Designing and Implementing a Patient Experience Bundle ... · • Taking a closer look demonstrates...

Designing and Implementing a Patient Experience Bundle©

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April 3rd, 2019

Christina Mouradian, MSProgram Manager, Clinical Transformation

DISCLOSURE POLICY

Northwell Health adheres to the ACCME’s New Standards for Commercial Support. Any individuals in a position to control the content of a activity, including faculty, planners, reviewers or others are required to disclose all financial relationships with commercial interests. All relevant conflicts of interest will be resolved prior to the commencement of the activity.

The following Northwell employees have nothing to disclose:

Name RoleMartin Doerfler, MD Executive Sponsor

Nancy Riebling, MS AVP Improvement Science

Sherry Norouzzadeh, PhD Assistant Director Clinical Transformation

Christina Mouradian, MS Program Manager Improvement Science

George Reeder, RN Program Manager Improvement Science

Alison Hillier, BS Improvement Science Specialist

Ryan Cowan, PA-C, MBA Physician Assistant, Cardiology

Kendra Brereton, MS Improvement Science Specialist

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Learning Objectives

• Understand how to use the bundle philosophy and process data to improve patient experience and “likelihood to recommend scores”

• Identification of key elements for a bundle approach to improving patient experience • Application of the Quick Start program to rapidly and successfully integrate meaningful

improvements using the Patient Experience Bundle© (PEB)

Overview

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4

New York’s largest private employer and health care provider, with 23 hospitals and more than 700 outpatient facilities

Problem Background

• Six Sigma and Lean Projects at Northwell Health’s Emergency Departments (ED) to reduce the waiting time and number of holds (10/21 hospitals)

• 10% increase in patient volume

• Decreasing trend in patient satisfaction

Collaborative Work to Improve Patient Experience

Why use the Bundle Concept?

• Assists health care providers to more reliably deliver the best possible care to patients• Ties changes together into a package of associated interventions that must be

followed for every patient, every time• Bundle elements, when performed collectively and reliably, have been proven to

improve patient outcomes - Sepsis

• Incorporates the concept of roll throughput yield:

90% 90% 90% 90%

66%

0%

50%

100%

Element 1 Element 2 Element 3 Element 4 Overall

Overall Achievement with 90% Reliability

• When we operate in silos, 90% reliability at an individual process step would appear to be highly reliable

• However, when considered from a complete experience only 66% of patients receive the intended experience

Traditional Patient Satisfaction Approach

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Exit

Do you know who your doctor is?

Do you know your plan of care?

Are your pain needs being managed?

How long did it take for your call bell needs to be met?

Are your food needs met?

Did you have a pillow/blanket when needed?

How long did it take for your bathroom needs to be met?

Was your personal privacy respected?

How was your experience?

Problems:1. Sample size2. Delayed feedback3. Too late to perform service recovery

Measured by 3rd

party survey vendors

Patient Experience Bundle© Approach

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Exit

Do you know who your doctor is?

Do you know your plan of care?

Are your pain needs being managed?

How long did it take for your call bell needs to be met?

Are your food needs met?

Did you have a pillow/blanket when needed?

How long did it take for your bathroom needs to be met?

Was your personal privacy respected?

How was your experience?

Measured by 3rd

party survey vendors

Communication

Logistics

Basic Needs/ Comfort

Environment

Measure Patient Experience Bundle© Compliance in real time

for targeted service recovery

Patient Experience Bundle©

Comparing Approaches

• Post-discharge survey which only assesses outcome metric to represent level of patient satisfaction- Very satisfied or dissatisfied - Approximately 30% return rate

• Not real time and not specifically tied to process

• Service recovery approach for patient satisfaction

• Silo-ed tactic to address a connected experience

• Daily survey of all patients • Metric is real time, process driven

measure• Pro-active approach to improve patient

satisfaction• Cohesive approach to a unified patient

experience- Reinforces the interactions of

processes to collectively drive a single outcome

Traditional Patient Satisfaction Approach


Approach

A new approach to improving patient care was needed. The team took an innovative look at a more proactive and real-time approach to increase patient satisfaction across units in the Organization


