac care or senior HCPs present for
either of the presentations. Of the HCPs that participated in the education session and surveys,
more than 56% of them had less than one year of experience (Appendix L). Furthermore, having
no way to link the HCPs tending to the HF in-patients with the HCPs that attended the education
session, did not provide an accurate account for the effectiveness of the intervention.
The potential for practice change would include mandating cardiology and HF
management focused providers to participate. However, the logistics of implementing this on a
larger scale may be challenging in this setting unless there were additional options for
attendance. Future recommendations to preclude this predicament would include offering
education modules on-line or a webinar attendance. In addition, consideration for specific
physician auditing for HF compliance may identify HCPs that would benefit from additional
training.
To conclude, the significance of this project brought forth the importance to continue
bringing awareness regarding the current recommend EBGs for HF to the primary HCPs
managing acute HF in-patients. It is of the utmost importance to provide the essential care to HF
patients and educate them before they transition to an outpatient setting if they are going to be

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

25

successful at maintaining their HF to avoid hospital readmissions. Although HF will likely
continue to plague millions of Americans, it is the responsibility of the HCPs that manage the
care of these patients to help reduce the mortality and morbidity related to this condition through
good EBP.

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

26

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Fleming, L. M., & Kociol, R. D. (2014). Interventions for heart failure readmissions: Successes
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http://dx.doi.org/10.1111/j.1365-2753.2008.01068.x

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Appendix A
Table 1
Evaluation Table

Conceptual
Citation
Framework
Bradley, E. H., (2012). TCM
Contemporary evidence
about hospital
strategies for reducing
30-day readmissions
Country: US
Funding:
Commonwealth Fund;
NIA; NIH; NHLBI; &
AFAR
Bias: Self-reported
data and the risk of
overstating results such
as hospitals enrolled in
the H2H quality
improvement initiative

Design/
Method
CSS

Sample/
Setting
N=537

Purpose: to
determine the
range and
prevalence of
practice being
implemented
by hospitals to
reduce 30-day
readmissions
of PT with HF
or AMI

Demographic:
multiple
hospitals in the
US
Setting:
hospital
Inclusion:
hospitals
enrolled in
H2H located in
New Haven,
CT and
Washington,
DC as of July
2010
Exclusion:
Non-H2H
enrolled
hospitals

Major
Variables
&
Definitio
ns
IV1=QI
resources
/teams &
PM
IV2=ME
D
monitorin
g
IV3=D/C
& FU
info
DV=RR
R30

Measurement
Web-based
survey on QI
efforts and
PM, MM,
hospital
teaching status,
NSB,
discharge &
follow-up
procedures

Data
Analysis
SF
analysis
IS t-tests
Chisquare
tests

Findings
N=537 hospitals
90.4% response
rate
IV1=87%
IV2=28.9%
IV3=25.5%

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 3
Strengths:
Large sample
size, length of
time for study
almost 1 year,
high response
rate
Weakness: no
randomization,
wide variation
of
implemented
practice which
we also self
reported,
descriptive
studies,

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

31

Note. AA – African American; AFAR – American Federation for Aging Research; AHA – American Heart Association; AMI – acute
myocardial infarction; ATC – ambivalence toward change; BC - British Columbia; CB – collaboration; CC – community clinic; CHC –
community health center; CIHR – Canadian Institutes of Health Research; CBP – collaborative practice; CP – clinical pathway; CS – case
studies; cs – conversation styles; CSS – cross sectional study; CT – Connecticut; DC – direct cost; D/C – discharge; DRs – doctors; DRTC –
dispositional resistance to change; DS – descriptive study; DV – dependent variable; EA - Ecological approaches; EDR – employees
dispositional resistance to change; ETCA – employees trust in change agent; ETM – employees trust in management; FG – female; FP – family
practice; FU – follow-up; GP – general practice; H2H – hospital to home; HCS – healthcare system; HCT – healthcare team; HF – heart
failure: HS&DR – Health Services and Delivery Research; HVP - home visiting programs; ICP – integrated care pathways; IDC - indirect cost;
IL – individual learning; info – information; IP – interprofessional; IPE – interprofessional education; IPM – interprofessional model; IP-SDM
– new interprofessional model with shared decision making; IS – independent sample; IV – independent variable; IWO – identification with the
organization; MA – mean age; macro – macro level; MED – medication; meso – meso level; MG – male gender; micro – micro level; MM –
medication management; MNG – management; MT – mean tenure; MDS-HF – multidisciplinary heart failure; N – sample size (people); n –
sample size (studies); NH&NE – National Health and Nutrition Examination; NG – negotiation; NHLBI –National Heart, Lung, and Blood
Institute; NIA – National Institute on Aging; NIH – National Institute of Health; NIHR – National Institute for Health Research; NR – not
reported; NSB – number of staffed beds; OCB – outpatient clinic based; OCT – organizational change theory; OPC – out patient clinic; OPR –
Oncology Physicians Resources; Ortho – orthopedic; PA – perceived autonomy; PC – primary care; PCP – primary care physician; PE –
primarily educational; PHYS – physicians; PM – performance monitoring; PPC – per person cost; PPL – percentage point lower; PR – pooling
of resources; prev – prevalence; psych – psychiatric; PT - patient; QI – quality improvement; RB – role blurring; RCT – random control trial;
RE – race/ethnicity; R&M – readmission and mortality; RNs – nurses; RR – risk ratio; RRR30 – reduced readmission rates in 30-days; R/T –
related to; RTC – resistance to change; SA – speech acts; SDM – shared decision making; SF – standard frequency; SGM - shared governance
models; SH – stakeholder; SIC – support in change; SOE – strength of evidence; SR & MA RCT – systematic review & meta-analysis RCT;
STS – structured telephone support; SW – social worker; TCI – transitional care intervention; TCM – Transitional Care Model; TICA - trust in
change agent; TIM – trust in management; TM – telemonitoring; TPB – Theory of Planned Behavior; UK – United Kingdom; US – United
States; WHOICTRP – World Health Organization International Clinical Trials Registry Platform; y – years;

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

Citation
Feinberg, B. A., (2012).
Implementation of
cancer clinical care
pathways: A success
model of collaboration
between payers and
providers
Country: US
Funding: OPR
Bias: none noted

Conceptual
Design/
Framework
Method
OCT
DS
Purpose:
determine if
collaborative
model
between
providers and
payers to
implement a
CP affects
PHYS
behavioral
change with
compliance
in the use of
CP

Sample/
Setting
N=3
Demographics:
Private practice
medical
oncologists
Setting:
Michigan
Inclusion:
Network
oncologist from
academic-based
practices and
community
based oncology
practices
Exclusion:
outside
oncology
groups from
selected 3

Major
Variables
&
Definitions
IV1 – SH
incentives
IV2 – CP
DV –
PHYS
behavior

32

Measurement
Expected:
70%
compliance
1st year
80%
subsequent
years
Compliance
measured
through
claims using
eobONE
software tool

Data Analysis
eobONE tool
augmented
and validated
data from
insurer of pt

Findings
88% CP
compliance
1st year
95% CP 2nd
year

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 6
Strengths: >
80%
compliance
Weakness:
120 different
treatment
options were
acceptable
within the
study,
incomplete
data capture
related to
problems with
eobONE
system used,
missing or
incomplete
paper based
forms and
revenue codes

