follow up on bedside reporting ihi expedition · improving your hcahps scores through patient...
TRANSCRIPT
1
Follow Up on Bedside Reporting
The call content prompted us to:
• Make concrete plans to move shift report
to the bedside
• Actually run a test of doing shift report at
the bedside
• Make revisions to the way we currently do
shift report at the bedside
• Try out unit leadership rounds
•1
IHI ExpeditionImproving Your HCAHPS Scores
Through Patient Centered Care
Post Discharge Phone CallsPost Discharge Phone Calls
Kelly Briggs, MBA, RN, CNA-BC, is the nurse manager of a 33 bed Acute Elder
Care Unit at Hackensack University Medical Center. Ms. Briggs earned her
MBA from Seton Hall University, BSN from Fairleigh Dickinson University and
well as a BS in Biology from Manhattan College. Ms. Briggs has been a leader
in the field of gerontological nursing for over 10 years.
Ms. Briggs is ANCC certified in
Gerontology and Nursing Administration. She was instrumental in
developing the fall reduction program at HUMC and designed the video
monitoring system to achieve a 50% reduction in patient falls on her unit.
She has presented at national conferences on the topic of fall
reduction and pain management initiatives.
Nina Setia currently serves as the
Administrative Director of Service Excellence at Hackensack University Medical Center in northern NJ. In her role, she is primarily responsible for all service-oriented market research activities while driving and monitoring improvement initiatives throughout the organization. Her focus is on total
customer satisfaction which includes patients, employees and physicians. Nina has been with the Medical Center for most of the last 14 years and during this time has presented successful initiatives at four Press Ganey National Conferences and two “What’s Right in Healthcare” Studer Group National
Conferences. She recently published an article in JONA (Journal of Nursing Administration) on discharge calls and leader rounding on patients, and has contributed to several other books, including Planetree’s “Putting Patients First”.
Nina’s creative and innovative measurement strategies have enhanced the way the organization looks at patient, physician and employee satisfaction results.
Nina received her BS in Broadcast Journalism/Communications from Syracuse
University and her MS in Advertising Strategy/Communications from Virginia Commonwealth University. She also possesses a private pilot license. For fun, she spends time with her two Yorkshire terriers, Kahlua and Martini.
Bundling the Value of Discharge
Phone Calls and Leader Rounding on Patients
Nina Setia, MS
Administrative Director
Service Excellence
Kelly Briggs, MBA, RN, CNA-BC
Nurse Manager
Acute Care Elder Unit, 4 St. John
Today’s Topics
• Learn how Hackensack University
Medical Center implemented a
Discharge phone call program
• Measuring success
• Case Study – operationalizing the
program on one unit
• Bundling discharge calls with leader
rounding on patients
• Where we are now
2
Hackensack University Medical Center
One of America’s 50 Best Hospitals:
Top One Percent in the Nation – THREE
Consecutive Years
“With this recognition, we
pledge to continue our
mission to improve the delivery of healthcare here
and in other institutions
nationwide.”-Robert C. Garrett
President & CEO
Driven by Quality Occupancy Rate(% Med/Surg Occupancy)
94.3% 92.2% 93.3% 93.7% 95.4%91.5%
88.3%
0
10
20
30
40
50
60
70
80
90
100
20
03
20
04
20
05
20
06
20
07
20
08
20
09
Length of Stay
4.4
4.5
4.6
4.7
4.8
4.9
5.0
5.1
5.2
20
03
20
04
20
05
20
06
20
07
20
08
20
09
All
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6.0
6.1
6.2
6.3
20
03
20
04
20
05
20
06
20
07
20
08
20
09
Medicare
What our patients were telling us:
• “I was told very little. I was not told how to take care of myself when I left nor did I have a full understanding of what happened & what was on my discharge papers.”
• “Don't think I was told enough about taking care post surgery at home.”
• “I was not given complete instructions regarding the care of my wound. I just learned how to dress my wound when I called up my physician & reviewing the instructions given upon discharge”
• “Needed more advice on home care.”
• “I was back at Dr.'s office a few days later w/problems and questions, was given little to no info on discharge.”
• “It took several hours to be discharged but I was okay w/ it I felt the home instructions part could have been a little more informative.”