Development

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Patient Experience Bundle© Development

• Assemble and collate PGLTR scores and comments

• Conduct a literature review to establish benchmark

• Collect ED Holds information in Six Sigma methodology

• Update PGLTR scores and comments


• Collect Floor Holds information in Six Sigma methodology


• Collect ED Holds information in Quick Start

• Collect Floor Holds information in Quick Start

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Building the Model Validating the Model Expanding the Model

Criti

cal C

ompo

nent

sPa

rtici

patin

g Lo

catio

ns

• LHH• LIJMC• NSUH• SSH• SIUH

• HH• CCMC• PMHC• MMC• PBMC

QS 1• SH• PH• MMC• LIJFH

QS 2• GC• PBMC• LIJVS• SSH

QS 3• LIJFH• SIUH• LIJVS• SSH• MMH

Six Sigma Round 1

• Voice of Customer (VOC) to Critical to Quality (CTQ) Criticisms from patients were compiled, analyzed, and categorized to understand the drivers of dissatisfaction

LHH

SSH

LIJ

NSUH

SIUH

Summary of Common Themes

Defects Per Patient Service

Bundle

Communication

Environment

Basic Needs/Comfort

Logistics

Privacy

Toileting Needs

POC (MD to RN acknowledgement)

Rounding

Proper/Timely Med Administration

Dietary (hunger/Thirst)

Comfort Items

Response to calls/Request

TAT(request to tray delivery)

# times tray requested but not delivered

How long did it take to have your needs acknowledged? (<5 <15,<30,<60,>60,never)

Where were you located? (Holding Room, Main ED, Hallway)

What was your request? (Entertainment, Food, Bathroom, Other)

TAT (MD admit orders to RN acknowledgement)

# of MD pt rounds/shift

# of RN pt rounds/shift

Pain assessment level/RN rounds TAT ( STAT med order to administration time)

Did pt have requested number of pillow/sheets/blankets? (If no what were they missing Pillow/Sheet/Blanket)

TAT (laundry notification to linen delivery)

# times privacy curtain requested but not provided

# privacy curtains available

# times your toileting needs were not met/shift

# times dx/meds/results were explained to you per shift? (1,2,3,4,never)

# time refreshments/snacks offered/shift

“The Patient Experience Bundle©”

Sample Manual Surveys

• Each team designed a survey which at least included 8 questions related to bundle compliance

• Manual Data collection (patients surveys) • Daily bundle compliance calculated based on survey responses

Outcomes and Results

Bundle compliance improved from a range of 42%-67% to a range of 71%-88% and correlated with an increase in “likelihood to recommend”

80

81

82

83

84

85

86

87

0102030405060708090

Baseline

Post Im

prove

Control

Sustainabilit

y

PG S

core

(Lik

elih

ood

to

Reco

mm

end)

Bund

le C

ompl

ianc

e (A

vg, S

td) Hospital A

8585.58686.58787.58888.58989.590

0102030405060708090

Baseline

Post Im

prove

Control

Sustainabilit

y

PG S

core

(Lik

elih

ood

to

Reco

mm

end)

Bund

le C

ompl

ianc

e (A

vg, S

td) Hospital B

70727476788082848688

01020304050607080

Baseline

Post Im

prove

Control

Sustainabilit

y

PG S

core

(Lik

elih

ood

to

Reco

mm

end)

Bund

le C

ompl

ianc

e (A

vg, S

td) Hospital C

81.5

82

82.5

83

83.5

84

0102030405060708090

Baseline

Post Im

prove

Control

Sustainabilit

y

PG S

core

(Lik

elih

ood

to

Reco

mm

end)

Bund

le C

ompl

ianc

e (A

vg, S

td) Hospital D

767880828486889092

0102030405060708090

100

Baseline

Post Im

prove

Control

Sustainabilit

y

PG S

core

(Lik

elih

ood

to

Reco

mm

end)