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

33

Note. AA – African American; AFAR – American Federation for Aging Research; AHA – American Heart Association; AMI – acute
myocardial infarction; ATC – ambivalence toward change; BC - British Columbia; CB – collaboration; CC – community clinic; CHC –
community health center; CIHR – Canadian Institutes of Health Research; CBP – collaborative practice; CP – clinical pathway; CS – case
studies; cs – conversation styles; CSS – cross sectional study; CT – Connecticut; DC – direct cost; D/C – discharge; DRs – doctors; DRTC –
dispositional resistance to change; DS – descriptive study; DV – dependent variable; EA - Ecological approaches; EDR – employees
dispositional resistance to change; ETCA – employees trust in change agent; ETM – employees trust in management; FG – female; FP – family
practice; FU – follow-up; GP – general practice; H2H – hospital to home; HCS – healthcare system; HCT – healthcare team; HF – heart
failure: HS&DR – Health Services and Delivery Research; HVP - home visiting programs; ICP – integrated care pathways; IDC - indirect cost;
IL – individual learning; info – information; IP – interprofessional; IPE – interprofessional education; IPM – interprofessional model; IP-SDM
– new interprofessional model with shared decision making; IS – independent sample; IV – independent variable; IWO – identification with the
organization; MA – mean age; macro – macro level; MED – medication; meso – meso level; MG – male gender; micro – micro level; MM –
medication management; MNG – management; MT – mean tenure; MDS-HF – multidisciplinary heart failure; N – sample size (people); n –
sample size (studies); NH&NE – National Health and Nutrition Examination; NG – negotiation; NHLBI –National Heart, Lung, and Blood
Institute; NIA – National Institute on Aging; NIH – National Institute of Health; NIHR – National Institute for Health Research; NR – not
reported; NSB – number of staffed beds; OCB – outpatient clinic based; OCT – organizational change theory; OPC – out patient clinic; OPR –
Oncology Physicians Resources; Ortho – orthopedic; PA – perceived autonomy; PC – primary care; PCP – primary care physician; PE –
primarily educational; PHYS – physicians; PM – performance monitoring; PPC – per person cost; PPL – percentage point lower; PR – pooling
of resources; prev – prevalence; psych – psychiatric; PT - patient; QI – quality improvement; RB – role blurring; RCT – random control trial;
RE – race/ethnicity; R&M – readmission and mortality; RNs – nurses; RR – risk ratio; RRR30 – reduced readmission rates in 30-days; R/T –
related to; RTC – resistance to change; SA – speech acts; SDM – shared decision making; SF – standard frequency; SGM - shared governance
models; SH – stakeholder; SIC – support in change; SOE – strength of evidence; SR & MA RCT – systematic review & meta-analysis RCT;
STS – structured telephone support; SW – social worker; TCI – transitional care intervention; TCM – Transitional Care Model; TICA - trust in
change agent; TIM – trust in management; TM – telemonitoring; TPB – Theory of Planned Behavior; UK – United Kingdom; US – United
States; WHOICTRP – World Health Organization International Clinical Trials Registry Platform; y – years;

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

Conceptual
Citation
Framework
Feltner, C., (2014).
TCM
Transitional care
interventions to
prevent readmissions
for persons with heart
failure
Country:
US; Spain; Germany;
UK; Canada;
Sweden; Netherlands;
Belgium; Brizil;
Hong Kong; Taiwan;
Ireland; Italy;
Australia
Funding:
Agency for
Healthcare Research
and Quality
Bias: publication bias
and selective
reporting

Design/
Method
SR & MA
RCT

Major
Variables &
Definitions
IV1 – HVP
IV2 – STS
IV3 – TM
IV4 – OCB
IV5 – PE
IV6 – MDSHF

Sample/
Setting
n=47 RCT
Demographics:
MA: 70;
Purpose: to
moderate to
assess the
severe HF
efficacy,
Setting: HVP;
comparative MDS-HF clinic
effectiveness, Inclusion: ≥
and harms of 18y with HF;
DV – 30 day
transitional
TCI; comparison readmissions
care
to usual care; ≥
interventions 30 day followto reduce
up; studies from
readmission
1990 – October
and mortality 2013; English
rates for
language;
adults
original research
hospitalized
Exclusion:
with HF
< 18y; hospital
at home
interventions;
< 30 day followup; studies
before 1990;
language other

34

Measurement
Data searches on
MEDLINE,
Cochorane,
CINAHL,
ClinicalTrials.gov,
WHOICTRP
Study selection by
2 reviewers –
RCT, English,
readmission or
mortality within 6
months
Stratified analyses
Meta-analysis
Graded SOE

Data Analysis
Categorized
interventions
DerSimonianLaird REM

Findings
47 trials
IV1 &
IV6=RRR30
& R&M
RR, 0.34
[95% CI,
0.19 to 0.62]
Both with
high
evidence
IV2=reduced
HF
readmission
only with
high
evidence
IV3, IV4,
IV5 were
insignificant

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 1
Strengths:
RCT, consistent
testing group
and variables,
use of systemic
reviews
Weakness:
publication bias
and selective
reporting, some
methodological
limitations,
heterogeneity
of outcome
measures

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

35

than English;
non-original
studies
Note. AA – African American; AFAR – American Federation for Aging Research; AHA – American Heart Association; AMI – acute
myocardial infarction; ATC – ambivalence toward change; BC - British Columbia; CB – collaboration; CC – community clinic; CHC –
community health center; CIHR – Canadian Institutes of Health Research; CBP – collaborative practice; CP – clinical pathway; CS – case
studies; cs – conversation styles; CSS – cross sectional study; CT – Connecticut; DC – direct cost; D/C – discharge; DRs – doctors; DRTC –
dispositional resistance to change; DS – descriptive study; DV – dependent variable; EA - Ecological approaches; EDR – employees
dispositional resistance to change; ETCA – employees trust in change agent; ETM – employees trust in management; FG – female; FP – family
practice; FU – follow-up; GP – general practice; H2H – hospital to home; HCS – healthcare system; HCT – healthcare team; HF – heart
failure: HS&DR – Health Services and Delivery Research; HVP - home visiting programs; ICP – integrated care pathways; IDC - indirect cost;
IL – individual learning; info – information; IP – interprofessional; IPE – interprofessional education; IPM – interprofessional model; IP-SDM
– new interprofessional model with shared decision making; IS – independent sample; IV – independent variable; IWO – identification with the
organization; MA – mean age; macro – macro level; MED – medication; meso – meso level; MG – male gender; micro – micro level; MM –
medication management; MNG – management; MT – mean tenure; MDS-HF – multidisciplinary heart failure; N – sample size (people); n –
sample size (studies); NH&NE – National Health and Nutrition Examination; NG – negotiation; NHLBI –National Heart, Lung, and Blood
Institute; NIA – National Institute on Aging; NIH – National Institute of Health; NIHR – National Institute for Health Research; NR – not
reported; NSB – number of staffed beds; OCB – outpatient clinic based; OCT – organizational change theory; OPC – out patient clinic; OPR –
Oncology Physicians Resources; Ortho – orthopedic; PA – perceived autonomy; PC – primary care; PCP – primary care physician; PE –
primarily educational; PHYS – physicians; PM – performance monitoring; PPC – per person cost; PPL – percentage point lower; PR – pooling
of resources; prev – prevalence; psych – psychiatric; PT - patient; QI – quality improvement; RB – role blurring; RCT – random control trial;
RE – race/ethnicity; R&M – readmission and mortality; RNs – nurses; RR – risk ratio; RRR30 – reduced readmission rates in 30-days; R/T –
related to; RTC – resistance to change; SA – speech acts; SDM – shared decision making; SF – standard frequency; SGM - shared governance
models; SH – stakeholder; SIC – support in change; SOE – strength of evidence; SR & MA RCT – systematic review & meta-analysis RCT;
STS – structured telephone support; SW – social worker; TCI – transitional care intervention; TCM – Transitional Care Model; TICA - trust in
change agent; TIM – trust in management; TM – telemonitoring; TPB – Theory of Planned Behavior; UK – United Kingdom; US – United
States; WHOICTRP – World Health Organization International Clinical Trials Registry Platform; y – years;

