Post on 12-May-2015
transcript
Innovation in Care Delivery SymposiumHCAHPS – Moving the Needle
October 29, 2013
Rick Evans, MA
Senior Director – Service Excellence
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Objectives
At the completion of this session participants will:
1. Have a deeper understanding of patient experience surveys, metrics and reimbursement implications
2. Learn about effective interventions that impact HCAHPS results
3. Link selected interventions with service metric outcomes
4. Describe how interventions can be implemented and sustained
The Context for ImprovementSurveys, Metrics and Emerging Reimbursement
Structures
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Our Goal – Improving the Patient Experience
• Focus Fostering Patient and Family Centered Care Integrating with quality and safety work
• Service is improved the same way that quality is improved:
By planning By using data to choose tactics and set achievable targets By engaging the entire team in the plan By being clear about everyone’s role in achieving improvement By holding everyone accountable for tasks and deadlines By keeping the team updated on progress By celebrating success!
• HCAHPS is an acronym for “Hospital Consumer Assessment of Healthcare Providers & Systems”
• This survey measures patients perception of “how often” they felt they received high quality clinical and customer service
• Random sampling of adult inpatient discharges
• Excludes psychiatry, rehabilitation, and pediatric discharges
• MGH administers through a vendor (QDM) by phone
HCAHPS Survey Basics
RATE HOSPITAL 0-10 Rating Scale: 9-10
RECOMMEND THIS HOSPITAL Rating Scale: Definitely yes
COMMUNICATION W/ NURSES Rating Scale: Always
Nurses treat with courtesy/respect
Nurses listen carefully to you
Nurses explained things in way you understand
RESPONSIVENESS OF HOSP STAFF Rating Scale: Always
Never pressed call button
Call button help soon as wanted it
Need help with bathroom/using bedpan
Help toileting soon as you wanted
COMMUNICATION W/ DOCTORS Rating Scale: Always
Doctors treat with courtesy/respect
Doctors listen carefully to you
Doctors explained things in way you understand
HOSPITAL ENVIRONMENT Rating Scale: Always
Room and bathroom kept clean
Area around room quiet at night
PAIN MANAGEMENTRating Scale: Always
Need medicine for pain
Pain well controlled
Staff do everything help with pain
COMMUNICATION RE: MEDICINES Rating Scale: Always
Given medicine had not taken before
Tell you what new medicine was for
Staff describe medicine side effect
DISCHARGE INFORMATIONRating Scale: Yes
Left hospital- destination
Staff talk about help when you left
Info re: symptoms/problems to look for
HCAHPS: Questions
Our Mission
Excellence Every Day
Our Reputation Public Reporting of
Data
Patient Experience Metrics
A New Era in Patient Experience
Operational Strength Healthcare Reform
& Reimbursement
Coming for Outpatient, Surgical and Pediatrics and other areas in the future…..
Healthcare Reform Efforts Puts Hospital Dollars at Risk
Value-based PurchasingProcess of care & Patient experience
Begins FY2013, full 2% annual payment update at risk by FY2017
By FY2017, $6 out of every $100 Medicare DRG reimbursement potentially is at risk
30-Day ReadmissionsUp to 8 conditions targeted including AMI, HF,
PNA1% DRG payment penalty beginning FY2013, rising to
3% by FY2015
Hospital-Acquired ConditionsUp to 8 conditions targeted
1% DRG payment penalty for hospitals in worst quartile beginning FY2015
• Attainment – Score for how well we perform compared to peers
• Improvement – Score for improvement over our own performance baseline
Reimbursed for each domain based
on which score is highest
Reimbursement Methodology
Everyone else is
improving too!
Innovation UnitsImplementing Effective Interventions
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Innovation Units – Focus Areas and Desired Outcomes
Focus1. New Culture through Relationship-Based Care
2. New Role of Attending Nurse; Domains of Practice
3. Standardized Processes Throughput and LOS Reduction Technology Controlling Variation Implementing Evidence-Based Practice
Outcomes1. Patient Satisfaction: care is equitable and patient- and family-
focused
2. Clinical Quality: to improve quality and to make care safer
3. Unit Cost Reductions: to make care more cost effective
4. Staff Satisfaction: to remain a great place to practice
How do we achieve “ALWAYS?”