• “There was no warning to my family before I was discharged & no advice as to what should happen afterwards.”
• “The last nurse I had was very rushed and didn't have time to explain anything.”
3
What they were really telling
us:
High Occupancy
Decreasing Length of Stay
Patient’s perception of feeling ready for discharge
+
=
Patient Satisfaction: Inpatient
4Q05
85.1 86.882.0
89.3
72nd
49th
78th
52nd
20
30
40
50
60
70
80
90
100
Extent felt ready
for discharge
Instructions for
care at home
Instructions
given about baby
care*
Likelihood of
recommending
Mean Score Nat'l %-tile Rank
Patient Satisfaction: ED 4Q05
80.477.2
80.8
42nd
20th20th
0
10
20
30
40
50
60
70
80
90
Information about
home care
Staff cared about you
as a person
Likelihood of
recommending
Mean Score Nat'l %-tile Rank
Rolling Out Discharge Calls
CEO Directive:
• Implement discharge phone calls to increase patient
satisfaction
Response:
• Plan was developed and adopted by the Satisfaction
Advisory Council (committee of Satisfaction Teams
Chairs)
─ Developed customized discharge follow up phone calls
logs (based on form from Studer group toolkits)
─ To be rolled out through Satisfaction Teams
Strategy
Discharge
Call Form
4
Discharge Call PracticeWho makes the calls?
• Mostly RN’s
• Most Nurse Managers participate
• Varies by unit
─ Per diems (if under budget)
─ Based on staffing ratio’s and # of discharges per day
─ Assigned RN to discharge calls
─ Each RN on unit making a few calls each, per day
• No method of reports other than patient satisfaction
Initiative: Discharge Calls
Patient’s perception of feeling ready for discharge
+
=
Healthcare Research…
• “Not understanding discharge instructions” is one of
the top 8 ‘dissatisfiers’ to patients.
• How the patient manages their recovery post
discharge is vital to maximizing clinical outcomes
Need for measurement of this initiative
Measuring Discharge Phone Calls:Added Question to the ED Survey Quality of calls...
87.480.3
88th99th
27th
46th
0
10
20
30
40
50
60
70
80
90
100
"Information
about home
care"
National % tile
Rank
60K+ Visit Peer
Group
Received
call
Did not
receive
call
Source: Press Ganey Associates, 2Q06
Impacts overall perception of care...
84.478.9
93rd
73rd
57th
37th
0
10
20
30
40
50
60
70
80
90
100
"Likelihood of
Recommending"
National % tile
Rank
60K+ Visit Peer
Group
Received
call
Did not
receive
call
Source: Press Ganey Associates, 2Q06
…and success increases quantity.
20
30
40
50
60
70
80
2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09
2Q06 3Q06
5
Enhancing the practice of Discharge Phone Calls
� Show patients we cared about them and their
well-being even after discharge
� Improve patient compliance with discharge
instructions
� Involve leadership in making the calls
� Provide real time feedback
• Involve attending physicians in
making the calls
Discharge Calls Improves Physician
Performance… (January-December 2008, Press Ganey National %tile rank)
91st95th
86th89th
20th
40th
0
10
20
30
40
50
60
70
80
90
100
Doctors Section Likelihood of
Recommending
Doctorsmakingcalls
Other callsbeingmade
No call
Patient Comments: Physicians Making Discharge Phone
Calls• “Special thanks go out to Dr. Feldman for his concern about me
after discharge. Dr. Feldman called me early in the morning about my well being. Thanks again.”
• “The ER doctor took the time needed to explain everything and order necessary tests. Even took the time to make a follow-up call the next day!”
• “Dr. Hewitt - Follow-up call to my home was detailed, informative, answered all my questions and gave me valuable recommendations for follow-up care. Patient and professional.”
• “Not only did Dr. Nierenberg treat me with top notch medical attention - he called my internist at my bedside to update him AND called after my visit to check up on me. Amazing!”