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

Citation
Heidenreich, P. A.,
(2013). Forecasting
the impact of heart
failure in the United
States: A policy
statement from the
American Heart
Association
Country: US
Funding: AHA
Bias: Sampling error
R/T estimated costs
of HF done with
survey data; human
capital approach used
to estimate indirect
costs, no account to
time value for
informal caregivers;
undervalued
morbidity costs of
none labor force; no
account for changes
in mortality or
admission rates once

Conceptual
Design/
Framework
Method
EA
CSS

Sample/
Setting
No exact
sample
Purpose: to
measurement
update &
projections
expand on
used
prior work
Setting: US
providing an HF populations
in-depth look Inclusion: HF
at how the
patients; age
changing
groups (18-44,
demographics 45-64, 65-79, ≥
in the US will 80 y); MG; FG;
impact the
RE
prevalence
Exclusion:
and cost of
other health
care for HF.
problems,
Hence, the
outside the US
need for
aggressive
prevention
and
management
of HF and its
complications

Major
Variables
&
Definitions
IV1 = age
IV2 = sex
IV3 = RE
DV1 = HF
DV2 = DC
DV3 =
IDC

36

Measurement
DV1 prev and
costs projected
estimated by
age, sex, RE
Data from
1999-2008
NH&NE
survey and US
Census Bureau
DV2&DV3
estimated with
2004-2008
MEPS

Data
Analysis
DV1=logit
regression
model with
stepwise
regressions
DV2=2-part
regression
model with
logistic
regression
model and
generalized
linear model
with gamma
distribution
DV3=MEP
S data &
negative
binomial
model

Findings
IV1=>80yrs >2
million pts with
HF
IV2=1%>in MG
IV3=greatest rise
in AA 2.8%-3.6%
from 2012-2030;
DV2=65-79 yrs
increase by 160%
from $11.50
billion to $29.93
billion

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 3
Strengths:
methodology
developed by
AHA to project
epidemiology
and future
costs of
HF did not
double count
costs for
comorbid
conditions
Weakness:
costs were
underestimated
for treating all
HF PT

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

37

HF occurred
Note. AA – African American; AFAR – American Federation for Aging Research; AHA – American Heart Association; AMI – acute
myocardial infarction; ATC – ambivalence toward change; BC - British Columbia; CB – collaboration; CC – community clinic; CHC –
community health center; CIHR – Canadian Institutes of Health Research; CBP – collaborative practice; CP – clinical pathway; CS – case
studies; cs – conversation styles; CSS – cross sectional study; CT – Connecticut; DC – direct cost; D/C – discharge; DRs – doctors; DRTC –
dispositional resistance to change; DS – descriptive study; DV – dependent variable; EA - Ecological approaches; EDR – employees
dispositional resistance to change; ETCA – employees trust in change agent; ETM – employees trust in management; FG – female; FP – family
practice; FU – follow-up; GP – general practice; H2H – hospital to home; HCS – healthcare system; HCT – healthcare team; HF – heart
failure: HS&DR – Health Services and Delivery Research; HVP - home visiting programs; ICP – integrated care pathways; IDC - indirect cost;
IL – individual learning; info – information; IP – interprofessional; IPE – interprofessional education; IPM – interprofessional model; IP-SDM
– new interprofessional model with shared decision making; IS – independent sample; IV – independent variable; IWO – identification with the
organization; MA – mean age; macro – macro level; MED – medication; meso – meso level; MG – male gender; micro – micro level; MM –
medication management; MNG – management; MT – mean tenure; MDS-HF – multidisciplinary heart failure; N – sample size (people); n –
sample size (studies); NH&NE – National Health and Nutrition Examination; NG – negotiation; NHLBI –National Heart, Lung, and Blood
Institute; NIA – National Institute on Aging; NIH – National Institute of Health; NIHR – National Institute for Health Research; NR – not
reported; NSB – number of staffed beds; OCB – outpatient clinic based; OCT – organizational change theory; OPC – out patient clinic; OPR –
Oncology Physicians Resources; Ortho – orthopedic; PA – perceived autonomy; PC – primary care; PCP – primary care physician; PE –
primarily educational; PHYS – physicians; PM – performance monitoring; PPC – per person cost; PPL – percentage point lower; PR – pooling
of resources; prev – prevalence; psych – psychiatric; PT - patient; QI – quality improvement; RB – role blurring; RCT – random control trial;
RE – race/ethnicity; R&M – readmission and mortality; RNs – nurses; RR – risk ratio; RRR30 – reduced readmission rates in 30-days; R/T –
related to; RTC – resistance to change; SA – speech acts; SDM – shared decision making; SF – standard frequency; SGM - shared governance
models; SH – stakeholder; SIC – support in change; SOE – strength of evidence; SR & MA RCT – systematic review & meta-analysis RCT;
STS – structured telephone support; SW – social worker; TCI – transitional care intervention; TCM – Transitional Care Model; TICA - trust in
change agent; TIM – trust in management; TM – telemonitoring; TPB – Theory of Planned Behavior; UK – United Kingdom; US – United
States; WHOICTRP – World Health Organization International Clinical Trials Registry Platform; y – years;

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

Citation
Legare, F., (2011).
Interprofessionalism
and shared decisionmaking in primary
care: A stepwise
approach towards a
new model
Country: US; Canada;
UK
Funding: CIHR
Bias: none noted

Conceptual
Design/
Framework
Method
IPM
CSS
Purpose
proposal of a
new model
for an IP
approach to a
SDM in PC
called IPSDM model

Sample/
Setting
N = 3231
n =38
Demographics:
PHYS; RNs; pt;
Setting: PC
Inclusion: 18
SDM concepts,
10 IP concepts,
2 open key
concepts

Major Variables
&
Definitions
IV1 = micro
(individual HCS
level)
IV2 = macro
(2 level HCS –
health policies,
social context,
& professional
organization)
IV3 = meso
(2 level HCS –
healthcare team
&
organizations)
DV1 = IP-SDM
model
DV2 = pt
Inclusion:
SDM model
defined as
decision making
between the pt
and provider;
describes the
concepts used;

38

Measurement
Review of 3
systematic
reviews on
SDM

Data
Analysis
Evaluation
of 38
studies to
create a
new IPSDM
model for
PC

Findings
IP-SDM for
PC has
potential to
unify the
process of
SDM in
different
HCS
Necessary
for HCT to
share
knowledge
and be
involved
throughout
the decision
making
process

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 3
Strengths:
systematic
reviews used,
various
professions
and
disciplines, 3
countries
participated
Weakness:
largely
weighted by
physicians as
participants
89% which
lacked
interprofessio
nal
perspective