Bund

le C

ompl

ianc

e (A

vg, S

td) Hospital E

Data is Collected: March 2015- April 2016











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Criti

cal C

ompo

nent

sPa

rtici

patin

g Lo

catio

ns






Six Sigma Round 2

Huntington

MMC

CCMC

PBMCPMHC

ED

Inpatients

Summary of Common Themes

Defects Per Patient Service

Bundle

Communication

Environment

Basic Needs/Comfort

Logistics

Privacy

Toileting Needs

POC (MD to RN acknowledgement)

Rounding

Proper/Timely Med Administration

Dietary (hunger/Thirst)

Comfort Items

Response to calls/Request

TAT(request to tray delivery)

# times tray requested but not delivered

How long did it take to have your needs acknowledged? (<5 <15,<30,<60,>60,never)

Where were you located? (Holding Room, Main ED, Hallway)

What was your request? (Entertainment, Food, Bathroom, Other)

TAT (MD admit orders to RN acknowledgement)

# of MD pt rounds/shift

# of RN pt rounds/shift

Pain assessment level/RN rounds TAT ( STAT med order to administration time)

Did pt have requested number of pillow/sheets/blankets? (If no what were they missing Pillow/Sheet/Blanket)

TAT (laundry notification to linen delivery)

# times privacy curtain requested but not provided

# privacy curtains available

# times your toileting needs were not met/shift

# times dx/meds/results were explained to you per shift? (1,2,3,4,never)

# time refreshments/snacks offered/shift

“The Patient Experience Bundle©”

Outcome and Results

• Taking a closer look demonstrates congruent movement between PEB© compliance and PG Likelihood to Recommend scores

• Using the daily PEB© compliance score from the 2,758 patient surveys, the variation index, and standard deviation, the PEB © compliance score is predicting the PG LTR score

0102030405060708090

100

Apr2

017

Jul2

017

Oct

2017

Mar

2017

Jun2

017

Sep2

017

Jun2

017

Sep2

017

Jun2

015

Sep2

015

Jan2

016

May

2016

Aug2

016

Jan2

017

Apr2

017

Jul2

017

Oct

2017

Jul2

017

Oct

2017

Sep2

016

Dec2

016

Mar

2017

Jun2

017

Sep2

017

Oct

2016

Jan2

017

Apr2

017

Mar

2017

Sep2

017

A B C E G H I1 I2

%ile

Ran

king

Facilities and their participation duration

PG LTR vs. PEB Compliance Score

PG LTR

PEB

Expanding to Quick Start Program

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Criti

cal C

ompo

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patin

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Book of Solutions

• The collective work from all teams was compiled and distilled into a collection of best practices

• Each bundle element has detailed examples of implemented solutions and contact information from the implementing site(s)

Quick Start Program Timeline

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Survey data collection is continuous throughout timeline

Electronic Surveys

• Moving to electronic survey data collection will improve sustainability of the processes• Electronic data collection will feed to a graphical dashboard, supporting front line

clinical staff change efforts

Dashboard

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Sustainability

“Pulse Checks”• Quarterly reports submitted by each

team and distributed to the Chief Operation Officer of Northwell Health

“Bring Back Day” • All participating teams brought back for

an in person presentation to senior leadership

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Breakout Activity

Communication

Logistics

Basic Needs/Comfort

Environment

Patient Experience Bundle© Survey Patient

Communication Logistics Basic Needs/ Comfort

Environment

123456789

10Total Sum

1 2 3 4 5 6 7 8 9 10

Patients to Survey

Survey the patients above by counting how many indicators, of each

color, a patient has. Tally the flags per patient in the table below:

Today’s date:

