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