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

39

indicates the
relationship
between
concepts
Exclusion: any
concepts
outside the 3
key ones
Note. AA – African American; AFAR – American Federation for Aging Research; AHA – American Heart Association; AMI – acute
myocardial infarction; ATC – ambivalence toward change; BC - British Columbia; CB – collaboration; CC – community clinic; CHC –
community health center; CIHR – Canadian Institutes of Health Research; CBP – collaborative practice; CP – clinical pathway; CS – case
studies; cs – conversation styles; CSS – cross sectional study; CT – Connecticut; DC – direct cost; D/C – discharge; DRs – doctors; DRTC –
dispositional resistance to change; DS – descriptive study; DV – dependent variable; EA - Ecological approaches; EDR – employees
dispositional resistance to change; ETCA – employees trust in change agent; ETM – employees trust in management; FG – female; FP – family
practice; FU – follow-up; GP – general practice; H2H – hospital to home; HCS – healthcare system; HCT – healthcare team; HF – heart
failure: HS&DR – Health Services and Delivery Research; HVP - home visiting programs; ICP – integrated care pathways; IDC - indirect cost;
IL – individual learning; info – information; IP – interprofessional; IPE – interprofessional education; IPM – interprofessional model; IP-SDM
– new interprofessional model with shared decision making; IS – independent sample; IV – independent variable; IWO – identification with the
organization; MA – mean age; macro – macro level; MED – medication; meso – meso level; MG – male gender; micro – micro level; MM –
medication management; MNG – management; MT – mean tenure; MDS-HF – multidisciplinary heart failure; N – sample size (people); n –
sample size (studies); NH&NE – National Health and Nutrition Examination; NG – negotiation; NHLBI –National Heart, Lung, and Blood
Institute; NIA – National Institute on Aging; NIH – National Institute of Health; NIHR – National Institute for Health Research; NR – not
reported; NSB – number of staffed beds; OCB – outpatient clinic based; OCT – organizational change theory; OPC – out patient clinic; OPR –
Oncology Physicians Resources; Ortho – orthopedic; PA – perceived autonomy; PC – primary care; PCP – primary care physician; PE –
primarily educational; PHYS – physicians; PM – performance monitoring; PPC – per person cost; PPL – percentage point lower; PR – pooling
of resources; prev – prevalence; psych – psychiatric; PT - patient; QI – quality improvement; RB – role blurring; RCT – random control trial;
RE – race/ethnicity; R&M – readmission and mortality; RNs – nurses; RR – risk ratio; RRR30 – reduced readmission rates in 30-days; R/T –
related to; RTC – resistance to change; SA – speech acts; SDM – shared decision making; SF – standard frequency; SGM - shared governance
models; SH – stakeholder; SIC – support in change; SOE – strength of evidence; SR & MA RCT – systematic review & meta-analysis RCT;
STS – structured telephone support; SW – social worker; TCI – transitional care intervention; TCM – Transitional Care Model; TICA - trust in

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

40

change agent; TIM – trust in management; TM – telemonitoring; TPB – Theory of Planned Behavior; UK – United Kingdom; US – United
States; WHOICTRP – World Health Organization International Clinical Trials Registry Platform; y – years;

Citation
Manning, B. T.,
(2013).
The orthopaedic
forum: Overcoming
resistance to
implementation of
integrated care
pathways in
orthopaedics
Country: US
Funding: none
Bias: a few of the
authors had a
financial relationship
with their institution
with an entity in the
biomedical arena
and a couple of
authors have had
another relationship
or engaged in
activity that could

Major
Variables
Conceptual
Design/
Sample/
&
Framework
Method
Setting
Definitions
OCT
CS
Demographics: IV1 = PA
Ortho PHYS;
IV2 =
resources
Purpose:
Setting:
recommendation hospital and
IV3 =
to prevent
office
incentives
orthopaedic
IV4 =
Inclusion and
surgeon
Exclusion: NR forcing
resistance to
ICP
DV1 =
RTC

Data
Measurement
Analysis
Findings
Review of
Comparison IV1&IV2
various
of multiple Promote CB and
studies
studies
provide
regarding
incentives
PHYS
DV1=reduced
resistance
RTC
to ICP to
formulate
best
approach to
prevent
resistance

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 4
Strengths:
proposal for
ICPs and
methods to
reduce RTC is
supported by
literature
Weakness:
Studies used
to support
theory do not
indicate level
of study. No
RCTs

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

41

have influenced their
written work
Note. AA – African American; AFAR – American Federation for Aging Research; AHA – American Heart Association; AMI – acute
myocardial infarction; ATC – ambivalence toward change; BC - British Columbia; CB – collaboration; CC – community clinic; CHC –
community health center; CIHR – Canadian Institutes of Health Research; CBP – collaborative practice; CP – clinical pathway; CS – case
studies; cs – conversation styles; CSS – cross sectional study; CT – Connecticut; DC – direct cost; D/C – discharge; DRs – doctors; DRTC –
dispositional resistance to change; DS – descriptive study; DV – dependent variable; EA - Ecological approaches; EDR – employees
dispositional resistance to change; ETCA – employees trust in change agent; ETM – employees trust in management; FG – female; FP – family
practice; FU – follow-up; GP – general practice; H2H – hospital to home; HCS – healthcare system; HCT – healthcare team; HF – heart
failure: HS&DR – Health Services and Delivery Research; HVP - home visiting programs; ICP – integrated care pathways; IDC - indirect cost;
IL – individual learning; info – information; IP – interprofessional; IPE – interprofessional education; IPM – interprofessional model; IP-SDM
– new interprofessional model with shared decision making; IS – independent sample; IV – independent variable; IWO – identification with the
organization; MA – mean age; macro – macro level; MED – medication; meso – meso level; MG – male gender; micro – micro level; MM –
medication management; MNG – management; MT – mean tenure; MDS-HF – multidisciplinary heart failure; N – sample size (people); n –
sample size (studies); NH&NE – National Health and Nutrition Examination; NG – negotiation; NHLBI –National Heart, Lung, and Blood
Institute; NIA – National Institute on Aging; NIH – National Institute of Health; NIHR – National Institute for Health Research; NR – not
reported; NSB – number of staffed beds; OCB – outpatient clinic based; OCT – organizational change theory; OPC – out patient clinic; OPR –
Oncology Physicians Resources; Ortho – orthopedic; PA – perceived autonomy; PC – primary care; PCP – primary care physician; PE –
primarily educational; PHYS – physicians; PM – performance monitoring; PPC – per person cost; PPL – percentage point lower; PR – pooling
of resources; prev – prevalence; psych – psychiatric; PT - patient; QI – quality improvement; RB – role blurring; RCT – random control trial;
RE – race/ethnicity; R&M – readmission and mortality; RNs – nurses; RR – risk ratio; RRR30 – reduced readmission rates in 30-days; R/T –
related to; RTC – resistance to change; SA – speech acts; SDM – shared decision making; SF – standard frequency; SGM - shared governance
models; SH – stakeholder; SIC – support in change; SOE – strength of evidence; SR & MA RCT – systematic review & meta-analysis RCT;
STS – structured telephone support; SW – social worker; TCI – transitional care intervention; TCM – Transitional Care Model; TICA - trust in
change agent; TIM – trust in management; TM – telemonitoring; TPB – Theory of Planned Behavior; UK – United Kingdom; US – United
States; WHOICTRP – World Health Organization International Clinical Trials Registry Platform; y – years;

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

Citation
Mickan, S., (2010).
Collaborative
practice in a global
health context:
Common themes
from developing
countries
Country: UK;
Canada; Oman;
Slovenia; Sweden;
Thailand; Denmark;
India; Japan; Napal
Funding: none
Bias: none noted