Reinforce Practice Through ResultsED “Information about your care at home”
(Press Ganey National %tile rank)
91
71
92 94
85
43
88
63
96
73
81
96
8784
98
14
27
36
1017
25
15 14
42
18
12
3743
18
27
0
10
20
30
40
50
60
70
80
90
100
2Q
06
3Q
06
4Q
06
1Q
07
2Q
07
3Q
07
4Q
07
1Q
08
2Q
08
3Q
08
4Q
08
1Q
09
2Q
09
3Q
09
4Q
09
Received call Did not receive call
Reinforce Practice Through ResultsED “Likelihood of recommending”
(Press Ganey National %tile rank)
76
9297 94
77 76
93
70
86
78
8794 94
98
89
47
38
78
3733
48
3037
67
43 41
6973
2529
0
10
20
30
40
50
60
70
80
90
100
2Q
06
3Q
06
4Q
06
1Q
07
2Q
07
3Q
07
4Q
07
1Q
08
2Q
08
3Q
08
4Q
08
1Q
09
2Q
09
3Q
09
4Q
09
Received call Did not receive call
Added Question to the Inpatient
Survey
6
Results: 4th Quarter 2006Targeted measurement for
initiative
vs.
Overall perception of care
Drill Down by Unit/Specialty• Example: Obstetrics
4Q06 1Q07
Reach rate more
than doubled in 3
months!?!?
Quality vs. Quantity
•Individual
coaching
opportunities
through unit-
based report
cards
•Goal: stay on
track with
intended
purpose of
initiative
Reinforce Practice through Results
Patient Perception of CareInpatient “Likelihood of Recommending”
(Press Ganey National %tile rank)
98 99 98 98 98 99 99 99 99 99 9893
97
76
5956
5962 64
71
61 61 62
73
65
54
30
40
50
60
70
80
90
100
4Q
06
1Q
07
2Q
07
3Q
07
4Q
07
1Q
08
2Q
08
3Q
08
4Q
08
1Q
09
2Q
09
3Q
09
4Q
09
Received call Did not receive call
Patient Comments
• “FYI: I also rec'd. a follow up phone call after discharge the next day - that was truly appreciated.”
• “I even received a follow-up phone call inquiring if all was well!!”
• “I really appreciate the follow up phone call I received from the nurses after I was home, 'great service!!‘”
• “I was very taken by the follow up call to my home the following day.”
• “Impressed by the follow up call to see how I was doing.”
Next Steps
• Accelerate practice through discharge call manager software
─ Simplifies the process
─ Get real-time feedback
─ Evaluate attempt and reach rates
• Evaluate impact of other initiative(s)
─ Hourly Rounding
─ Nurse Leader rounding on patients
• Apply bundle science concept to practices
• Implement measurement coaching track to increase awareness
and accountability
• Implement peer coaching and validation tools to ensure alignment
of knowledge and to reduce variance in practices
Jun 2007 - Present
Jun 2007 - Present
Ongoing since Nov 2006
Late 2008 - Present
Ongoing since Jun 2007
7
Clinical Call
Auto fill’s name of caller
Evaluates Hourly Rounding
Service Recovery &
RecognitionGoals
• 100% attempt rate – all services
• 75% complete rate – Inpatient
• 60% complete rate – Emergency Services
Monthly Progress Toward Goal:
DCM Stats
Quarterly Progress Toward Goal
8
Quarterly AuditCase Study:
4 St. John Acute Care Elder Unit
• 33 Bed geriatric unit
• RN staffing ratio 1:6
• Discharge phone calls made by all RN’s
• Charge RN ensures that calls are made
daily
• Nurse Manager reviews DC phone call
comments daily and rewards and
recognizes and provides coaching as
needed.
Teamwork !Unit Discharge Call Dashboard
(%)Month
#
Discharges
%
attempted
Difference from
100% goal
%
completed
Difference from
75% goals
Oct-08 193 49.2 (50.8) 40.4 (34.6)
Nov-08 163 22.1 (77.9) 14.1 (60.9)
Dec-08 198 0.5 (99.5) 0.0 (75.0)
Jan-09 183 60.1 (39.9) 54.1 (20.9)
Feb-09 186 100 0.0 91.9 16.9
Mar-09 201 99.5 (0.5) 93.5 18.5
Apr-09 210 98.1 (1.9) 89.1 14.1
May-09 191 89.5 (10.5) 78.5 3.5
Jun-09 207 98.1 (1.9) 89.3 14.3
Jul-09 183 99.5 (0.5) 81.4 6.4
Aug-09 170 98.2 (1.8) 90.6 15.6
Sep-09 184 98.9 (1.1) 91.8 16.8
Oct-09 175 97.1 (2.9) 90.9 15.9
Nov-09 181 99.5 (0.5) 93.9 18.9
Dec-09 180 99.4 (0.6) 91.7 16.7
% of Discharge Calls
0
100
200
300
400
500
600
700
0
10
20
30
40
50
60
70
80
90
100
# Discharges 512 544 554 570 608 539 536
% attempted 42 22 24 87 95 99 99
% completed 29 17 18 80 85 87 92
2Q08 3Q08 4Q08 1Q09 2Q09 3Q09 4Q09
Positive comments from ourpatients…
• “Irene was excellent.”