“ALWAYS” Demands Consistency
Consistency = Across shifts, team members, services and locations…
Standardized Best Practices create consistency!
SUCCESS!!
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Before During After
Admission process: ED, direct admits,
transfers
Patient stay; direct patient care; tests; treatments; procedures;
clinical support; operational support
Discharge process
Post-discharge
care
Pre-admission
care
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Innovations in Care Delivery “Patient Journey” Framework – Initial 15 Interventions
Relationship-based care ♦ The Attending Nurse role ♦ Hand-Over Rounding Checklist
Discharge Planning: -Est. discharge date -Discharge disposition
Welcome Packet (notebook and discharge envelope)
Domains of PracticeDaily Interdisciplinary Team RoundsElectronic Unit WhiteboardsIn-Room WhiteboardsSmart Phones Wireless laptop computers/tabletsBusiness cards Hourly roundingQuiet hours
Discharge -Follow-up Call Program
Goal: High-performing, inter-disciplinary teams that deliver safe, effective, timely, efficient, and equitable care that is patient- and family-centered
Copyright MGH 2012Copyright MGH 2012
Intervention: Welcome Packet
GOALS:• Engage Patients and Families• Facilitate Questions• Encourage Teaching• Facilitate Discharge
HCAHPS Indicators Impacted:• Nurse Communication• Doctor Communication• Pain Management• Communication About
Medicines• Discharge Information
Introducing the Innovation Units
• Introduces Innovation Units
• Assures patients and families of continued quality care
• Invites participation
The Compact - Inviting Patients and Families to Engage
• Invites patient and family to be our partner
• Outlines patient and family responsibilities
• Communicates our promise to care and sets expectations
• Sets a tone• Invites Relationship
Based Care
Introducing the Team
• Orients patients and families
• Patient friendly role descriptions
• Facilitates discussion and questions
• Situates patients and families “on the team”
Encouraging Questions and Teaching
• Prompts questions and important themes
• Facilitates teaching• Collects and supports
discharge readiness• A place to
integrate/collect family questions and concerns
Success Factors - The Notebook
It only works if it is used:• Use to build relationship – with patients and with families• Use the notebook in daily rounds
• Promote with all care team members as appropriate
• Use when conducting patient education• Promote with families whenever appropriate• Use to start and document discussions• Integrate with white board information
Success Factors - The Envelope
• Use from first day to introduce going home checklist• Review with patients AND families – identify challenging
issues early• Issues with special populations (ICU’s, Psych)
• Take out everytime material is given to the patient to take home
• Use to hold all patient education materials• Use Key Words - connect dots with materials and self
care after discharge
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Communication: In-Room White Boards
A “communication basic” Supports knowledge of care team Builds relationships Articulates patient’s goal Keeps an eye on discharge Can be integrated with notebook
and other teaching tools Keeping the board current is
critical It’s only as good a resource as it
is used…
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Intervention: Quiet Times
Designated hours on inpatient units where activity and conversation is minimized to allow patients to rest
Most effective model is to have a period in the afternoon and during the night when quiet hours are observed
What happens during Quiet Times?
• Communicate Quiet Times with patients• Where possible, turn down lights across
the unit and in patient rooms• Close doors where possible• Minimize conversations in nursing
stations and other areas• Encourage visitors to take breaks to let
their loved one rest• Where possible, TV’s and music are
allowed for patients only when headphones are used
• Phone conversations are allowed only in designated areas away from patient rooms
• Clinical interventions are minimized or eliminated
The Quietness Effort at MGH
• Quiet Times – implementation, training and education• Collaboration with Buildings and Grounds
• Doors• Pneumatic Tubes• Door alarms• “Addressographs”
• Collaboration with Facilities• Rolling stock work
• Collaboration with Food and Nutrition• Galley kitchens• Food delivery
• Outreach to all disciplines
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Intervention: Discharge Follow-up Calls
100% of patients in the inpatient setting being discharged to home will be asked to consent to receiving a discharge follow-up call.
Calls are made within 24-48 hours We estimate 3-5 calls per day per nurse or attending nurse Average call time is 3-5 minutes Standard is two attempts to reach patient Scripts are utilized
Why make these calls?