Conceptual
Framework
EA

Major
Variables
Design/
Sample/
&
Method
Setting
Definitions
CS
n=10
IV1 =
Purpose:
Demographics: SGM
explore
DRs; RNs; pts; IV2 = IPE
common
dentists; SW
DV =CBP
themes of
Setting: FP
collaborative urban; GP
practice
urban; psych
hospital semiurban; hospital;
CHC urban; CC
rural; OPC
urban;
Inclusion: case
studies, diverse
geographical
organizations
focused on PC,
English and
non-English
speaking,
collaborative
practice
Exclusion:
answers that did
not fit their

42

Measurement
Short
questioner
with open
ended
questions

Data
Analysis
Descriptive
analysis
guided by
definitions
of CB
practice

Findings
CB practice
encourage team
working across
sectors; need for
good MNG &
leadership, IPE

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 4
Strengths:
case studies
were
consistent
with research
literature
from
developed
and
developing
countries,
global study
Weakness:
all
information
pulled from
one
organization

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

43

definition of
collaborative
practice
Note. AA – African American; AFAR – American Federation for Aging Research; AHA – American Heart Association; AMI – acute
myocardial infarction; ATC – ambivalence toward change; BC - British Columbia; CB – collaboration; CC – community clinic; CHC –
community health center; CIHR – Canadian Institutes of Health Research; CBP – collaborative practice; CP – clinical pathway; CS – case
studies; cs – conversation styles; CSS – cross sectional study; CT – Connecticut; DC – direct cost; D/C – discharge; DRs – doctors; DRTC –
dispositional resistance to change; DS – descriptive study; DV – dependent variable; EA - Ecological approaches; EDR – employees
dispositional resistance to change; ETCA – employees trust in change agent; ETM – employees trust in management; FG – female; FP – family
practice; FU – follow-up; GP – general practice; H2H – hospital to home; HCS – healthcare system; HCT – healthcare team; HF – heart
failure: HS&DR – Health Services and Delivery Research; HVP - home visiting programs; ICP – integrated care pathways; IDC - indirect cost;
IL – individual learning; info – information; IP – interprofessional; IPE – interprofessional education; IPM – interprofessional model; IP-SDM
– new interprofessional model with shared decision making; IS – independent sample; IV – independent variable; IWO – identification with the
organization; MA – mean age; macro – macro level; MED – medication; meso – meso level; MG – male gender; micro – micro level; MM –
medication management; MNG – management; MT – mean tenure; MDS-HF – multidisciplinary heart failure; N – sample size (people); n –
sample size (studies); NH&NE – National Health and Nutrition Examination; NG – negotiation; NHLBI –National Heart, Lung, and Blood
Institute; NIA – National Institute on Aging; NIH – National Institute of Health; NIHR – National Institute for Health Research; NR – not
reported; NSB – number of staffed beds; OCB – outpatient clinic based; OCT – organizational change theory; OPC – out patient clinic; OPR –
Oncology Physicians Resources; Ortho – orthopedic; PA – perceived autonomy; PC – primary care; PCP – primary care physician; PE –
primarily educational; PHYS – physicians; PM – performance monitoring; PPC – per person cost; PPL – percentage point lower; PR – pooling
of resources; prev – prevalence; psych – psychiatric; PT - patient; QI – quality improvement; RB – role blurring; RCT – random control trial;
RE – race/ethnicity; R&M – readmission and mortality; RNs – nurses; RR – risk ratio; RRR30 – reduced readmission rates in 30-days; R/T –
related to; RTC – resistance to change; SA – speech acts; SDM – shared decision making; SF – standard frequency; SGM - shared governance
models; SH – stakeholder; SIC – support in change; SOE – strength of evidence; SR & MA RCT – systematic review & meta-analysis RCT;
STS – structured telephone support; SW – social worker; TCI – transitional care intervention; TCM – Transitional Care Model; TICA - trust in
change agent; TIM – trust in management; TM – telemonitoring; TPB – Theory of Planned Behavior; UK – United Kingdom; US – United
States; WHOICTRP – World Health Organization International Clinical Trials Registry Platform; y – years;

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

Citation
Oreg, S.,
(2011).
Ambivalence
toward
imposed
change: The
conflict
between
dispositional
resistance to
change and the
orientation
toward the
change agent
Country:
Israel
Funding:
partial funding
by The Open
University of
Israel
Research Fund
Bias: none
noted

Conceptual
Design/
Framework
Method
TPB
CSS
Purpose: to
determine if
how
employees
feel about
the concept
of change
and how
they feel
about the
change
agent yield
ambivalence
toward
change

Sample/
Setting
N1 = 172
MG = 88%
MNG = 54%
MA = 42.57
MT = 13.89
DRTC =3.20
TIM = 3.84
ATC = 1.49
N2 = 104
FG = 66%
MA = 39.65
DRTC = 2.95
ATC =2.85
N3 = 89
MG= 49%
FG = 42%
MA = 45
MT = 2.27
DRTC = 3.18
TICA = 2.53
ATC = 3.47
SIC = 2.34
Demographics:

Major
Variables &
Definitions
IV1 = EDR
IV2 = ETM
IV3=IWO
IV4=ETCA
DV1 = ATC
DV2=DRTC

Measurement
N1=survey
DRTC
scale=Cronbach’s
alpha coefficient
0.86
ETM scale=0.92
ATC scale=pos or
neg ambivalence
N2=questionnaires
DRTC
scale=Cronbach’s
alpha 0.88
IWO scale=0.87
ATC scale=0.85
N3=questionnaires
DRTC
scale=Cronbach’s
alpha 0.90
ETCA scale=0.92
ATC scale=0.86

44

Data Analysis
Descriptive
statistics; t-test
used to
compare the
groups

Findings
N1=descriptive
stats; simple
slope=0.50,
t(170)=2.79, p<0.1
relationship btw
DRTC and ATC not
sig different
N2=descriptive stat;
relationship btw
DRTC & ATC was
pos for high IWO;
simple slope=0.79,
t(104)=2.99,
p<0.01; low IWO
was neg simple
slope= -0.49,
t(104)=1.67,
p<0.05; statistically
sig
N3=descriptive stat;
relationship btw
DRTC & ATC with
high trust simple
slope=0.54,
t(89)=2.72, p<0.01;

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 3
Strengths:
ample sample
size, each
study was
measured by
descriptive
statistics
Weakness:
data was
collected
from a single
source with
the same
survey
methodology

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

employees from
a defense
industry
undergoing a
merger;
Setting:
defense
industry;
electric
company
Inclusion: data
from a defense
industry
collected
several months
into the change
measuring
dispositional
RTC, TIM,
DRTC,
identification
with the
organization,
TICA, and
ambivalence
Exclusion:
information
from people
outside the
defense
industry

45

DRTC & ATC low
trust simple slope=
- 0.36, t(89)=-2.04,
p<0.05;
Polynomial
regression analysis
to test hypothesis 2
B=-0.24, p<0.05