April 3rd, 2019CC C C C CC

LL L

L L

LL

L

BB

B

BB B

B

BB

EE EE E E EE E

C L B E

Communication

Logistics

Basic Needs/Comfort

Environment

Patient Experience Bundle© Survey Patient

Communication Logistics Basic Needs/ Comfort

Environment

1 1 1 12 1 1 13 1 1 14 1 1 1 15 1 1 16 1 1 1 17 1 1 18 1 1 19 1 1 1

10 1 1 1 1Total Sum 7 8 9 9

1 2 3 4 5 6 7 8 9 10

Patients to Survey

Today’s date:April 3rd, 2019

CC C C C CC

L L LL L

LL

LB

BB

BB BB

B B

EE EE E E EE E

C L B E

Survey the patients above by counting how many indicators, of each color, a patient has. Tally the flags per patient in the table below:

Patient Experience Bundle© Dashboard

43%

29%

14%

14%Communication

Logistics

Basic Needs/Comfort

Enviornment

Daily Bundle Compliance

Average PEB Score

0

20

40

60

80

4/2/20193/31/2019 4/1/2019 4/3/2019

%

% Defects by Bundle Element

64.5%

0

5

10

15

4/3/20193/31/2019 4/1/2019 4/2/2019

Count

Daily # of Surveys

Average Surveys per Day

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Conclusion and Discussion

• Although it is routine to measure individual processes to improve patient experience, patients do not view these as separate events, but rather as a collection of encounters that determine the patient’s perception of his or her experience

• The Patient Experience Bundle© is built upon identification of common specific elements of care that impact patient satisfaction and detailed mathematical analysis of the relationship between factors

• Current patient satisfaction assessment results are delayed and selective making it difficult for hospitals to assess standings and evaluate process improvement initiatives real time

• Implementing the Patient Experience Bundle© will improve all facility scores, regardless of starting position:- Low-performing sites move to the middle of the distribution- Mid-tier sites are able to spring board to the upper tier- Top-tier achieve and sustain 90th percentile and higher ratings

References

1. Riebling, N. S. Norouzzadeh, C. Mouradian, G. Reeder, A. Hillier, and M.E. Doerfler. 2018. Quantifying Patient Satisfaction with Process Metrics using a Weighted Approach. BMJ Open Quality. (https://bmjopenquality.bmj.com/content/8/1/e000458).

2. S. Norouzzadeh, N. Riebling, C. Mouradian, G. Reeder, A. Hillier. Improving Patient Experience with High Reliability. CipherHealth'sPartners in Excellence Conference, San Diego CA, June 19-20, 2019. (Accepted)

3. Norouzzadeh, S., N. Riebling, C. Mouradian, G. Reeder, A. Hillier. Using Real-Time Surveys to Deliver Exceptional Patient Experience with High Reliability. The Beryl Institute call for case studies 2019. (Accepted)

4. Mouradian, C., N. Riebling, S. Norouzzadeh, G. Reeder, A. Hillier, and M.E. Doerfler. Designing & Implementing a Patient Experience Bundle. The Beryl Institute Patient Experience Conference, Dallas, Texas April 1-5, 2019. (Accepted)

5. Riebling, N. S. Norouzzadeh, C. Mouradian, G. Reeder, A. Hillier, and M.E. Doerfler. How to Measure and Improve Patient Comfort: Designing and Implementing a Patient Experience Bundle. BMJ & IHI Quality Forum: International Forum on Quality and Safety in Healthcare. Melbourne, Australia, September 10-12, 2018.

6. Norouzzadeh, S., R. Cowan, C. Mouradian, E. Chen, G. Reeder, and N. Riebling. Weighted Yield Bundle to Quantify Patient Experience in Hospitals. 2017 INFORMS Annual Meeting, Houston, Texas, October 22-25.

7. Riebling, N., S. Norouzzadeh, G. Reeder, C. Mouradian, E. Chen, M. Doerfler. Quantifying Patient Satisfaction with Process Metrics Using a Weighted Bundle Approach. Institute for Healthcare Improvement, 28th Annual National Forum on Quality Improvement in Healthcare, Orlando, Florida, December 4-7, 2016.

8. Norouzzadeh, S. and G. Reeder. Weighted Bundle to Quantify Patient Experience. 25th Annual Service Quality Conference, Chicago, IL, October 24-25, 2016.

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Thank you!

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