Service Benefits: Communicate care and concern Opportunity to assess overall impression of hospital
performance Opportunity for quick service recovery, if needed Opportunity for staff recognition
Clinical Benefits: Assess patient’s compliance with discharge instructions Evaluate understanding of patient education provided
before discharge Identify opportunities for improvements in practice
The Studer Patient Call Manager Program (PCM)
• Automates post-discharge calling process
• Daily download of discharges
• Scripts for callers to use• Data for accountability
• Call rates• Connect rates• Interventions• Summarizes feedback
• Ability to interface with EMR
• Recognition features
Discharge Phone Calls Implementation
• Number of units live as of September: 36• Calls made to date: 10,984• Call Attempt Rate: 96%• Call Completion Rate: 66%• Average call length: 5 minutes (approx.)• Peak calling times: 11:00 AM – 3:00 PM• Percent of calls with clinical advice or
care coordination given: 22%• Percent of patients with questions about
their discharge instructions: 11%
• Popular Themes for Reward/Recognition: oNursing Care (45%), Doctors (12%)
*Data for Patients discharged 4/5/13 – 9/4/13 on units live with PCM
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Intervention: Hourly Rounds – The Four Ps
Evidence-based research indicates that hourly rounding increases patient satisfaction, decreases fall rates, decreases skin breakdown rates, and increases staff satisfaction.
The Four Ps Presence: Establish personal connection at the beginning and end of each shift and with each hourly round
Pain: Assess and address patient’s pain
Positioning: Patient’s physical position and comfort; Positioning of needed items within reach
Personal Hygiene: Help with toileting
Implementation - Three Key Elements of the Best Practice
1. Strengthening Rounding – Using the 4 P’s: Training for all staff Hourly Rounds using our process and scripts
2. Documentation of rounds in the presence of the patient and family
Two methods Bedside Logs White Boards
3. Validation of rounds by the nurse leader Rounds on 5 patients per week using log Feedback to staff Monitoring of HCAHPS results
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The “HOW” - Presence
With new patients and at the beginning of each shift: Focus on making a personal connection
When possible – sit next to the bed at eye level
Learn about the patient’s priority for the day/your shift Introduce the practice of Hourly Rounds Communicate your knowledge of the clinical plan for the
day/shift
With each hourly round: Reinforce that you are conducting your Hourly Round Address the patient by name Assure needs are met before leaving Assure that someone will be back within the hour
The “WHAT” – The Three P’s
Pain Assess and address
Positioning Patient’s physical position and comfort Positioning of needed items within reach
Personal Hygiene Help with toileting
Attending to these basics improves outcomes AND achieves efficiency
Hourly Rounding – A Team Response
MGH Model includes others: PCA’s
Alternating hours through the day
Other disciplines trained Trained to address “P’s” when they are in the room
Documenting the Hourly Rounds
Rounds should be documented in the presence of the patient
Two Options for MGH Units: Use of the White Board Logs at the bedside
Why is this important? Assures the practice is happening Reinforces the practice with patients and family
Validation – A Key Component
Methods to validate Hourly Rounding is happening will include:
Nurse Leader Rounding on patients and families Explicit questions on hourly rounding
HCAHPS Survey Ask patients if they experienced Hourly Rounding
Data from these validation sources will be shared with staff
Innovation - Involving Patient Advocates
Led by Office of Patient Advocacy Advocates assigned to units
Tracking of complaints or issues Conducting focus groups Gathering data through patient and family interviews
Co-Led development of some interventions Links to Patient and Family Advisor Councils (PFACs)
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Did the Needle Move?Summary of Results to Date
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HCAHPS Results – 2011 vs. 2012MGH-wide vs. Phase 1 Innovation Units
Survey MeasureMGH
2012
Change (2011 - 2012)
Innovation Units 2012
Change (2011 - 2012)
Nurse Communication Composite 81.0 +1.6 80.8 +4.5Doctor Communication Composite 81.6 -0.3 82.0 +0.5Room Clean 72.9 +3.1 70.6 +4.2Quiet at Night 48.5 +3.3 49.8 +6.2Cleanliness/Quiet Composite 60.7 +3.2 60.2 +5.2Staff Responsiveness Composite 64.9 +1.3 64.0 +1.7Pain Management Composite 71.9 +0.4 73.3 +3.7Communication About Meds Composite 64.0 +1.3 65.7 +6.8
Discharge Information Composite 91.2 +1.4 92.3 +2.7Overall Rating 80.1 +1.0 78.5 +2.4Likelihood to Recommend 90.5 +1.1 90.3 +2.4
• HCAHPS Data for Innovation Units includes 6 units for which data is available – Bigelow 14, Blake 13, Ellison 16, Lunder 9, White 6 and White. Data not available for ICU’s and Psych.