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

46

Note. AA – African American; AFAR – American Federation for Aging Research; AHA – American Heart Association; AMI – acute
myocardial infarction; ATC – ambivalence toward change; BC - British Columbia; CB – collaboration; CC – community clinic; CHC –
community health center; CIHR – Canadian Institutes of Health Research; CBP – collaborative practice; CP – clinical pathway; CS – case
studies; cs – conversation styles; CSS – cross sectional study; CT – Connecticut; DC – direct cost; D/C – discharge; DRs – doctors; DRTC –
dispositional resistance to change; DS – descriptive study; DV – dependent variable; EA - Ecological approaches; EDR – employees
dispositional resistance to change; ETCA – employees trust in change agent; ETM – employees trust in management; FG – female; FP – family
practice; FU – follow-up; GP – general practice; H2H – hospital to home; HCS – healthcare system; HCT – healthcare team; HF – heart
failure: HS&DR – Health Services and Delivery Research; HVP - home visiting programs; ICP – integrated care pathways; IDC - indirect cost;
IL – individual learning; info – information; IP – interprofessional; IPE – interprofessional education; IPM – interprofessional model; IP-SDM
– new interprofessional model with shared decision making; IS – independent sample; IV – independent variable; IWO – identification with the
organization; MA – mean age; macro – macro level; MED – medication; meso – meso level; MG – male gender; micro – micro level; MM –
medication management; MNG – management; MT – mean tenure; MDS-HF – multidisciplinary heart failure; N – sample size (people); n –
sample size (studies); NH&NE – National Health and Nutrition Examination; NG – negotiation; NHLBI –National Heart, Lung, and Blood
Institute; NIA – National Institute on Aging; NIH – National Institute of Health; NIHR – National Institute for Health Research; NR – not
reported; NSB – number of staffed beds; OCB – outpatient clinic based; OCT – organizational change theory; OPC – out patient clinic; OPR –
Oncology Physicians Resources; Ortho – orthopedic; PA – perceived autonomy; PC – primary care; PCP – primary care physician; PE –
primarily educational; PHYS – physicians; PM – performance monitoring; PPC – per person cost; PPL – percentage point lower; PR – pooling
of resources; prev – prevalence; psych – psychiatric; PT - patient; QI – quality improvement; RB – role blurring; RCT – random control trial;
RE – race/ethnicity; R&M – readmission and mortality; RNs – nurses; RR – risk ratio; RRR30 – reduced readmission rates in 30-days; R/T –
related to; RTC – resistance to change; SA – speech acts; SDM – shared decision making; SF – standard frequency; SGM - shared governance
models; SH – stakeholder; SIC – support in change; SOE – strength of evidence; SR & MA RCT – systematic review & meta-analysis RCT;
STS – structured telephone support; SW – social worker; TCI – transitional care intervention; TCM – Transitional Care Model; TICA - trust in
change agent; TIM – trust in management; TM – telemonitoring; TPB – Theory of Planned Behavior; UK – United Kingdom; US – United
States; WHOICTRP – World Health Organization International Clinical Trials Registry Platform; y – years;

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

Citation
Pieterse, J. H.,
(2012).
Professional
discourses and
resistance to
change
Country: The
Netherlands
Funding: none
noted
Bias: none noted

Conceptual
Design/
Framework
Method
OCT
CS
Purpose: to
investigate how
RTC might be a
consequence of
differences in
professional
discourse of
professional
groups working
together in a
change program

Sample/
Setting
N=27
Demographics
: technical
department
employees
including MNG
& shop floor
staff working
together in a
change program
Setting:
technical
department of a
European
airline
Inclusion:
European
airline,
employees of
the technical
department that
were introduced
to the ICT
system (TRAX)
Exclusion:

Major
Variables
&
Definitions
IV1 = SA
IV2 = cs
IV3 = NG
DV = RTC

47

Measurement
Semistructured
interviews
Desk
research
Observation
of team

Data
Analysis
Qualitative
research
design
Syntgmatic
analysis
using
WordSmith

Findings
IV1=lack of
reflection with
assertive speech vs
general caused
deterioration in the
group
IV2=scorning in
conversation lead to
closed conversations
IV3=formal
conversations showed
cooperative styles –
informal setting
identified noncooperative

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 4
Strengths:
simultaneous
use of
different
discourse
measurement
tools
Weakness:
formal
discourse
analysis was
based on
transcripts
from only two
sessions,
selection of
utterances in
the discourse
analysis was
somewhat
subjective

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

48

other
departments
from the airline
Note. AA – African American; AFAR – American Federation for Aging Research; AHA – American Heart Association; AMI – acute
myocardial infarction; ATC – ambivalence toward change; BC - British Columbia; CB – collaboration; CC – community clinic; CHC –
community health center; CIHR – Canadian Institutes of Health Research; CBP – collaborative practice; CP – clinical pathway; CS – case
studies; cs – conversation styles; CSS – cross sectional study; CT – Connecticut; DC – direct cost; D/C – discharge; DRs – doctors; DRTC –
dispositional resistance to change; DS – descriptive study; DV – dependent variable; EA - Ecological approaches; EDR – employees
dispositional resistance to change; ETCA – employees trust in change agent; ETM – employees trust in management; FG – female; FP – family
practice; FU – follow-up; GP – general practice; H2H – hospital to home; HCS – healthcare system; HCT – healthcare team; HF – heart
failure: HS&DR – Health Services and Delivery Research; HVP - home visiting programs; ICP – integrated care pathways; IDC - indirect cost;
IL – individual learning; info – information; IP – interprofessional; IPE – interprofessional education; IPM – interprofessional model; IP-SDM
– new interprofessional model with shared decision making; IS – independent sample; IV – independent variable; IWO – identification with the
organization; MA – mean age; macro – macro level; MED – medication; meso – meso level; MG – male gender; micro – micro level; MM –
medication management; MNG – management; MT – mean tenure; MDS-HF – multidisciplinary heart failure; N – sample size (people); n –
sample size (studies); NH&NE – National Health and Nutrition Examination; NG – negotiation; NHLBI –National Heart, Lung, and Blood
Institute; NIA – National Institute on Aging; NIH – National Institute of Health; NIHR – National Institute for Health Research; NR – not
reported; NSB – number of staffed beds; OCB – outpatient clinic based; OCT – organizational change theory; OPC – out patient clinic; OPR –
Oncology Physicians Resources; Ortho – orthopedic; PA – perceived autonomy; PC – primary care; PCP – primary care physician; PE –
primarily educational; PHYS – physicians; PM – performance monitoring; PPC – per person cost; PPL – percentage point lower; PR – pooling
of resources; prev – prevalence; psych – psychiatric; PT - patient; QI – quality improvement; RB – role blurring; RCT – random control trial;
RE – race/ethnicity; R&M – readmission and mortality; RNs – nurses; RR – risk ratio; RRR30 – reduced readmission rates in 30-days; R/T –
related to; RTC – resistance to change; SA – speech acts; SDM – shared decision making; SF – standard frequency; SGM - shared governance
models; SH – stakeholder; SIC – support in change; SOE – strength of evidence; SR & MA RCT – systematic review & meta-analysis RCT;
STS – structured telephone support; SW – social worker; TCI – transitional care intervention; TCM – Transitional Care Model; TICA - trust in
change agent; TIM – trust in management; TM – telemonitoring; TPB – Theory of Planned Behavior; UK – United Kingdom; US – United
States; WHOICTRP – World Health Organization International Clinical Trials Registry Platform; y – years;