• “Everyone that took care of my mom was great.”
• “Kerry, Kelly, Ria, and Sherrie were all excellent
nurses.”
• “Julia walked my mother each day to see my father
who was a patient down hall. She was very nice.”
• “Sonny and Fran were excellent nurses.”
• “Leonor was very attentive.”
• “I loved everyone on 4 St John- the nurses and nursing
assistants were wonderful.”
9
Unit Patient Satisfaction
78
79
80
81
82
83
84
85
86
87
88
89
0
10
20
30
40
50
60
70
80
Mean score 81.9 84.7 85.6 86.3 85.2 87.8 86.8
National Rank w/in
Geriatrics specialty
35 52 64 76 74 74 74
2Q08 3Q08 4Q08 1Q09 2Q09 3Q09 4Q09
Added Another Question to the
Inpatient Survey
“Did a Nurse Manager Visit You
During Your Stay?”
96th92nd85th92nd84th
96th
16th 12th8th 7th
3rd
37th
0
10
20
30
40
50
60
70
80
90
100
Overall Extent Felt
Ready for
Discharge
Instructions
re: Care at
Home
Nurses
Section
Response to
Concerns/
Complaints
Likelihood to
Recommend
Na
tio
na
l P
erc
en
tile
Ra
nk
ing
Yes No
Source: Inpatient surveys received 4Q09
n=996 responses (67%=YES; 33%=NO)
“Did you receive a follow up phone
call after your stay?”
97th93rd 92nd 95th86th
78th
12th 12th19th
8th
54th
17th
0
10
20
30
40
50
60
70
80
90
100
Overall Extent Felt
Ready for
Discharge
Instructions
re: Care at
Home
Nurses
Section
Response to
Concerns/
Complaints
Likelihood to
Recommend
Na
tio
na
l P
erc
en
tile
Ra
nk
ing
Yes No
Source: Inpatient surveys received 4Q09
n=1105 responses (72%=YES; 28%=NO)
Bundle Approach:“Did you receive a follow up phone call after your stay?”
+ “Did a Nurse Manager visit you during your stay?”
99th98th97th99th98th99th
6th 4th 7th 7th1st
20th
0
10
20
30
40
50
60
70
80
90
100
Overall Extent Felt
Ready for
Discharge
Instructions
re: Care at
Home
Nurses
Section
Response to
Concerns/
Complaints
Likelihood to
Recommend
Na
tio
na
l P
erc
en
tile
Ra
nk
ing
Yes No
Source: Inpatient surveys received 4Q09
n=598 responses (76%=YES to both question, 24%=NO to both questions)
Bundle Approach:“Did you receive a follow up phone call after your stay?”
+ “Did a Nurse Manager visit you during your stay?”