• Date pull: 3.04.13
KEY
2012 Score exceeds that of entire hospital
Rate of Improvement Exceeds that of the entire hospital
KEY
2012 Score exceeds that of entire hospital
Rate of Improvement Exceeds that of the entire hospital
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HCAHPS Results – Q2 YTDMGH-wide vs. Phase 2 Innovation Units
• * HCAHPS Data for Innovation Units includes 22 units for which data is available – Blake 6, Bigelow 6, 9,11,13, Ellison 6,7,8,10,11,13,19, Lunder 7,8,10, Philips House 20,21,22, White 8,9,10,11
• Date pull: 6.26.13
KEY
Phase 2 Units Score exceeds that of entire hospital
2013 YTD 2013 Quarter 2 YTD
Survey Measure MGH Overall
Phase 2 Units
MGH Overall
Phase 2 Units
Nurse Communication Composite 80.6 80.4 81.3 81.5Doctor Communication Composite 81.7 81.5 82.1 81.8Room Clean 74.2 74.6 75.6 77.0Quiet at Night 50.1 50.3 52.3 53.2Cleanliness/Quiet Composite 62.1 62.4 63.9 65.1Staff Responsiveness Composite 63.5 62.8 65.0 64.6Pain Management Composite 71.1 72.2 71.9 74.2Communication About Meds Composite 65.1 65.1 68.0 69.4
Discharge Information Composite 91.3 90.8 92.5 92.1Overall Rating 80.1 79.8 80.1 80.5Likelihood to Recommend 90.4 90.2 91.3 92.2
HCAHPS Indicator Results - Quiet at Night
* Period incomplete
Date Range
By YearBy 6 MonthsBy QuarterBy Month
Cases Per Point
819240962048102451225612864321684
Date RangeCases Per PointOrganization: MGH
Survey: HCAHPSPlus
Date Range: Range: 7/1/2011~6/30/2013
Info Box
42
44
46
48
50
52
Q3-2011 Q4-2011 Q2-2012 Q4-2012 Q2-2013
% of maximum achievable score
How has Quiet at Night (Top Box %) been evolving over time?Our patients
Upper/lower natural process limit
Quiet Times
Launched
HCAHPS Indicator Results - Nurse Communication
* Period incomplete
Date Range
By YearBy 6 MonthsBy QuarterBy Month
Cases Per Point
819240962048102451225612864321684
Date RangeCases Per PointOrganization: MGH
Survey: HCAHPSPlus
Date Range: Range: 7/1/2011~6/30/2013
Info Box
76
78
80
82
84
Q3-2011 Q4-2011 Q2-2012 Q4-2012 Q2-2013
% of maximum achievable score
How has Nurse Communication (Top Box %) been evolving over time?Our patients
Upper/lower natural process limit
HCAHPS Indicator Results - Discharge Information
* Period incomplete
Date Range
By YearBy 6 MonthsBy QuarterBy Month
Cases Per Point
819240962048102451225612864321684
Date RangeCases Per PointOrganization: MGH
Survey: HCAHPSPlus
Date Range: Range: 7/1/2011~6/30/2013
Info Box
88
89
90
91
92
93
94
Q3-2011 Q4-2011 Q2-2012 Q4-2012 Q2-2013
% of maximum achievable score
How has Discharge Info (Top Box %) been evolving over time?Our patients
Upper/lower natural process limit
What we know…
• Our chosen best practices are evidence based
• They require commitment to implement, but…
• These practices work!• Phase one results are
compelling• Phase two results show
similar promise• Focus – sustaining
practices and improvement
Anything else I can do for you?
Rick EvansSenior Director – Service ExcellenceMassachusetts General Hospital and Mass General
Physicians Organizationrevans6@partners.org617-724-2838