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

Major
Variables
Conceptual
Design/
Sample/
&
Citation
Framework
Method
Setting
Definitions
Sims, S., (2014).
IPM
CSS
n=109
IV1 = CB
Evidence of
Demographics: IV2 = PR
collaboration, pooling of
Purpose: to professionals
IV3 = IL
resources, learning and
help policy
working in a
IV4 = RB
role blurring in
makers and
team setting in
DV = IPinterprofessional
practitioners a collaborative HCT
healthcare teams: A
“make
and cooperative
realist syntheses
sense” of a
manner
Country: UK
complex
Setting:
Funding: NIHR &
intervention hospital &
HS&DR
and help
home
Bias: none noted
resolve
Inclusion:
unexplained literature search
variation in
with AMED,
intervention CINAHL,
effectiveness MEDLINE,
IBSS,
electronic
health and
social care
databases
HMIC,
Psychinfo,
ASSIA, and
Scopus

49

Measurement
8 databases
AMED,
CINAHL
MEDLINE
IBSS
HMIC
Psychinfo
ASSIA
Scopus
Inclusion
criteria of
interprofessional
teamworking
(collaboration,
coordination,
pooling of
resources,
individual
learning, role
blurring)

Data
Analysis
Realist
synthesis
was
exhausted
until no
new
evidence
was
found

Findings
IV1 – n=47
CB built
trust and respect
promoting
confidence in
colleagues abilities;
role clarity;
reinforced team
goals helped
problem solve
IV2 – n=23
PR improved
problem solving;
IV3 – n=15
IL promoted by
interaction to learn
from each other in
meetings
IV4 – n=24
Sharing other team
members
knowledge gained
greater individual
expertise and
confidence

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 3
Strengths:
ample sample
size and data
bases used
with
exhausted
research
Weakness:
evidence for
individual
learning

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

50

Exclusion:
papers and
information that
did not include
collaboration,
coordination,
pooling of
resources,
individual
learning or role
blurring
Note. AA – African American; AFAR – American Federation for Aging Research; AHA – American Heart Association; AMI – acute
myocardial infarction; ATC – ambivalence toward change; BC - British Columbia; CB – collaboration; CC – community clinic; CHC –
community health center; CIHR – Canadian Institutes of Health Research; CBP – collaborative practice; CP – clinical pathway; CS – case
studies; cs – conversation styles; CSS – cross sectional study; CT – Connecticut; DC – direct cost; D/C – discharge; DRs – doctors; DRTC –
dispositional resistance to change; DS – descriptive study; DV – dependent variable; EA - Ecological approaches; EDR – employees
dispositional resistance to change; ETCA – employees trust in change agent; ETM – employees trust in management; FG – female; FP – family
practice; FU – follow-up; GP – general practice; H2H – hospital to home; HCS – healthcare system; HCT – healthcare team; HF – heart
failure: HS&DR – Health Services and Delivery Research; HVP - home visiting programs; ICP – integrated care pathways; IDC - indirect cost;
IL – individual learning; info – information; IP – interprofessional; IPE – interprofessional education; IPM – interprofessional model; IP-SDM
– new interprofessional model with shared decision making; IS – independent sample; IV – independent variable; IWO – identification with the
organization; MA – mean age; macro – macro level; MED – medication; meso – meso level; MG – male gender; micro – micro level; MM –
medication management; MNG – management; MT – mean tenure; MDS-HF – multidisciplinary heart failure; N – sample size (people); n –
sample size (studies); NH&NE – National Health and Nutrition Examination; NG – negotiation; NHLBI –National Heart, Lung, and Blood
Institute; NIA – National Institute on Aging; NIH – National Institute of Health; NIHR – National Institute for Health Research; NR – not
reported; NSB – number of staffed beds; OCB – outpatient clinic based; OCT – organizational change theory; OPC – out patient clinic; OPR –
Oncology Physicians Resources; Ortho – orthopedic; PA – perceived autonomy; PC – primary care; PCP – primary care physician; PE –
primarily educational; PHYS – physicians; PM – performance monitoring; PPC – per person cost; PPL – percentage point lower; PR – pooling
of resources; prev – prevalence; psych – psychiatric; PT - patient; QI – quality improvement; RB – role blurring; RCT – random control trial;
RE – race/ethnicity; R&M – readmission and mortality; RNs – nurses; RR – risk ratio; RRR30 – reduced readmission rates in 30-days; R/T –
related to; RTC – resistance to change; SA – speech acts; SDM – shared decision making; SF – standard frequency; SGM - shared governance

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

51

models; SH – stakeholder; SIC – support in change; SOE – strength of evidence; SR & MA RCT – systematic review & meta-analysis RCT;
STS – structured telephone support; SW – social worker; TCI – transitional care intervention; TCM – Transitional Care Model; TICA - trust in
change agent; TIM – trust in management; TM – telemonitoring; TPB – Theory of Planned Behavior; UK – United Kingdom; US – United
States; WHOICTRP – World Health Organization International Clinical Trials Registry Platform; y – years;

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

52

Appendix B
Synthesis Table
Bradley
2012
CSS

Feinberg
2012
DS

Feltner
2014
SR &
MA
RCT

Heidenreich
2013
CSS

Legara
2011
CSS

Manning
2013
CS

Mickan
2010
CS

Oreg
2011
CSS

Pietrerse
2012
CS

Sims
2014
CSS

N=people
n=studies

N=599

UNK

n=47

UNK

N=3231
n=38

UNK

n=10

N=27

n=109

LOE
Demographics
HF
Other Dz
Non-Healthcare
OC
Interventions
Written protocol
MED monitoring
F/U scheduled
before d/c
CP
MDS-HFC
TCC
STS
HVP
Interprofessional
or
Multidisciplinary
Collaboration
OTC
Outcomes
Reduced 30-day
Readmissions
Cost increase
Cost decrease
Decrease RTC
Improve patient
satisfaction
Improve
professionals
satisfaction

III

VI

I

III

III

IV

IV

N=172
N=104
N=89
III

IV

III

X
X

X

X

X

X

X

X

X

X

X

X

X
X

X
X

X
X

X
X
X

X
X

X
X

X

X

Year
Design

X

X

X

X

X

X
X

X

X

X
X
X
X
X
X

X

X

X

X

X

X
X

X
X

X
X

X
X

X
X

X
X

X
X

X

X

X

X

X

X
X

X

X

X

X

X

X

X

X
X
X

X

X

X

X

Note: CP – clinical pathway; CS – case study; CSS – cross sectional study; D/C –
discharge; DS – descriptive study; Dz – disease; F/U – follow up; HF – heart failure; HVP –
home visiting programs; LOE – level of evidence; RCT – resistance to change; MED –
medication; MDS-HFC – multidisciplinary heart failure clinic; N – sample size (people); n –
sample size (studies); OC – organizational change; OTC – orientation toward change; PCP
– primary care physician; SR&MA RCT - systematic review & meta-analysis RCT; STS –
structured telephone support; TCC – transitional care center; UNK – unknown

X

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE
Appendix C
EBP Model: Rosswurm and Larrabee – Model for Change to EBP

53

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

Appendix D
Conceptual Framework

54

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE
Appendix E
IRB Approval Letter

