The next phase to implement the CCOT resembled a well-run military operation. A presentation, “Implementation of CCOT” to Senior Management in 2008/2009 by the ICU Management group summarised the process by which the nurse-led CCOT was introduced into the hospital. Approval from Senior Management had been secured and the resources were available which enabled the implementation of the nurse-led CCOT.
Several presentations were made to Management in the 2006-2009 periods. Figure three is an example:
60
Know the Enemy?
• Literature and research review. • Discussion with allies. • Review of current practice. • Awareness of other DHB plans. • Creation of diplomatic relationships. • Intelligence reports on potential resistance.
Figure 3. Presentation to Senior Management. (Note the military metaphor used in the presentation)
The chairperson of the Critical Care Development Group managed the work-load by allocating specific people to a job. Weekly documented meetings of the core group took place. Action points, time frames and updates from uncompleted targets were discussed for barriers and resolution to problems encountered. The minutes present a very business-like approach to setting up the nurse-led CCOT. An excerpt from the minutes illustrates how efficiently the meetings were run:
Table 2. Critical Care Development Group, Minutes December 1 2005.
TOPIC DISCUSSION OUTCOME
Project timeline
Updated plan tabled. Discussion re proposed dates for rolling out outreach on wards.
Short meeting to be arranged for tomorrow to discuss timeline as not all key players present
[Manager] to amend timeline and circulate
61 Database Information required includes demographics,
follow-up data on what happened to the patient, target data and audit times for medical staff to meet
[CNS] and [SPECIALTY CONSULTANTS] to present more information re this at the next meeting
[CNS] to talk to [Manager] about existing databases within the DHB
Source: (DHB minutes).
Initially the core team was from ICU personnel. As the project developed it extended to all levels of nursing and multidisciplinary clinicians and some Management. The core development group was very clear about the scope of the project and the tasks to be achieved. The CNS who was a key member of the Critical Care Development Group appointed to set up CCOT reflected on those meetings:
CNS: We [core group] gave ourselves very, very strict time lines that were non-
negotiable because what we felt, that in the introduction, if we drifted...if we drift by one week at the beginning, by the end of year it would be a month, two months, so we had to be very strict on that (p.8).
CNS: We were very clear that they [objectives] had to be achieved, so a meeting with
Charge Nurses, meeting with the consultants. And so, therefore, meetings with the consultant group, [the Consultant] may lead that but I would be there to support him. Meetings, um, meetings about training, that may be [Nurse Educator] and myself going to those. Um, meetings about resources of course [Charge Nurse Manager] and myself may go. But the idea was that we all gave ourselves jobs and we were very close. And
that “we” became a much bigger group and I like to think that that “we” still exists even though we have a team of outreach nurses. The “we” also includes the Charge
Nurses on the wards and it also includes many of the consultants. It involves some of
the managers, it involves pharmacists, it involves physiotherapists. The “we” is the
62 The CNS was emphatic that there needed to be a consistent approach to Outreach throughout the hospital. Acknowledging the importance of trust, he determined that getting ‘buy-in’ from that extended core team was an essential task during the implementation period. He explains:
CNS: I think....I think the key task was to get buy-in from everyone. I think the one thing that I was very clear on was that we couldn't have a service which consultant A accepted but Consultant B didn't. Ward X had, but ward Y didn't have. It had to be, if it was for the patient, it had to be across the board. So I think the first consideration was that everyone had to recognise what this was about and the thing is, when you actually put outreach down on a bit of paper, that is what we did at XXXX, it was a win/win situation for everyone (p.2).
CNS: One of the key tasks was to get people's trust (p.3).
The concept of a CCOT which crossed all specialties was new to the organisation. Establishing trust with key stakeholders would contribute to a smooth implementation of Outreach and add to organisational wide communication and buy-in.
With participants of the Critical Care Development Group each taking responsibility for tasks from their area of expertise, the project continued to progress. Development of an EWS, a six week modular ward nurse education programme, a new observation chart, Acute Care Study course material, administration responsibilities and continued liaison with other medical and surgical specialties advanced to the point where content development, tools and education packages could be finalised.