89.791.0
89.3
94.6
91.689.5
81.881.1 80.6
83.9
75.7
85.3
70
75
80
85
90
95
100
Overall Extent Felt
Ready for
Discharge
Instructions
re: Care at
Home
Nurses
Section
Response to
Concerns/
Complaints
Likelihood to
Recommend
HU
MC
Me
an
Sco
re
Yes No
Source: Inpatient surveys received 4Q09
n=598 responses (76%=YES to both question, 24%=NO to both questions)
10
Quarterly Tracking Tools by Unit… Measures effectiveness of
practices
Internal Coaching Model (as of Oct 2008)
• Ability to leverage professionals within HUMC to serve as peer coaches, who were selected based on:─ Proven results
─ Relationship with staff & understanding of the culture
─ Vested Interest
─ Demonstrated competency in key tactics
─ Ability to role model and coach behaviors
─ Pride in the organization and the delivery of quality patient care
• Implement Internal Peer Coaching model in Nursing─ Novice to expert coaching model using Expert Coaches as internal
Subject Matter Experts
─ 6 internal coaches selected
• To ensure standardization, all nursing leaders have been assigned a peer coach, regardless of their tenure, results or competency
• New tactics will be added in sequential manner to allow time for skills-building and implementation before adding other behaviors
Peer Coaching ModelRef – Benner, P. (1984). From Novice to Expert: Excellence and power in clinical
nursingThose designated as Experts will use the following schedule for coaching or validation of competency on Key Initiatives
Novice – Meet with Coach every two weeks
1) Have no experience in the behavior-must follow the "rules“
2) New manager to HUMC - need to learn culture
3) Experienced nurse - new to management
Advanced Beginner – Meet with Coach Monthly
1) Demonstrates acceptable performance after training
2)Tend to "think" they are doing it but no measurable results
3) They do the behavior when they have the time
Competent – Meet with Coach Quarterly
1) Begins to see actions connected to goal attainment
2) Proactively correlate behavior to results (use logs)
3) Demonstrate skill and cognitive understanding the concept
Proficient – Meet with Coach every Six Months
1) Can adapt to nuances of the concept, are nimble and flexible
2) Perceive as part of the culture and can role model to others
3) Achieve measurable and sustained results
Expert – Meet with Coaching Group Annually
1) Have an intuitive grasp on the concept, "second nature"
2) Are firm believers and can coach, influence others
3) Can teach and verify competence in others
Sample Verification Tool
End Goal/Result:
•Create a model for internal coaching
that will hardwire the processes and sustain the behaviors long-term
•Raise the skill and confidence level of middle managers
•Help move a very good organizationto a great one
Example: Discharge Call PracticeWho makes the calls?
Past
• Mostly RN’s
• Most Nurse Managers participate
• Varies by unit─ Per diems (if under
budget)
─ Based on staffing ratio’s and # of discharges per day
─ Assigned RN to discharge calls
─ Each RN on unit making a few calls each, per day
• I.T. running reports
Current & Future
• 6 coaches met with assigned Nurse Manager to identify current practice for efficiency and effectiveness
• Moving towards:
─ Each RN on unit making a few calls each, per day
─ Will identify supplemental staff to assist, i.e. ICU staff
• Nurse Manager runs own unit compliance
11
In Summary…
“Instructions about your home care”
83
84
85
86
87
88
89
1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q09 4Q09
Mean
Sco
re
0
10
20
30
40
50
60
70
80
90
100
Natio
nal P
erc
en
tile R
an
k
Mean Score National rank
51st
76th87th
In Summary…
Overall Satisfaction
82
83
84
85
86
87
1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q09 4Q09
Mea
n S
co
re
0
10
20
30
40
50
60
70
80
90
100
Natio
na
l Pe
rce
ntile
Ra
nk
Mean Score National rank
74th
51st
87th
In Summary…
“Likelihood of recommending”
84
85
86
87
88
89
90
91
92
93
1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q09 4Q09
Me
an
Sc
ore
10
20
30
40
50
60
70
80
90
100
Na
tion
al P
erc
en
tile R
an
k
Mean Score National rank
Attempt to call
100% of patientsInternal
Coaches
Started
Discharge Calls
Measured
discharge calls
87th
53rd
Measured Nurse
Leader rounding
Measurement
Coaching Track
Measured
“Bundle” 93rd
A Final Thought
• “It’s interesting to know how patients think
when they have had a chance to reflect on
their experience with the hospital. If they feel
comfortable when they get home about how
to manage their care, felt cared about, and
knew they were in good hands, they are more
likely to perceive their care as better.”
Thank you.
Reference
s
Thank you.
Your Challenge
Before the Next Expedition Call….
• Develop a plan to test post-discharge phone calls for a subgroup of high-risk patients
66
12
Next Call: February 9th 1:00-2:00pm ET
Transform Care in Six StepsTransform Care in Six StepsDelivering Exceptional Care Experiences by
using the Patient and Family Centered Care (PFCC) Methodology and Practice
Patty EmbreeSr. Director, PFCC Project Management, Innovation Center
University of Pittsburgh Medical Center
67