APPROVAL: EXPEDITED REVIEW
Monica Rauton
CONHI - DNP
928/639-7242
monica.rauton@asu.edu
Dear Monica Rauton:
On 9/8/2015 the ASU IRB reviewed the following protocol:
Type of Review: Initial Study
Title: Effects of Education for Hospital Providers on
Compliance with Core Measures for Heart Failure
Investigator: Monica Rauton
IRB ID: STUDY00002999
Category of review: (5) Data, documents, records, or specimens, (7)(a)
Behavioral research
Funding: None
Grant Title: None
Grant ID: None
Documents Reviewed: • Demographic Questionnaire .pdf, Category:
Screening forms;
• Conway Student Consent_COVER_LETTER.pdf,
Category: Consent Form;
• Post-Education Survey.pdf, Category: Measures
(Survey questions/Interview questions /interview
guides/focus group questions);
• Effects of Education for Heart Failure Core
Measures , Category: IRB Protocol;
• Provider Recruitment Flyer Conway.pdf, Category:
Recruitment Materials;
• Systems process outcomes copy.pdf, Category:
Measures (Survey questions/Interview questions
/interview guides/focus group questions);
• DNP Projects Content Validity report.pdf, Category:
Measures (Survey questions/Interview questions

Page 1 of 2

55

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

/interview guides/focus group questions);
• Letter of Support from St. Joes.pdf, Category: Other
(to reflect anything not captured above);
• Pre-Educaiton Survey.pdf, Category: Measures
(Survey questions/Interview questions /interview
guides/focus group questions);
• Student Recruitment email invitation .pdf, Category:
Recruitment Materials;
• Conway Educational Session Topical outline .docx,
Category: IRB Protocol;
The IRB approved the protocol from 9/8/2015 to 9/7/2016 inclusive. Three weeks before
9/7/2016 you are to submit a completed Continuing Review application and required
attachments to request continuing approval or closure.
If continuing review approval is not granted before the expiration date of 9/7/2016
approval of this protocol expires on that date. When consent is appropriate, you must use
final, watermarked versions available under the “Documents” tab in ERA-IRB.
In conducting this protocol you are required to follow the requirements listed in the
INVESTIGATOR MANUAL (HRP-103).
Sincerely,

IRB Administrator
cc:

Beth Conway

Page 2 of 2

56

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE
Appendix F
Site Approval Letter

57

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

58

Appendix G
Systems Process Outcomes

ID______________

Observation Period___________________

Systems Process Outcomes

1. Measure of Ejection Fraction function

2. ACE/ARB

Yes

No

≤ 20% ≤ 30% ≤ 40% ≤ 50% > 50%

NA with clinical indication listed

3. Beta-Blocker Yes No NA with clinical indication listed
a. Bisoprolol
b. Carvedilol (Coreg)
c. Metoprolol Succinate CR/XL
d. Other

4. 60 minutes of HF education

Yes

No

5. Follow-up appointment scheduled within 7 days of discharge

6. Aldosterone Antagonist at discharge Yes No

7. Anticoagulation for A-Fib/Aflutter

Yes

No

Yes

No

NA with clinical indication listed

NA with clinical indication listed

8. Hydralazine Nitrate at discharge Yes No NA with clinical indication listed

9. Heart failure core measures documentation completed in Cerner

IRB Number 00002999
September 8, 2015

Yes

No

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE
Appendix H
Overview of Education Presentation

59

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE
Appendix I
Education Session and Project Outline

60

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

61

Appendix J
Demographic Questionnaire

ID

Demographic Questionnaire
Circle which best apply or fill in “other”
1. Gender
Male

Date

5. Employment Title Specialty
Female

Cardiology

2. Age

Internal Medicine

< 25 years

Hospitalist

25 to 35 years

Heart and Lung

36 to 45 years

Pulmonology

46 to 55 years

Other:____________________
6. Years of Practice

56 to 65 years
> 65 years

< 1year

3. Employee of:

1 to 5 years

Dignity Health

6 to 10 years

Partner Association

11 to 20 years

Other: _____________________

> 20 years

4. Employment Title

7. Years with Dignity Health

Attending Physician

< 1year

Resident Physician

1 to 5 years

Medical Student

6 to 10 years

Nurse Practitioner

11 to 20 years

Physician Assistant

> 20 years

Other:_____________________

IRB #
Date

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

62

Appendix K
Pre/Post Education Survey

ID:

Education Pre-Test

Date:

1. I am knowledgeable with the current 2013 AHA Get With The Guidelines Heart
Failure/Acute MI Quality Measures?

Strongly Disagree

Disagree

Undecided

Agree

Strongly Agree

2. I implement all of the recommended therapies or medications according to the
guidelines unless there is a contraindication?
Strongly Disagree

Disagree

Undecided

Agree

Strongly Agree

3. I understand the importance of completing the core measures documentation on
every heart failure/acute MI patient?
Strongly Disagree

Disagree

Undecided

Agree

Strongly Agree

4. I know how to access and I am comfortable filling out the core measures
documentation for heart failure/acute MI in Cerner?
Strongly Disagree

Disagree

Undecided

Agree

Strongly Agree

5. I know how to reconcile home, admission, and discharge medication using the
medication reconciliation tab in Cerner?
Strongly Disagree

Disagree

Undecided

Agree

Strongly Agree

6. I know how to put in a request to consult cardiac rehab for my patients with heart
failure or acute MI?
Strongly Disagree

Disagree

Undecided

Agree

Strongly Agree

7. I think an education session on the current 2013 AHA Get With The Guidelines
Heart Failure/Acute MI Quality Measures and review of using the core measures
documentation tool is helpful to provide quality care for my patients?
Strongly Disagree

Disagree

Undecided

IRB #
Date of Approval

Agree

Strongly Agree

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE
Appendix L
Table 2
Sample Demographics
Characteristic
Gender
Male
Female

n

(%)

13 (43.3)
17 (56.7)

Age
<25 years
26-35 years
36-45 years

3 (10)
25 (83.3)
2 (6.7)

Title
Attending physician
Resident physician
Medical student
Nurse practitioner

0
25
5
0

(0)
(83.3)
(16.7)
(0)

Specialty
Cardiology
Internal Medicine
Hospitalist
Family
Pulmonology
Other

0
9
1
14
0
5

(0)
(30)
(3.3)
(46.7)
(0)
(20)

Years in practice
<1 year
1-5 years

17 (56.7)
13 (43.3)

63

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

64

Appendix M
Table 3
Pre/Post education surveys
Paired differences
Mean
-1.400

Std Dev
1.133

Std Error
Mean
0.207

Implementations of Recommendations

-0.767

0.858

Understand Importance of completing
CMD

-0.733

How to access core measure in EMR
How to reconcile meds in EMR

Overall Knowledgeable Level

How to request Cardiac rehab
Is education helpful for quality care

95% CI
LL
UL
-1.823
-0.977

t
-6.770

0.157

-1.087

-0.446

0.828

0.151

-1.042

-0.900

0.759

0.139

-0.367

0.669

0.167
-0.233

Note: * denotes statistical significance of p = <0.05.

df
29

Sig
<0.001*

-4.892

29

<0.001*

-0.424

-4.853

29

<0.001*

-1.183

-0.617

-6.496

29

<0.001*

0.122

-0.616

0.117

-3.003

29

0.005*

5.509

1.006

-1.890

2.224

0.166

29

0.870

0.935

0.171

-0.583

0.116

-1.366

29

0.182

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE

Appendix N
Figure 1.0. Monthly Quality Measures Compliance

65

EDUCATION FOR HOSPITAL PROVIDERS ON HEART FAILURE
Appendix O
Table 4:
Cost of project implementation
Item
Printed paper for surveys (200 copies)
Consent Forms (100 copies)
Education handouts (200 color copies)
Demographic sheet (100 copies)
Quality measures (200 count)
Lunch/Snack
Educational Session

Cost
$8.00
$4.00
$24.00
$4.00
$8.00
$350.00
$35-45 estimated nurse educator hr/rate

66