HCAHPS: Moving the Needle

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Innovation in Care Delivery Symposium HCAHPS – Moving the Needle October 29, 2013 Rick Evans, MA Senior Director – Service Excellence

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  • 1.Innovation in Care Delivery Symposium HCAHPS Moving the NeedleOctober 29, 2013 Rick Evans, MA Senior Director Service Excellence

2. 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-2- 3. The Context for Improvement Surveys, Metrics and Emerging Reimbursement Structures-3- 4. 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 everyones role in achieving improvement By holding everyone accountable for tasks and deadlines By keeping the team updated on progress By celebrating success! 5. HCAHPS Survey Basics 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 6. HCAHPS: Questions RATE HOSPITAL 0-10HOSPITAL ENVIRONMENTRating Scale: 9-10Rating Scale: Always Room and bathroom kept cleanRECOMMEND THIS HOSPITAL Rating Scale: Definitely yesCOMMUNICATION W/ NURSES Rating Scale: Always Nurses treat with courtesy/respect Nurses listen carefully to you Nurses explained things in way you understandArea around room quiet at nightPAIN MANAGEMENT Rating Scale: Always Need medicine for pain Pain well controlled Staff do everything help with painRESPONSIVENESS OF HOSP STAFFCOMMUNICATION RE: MEDICINESRating Scale: AlwaysRating Scale: AlwaysNever pressed call buttonGiven medicine had not taken beforeCall button help soon as wanted itTell you what new medicine was forNeed help with bathroom/using bedpanStaff describe medicine side effectHelp toileting soon as you wantedCOMMUNICATION W/ DOCTORS Rating Scale: Always Doctors treat with courtesy/respect Doctors listen carefully to you Doctors explained things in way you understandDISCHARGE INFORMATION Rating Scale: Yes Left hospital- destination Staff talk about help when you left Info re: symptoms/problems to look for 7. A New Era in Patient Experience Coming for Outpatient, Surgical and Pediatrics and other areas in the future..Our Mission Excellence Every DayPatient Experience Metrics Operational Strength Healthcare Reform & ReimbursementOur Reputation Public Reporting of Data 8. Healthcare Reform Efforts Puts Hospital Dollars at RiskValue-based PurchasingProcess of care & Patient experienceBegins FY2013, full 2% annual payment update at risk by FY201730-Day ReadmissionsUp to 8 conditions targeted including AMI, HF, PNA1% DRG payment penalty beginning FY2013, rising to 3% by FY2015Hospital-Acquired Conditions Up to 8 conditions targeted1% DRG payment penalty for hospitals in worst quartile beginning FY2015By FY2017, $6 out of every $100 Medicare DRG reimbursement potentially is at risk 9. Reimbursement Methodology Attainment Score for how well we perform compared to peers Everyone Improvement Score for else is improvement over our own improving performance baseline too!Reimbursed for each domain based on which score is highest 10. Innovation Units Implementing Effective Interventions- 10 - 11. Innovation Units Focus Areas and Desired Outcomes Focus 1. 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 PracticeOutcomes 1. Patient Satisfaction: care is equitable and patient- and familyfocused 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 - 11 - 12. How do we achieve ALWAYS? ALWAYS Demands Consistency Consistency = Across shifts, team members, services and locationsStandardized Best Practices create consistency!SUCCESS!! 13. Innovations in Care Delivery Patient Journey Framework Initial 15 InterventionsPatient stay; direct patient care; tests; treatments; procedures; clinical support; operational supportDischarg e processInterventionAdmission process: ED, direct admits, transfersAfter InterventionInterventionPreadmission careDuring InterventionBeforePostdischarge careGoal: High-performing, inter-disciplinary teams that deliver safe, effective, timely, efficient, and equitable care that is patient- and family-centered Discharge Planning: -Est. discharge date -Discharge dispositionDomains of Practice Daily Interdisciplinary Team Rounds Electronic Unit Whiteboards In-Room Whiteboards Smart Phones Wireless laptop computers/tablets Business cards Hourly rounding Quiet hoursWelcome Packet (notebook and discharge envelope)Relationship-based careThe Attending Nurse roleCopyright MGH 2012 - 13 -Discharge -Follow-up Call ProgramHand-Over Rounding Checklist 14. 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 15. Introducing the Innovation Units Introduces Innovation Units Assures patients and families of continued quality care Invites participation 16. 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 17. Introducing the Team Orients patients and families Patient friendly role descriptions Facilitates discussion and questions Situates patients and families on the team 18. 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 19. 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 20. 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 (ICUs, 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 21. Communication: In-Room White Boards A communication basic Supports knowledge of care team Builds relationships Articulates patients goal Keeps an eye on discharge Can be integrated with notebook and other teaching tools Keeping the board current is critical Its only as good a resource as it is used- 21 - 22. 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- 22 - 23. 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, TVs 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 24. 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 25. 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- 25 - 26. 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 patients compliance with discharge instructions Evaluate understanding of patient education provided before discharge Identify opportunities for improvements in practice 27. 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 28. 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 29. 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 patients pain Positioning: Patients physical position and comfort; Positioning of needed items within reach Personal Hygiene: Help with toileting- 29 - 30. Implementation - Three Key Elements of the Best Practice 1. Strengthening Rounding Using the 4 Ps: Training for all staff Hourly Rounds using our process and scripts2. Documentation of rounds in the presence of the patient and family Two methods Bedside Logs White Boards3. Validation of rounds by the nurse leader Rounds on 5 patients per week using log Feedback to staff Monitoring of HCAHPS results30 31. 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 patients 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 32. The WHAT The Three Ps Pain Assess and address Positioning Patients physical position and comfort Positioning of needed items within reach Personal Hygiene Help with toileting Attending to these basics improves outcomes AND achieves efficiency 33. Hourly Rounding A Team Response MGH Model includes others: PCAs Alternating hours through the day Other disciplines trained Trained to address Ps when they are in the room 34. 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 35. 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 36. 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)- 36 - 37. Did the Needle Move? Summary of Results to Date- 37 - 38. HCAHPS Results 2011 vs. 2012 MGH-wide vs. Phase 1 Innovation UnitsMGH 2012Survey Measure Nurse Communication Composite Doctor Communication Composite Room Clean Quiet at Night Cleanliness/Quiet Composite Staff Responsiveness Composite Pain Management Composite Communication About Meds Composite Discharge Information Composite Overall Rating Likelihood to Recommend81.0 81.6 72.9 48.5 60.7 64.9 71.9 64.0 91.2 80.1 90.5HCAHPS 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 ICUs and Psych. Date pull: 3.04.13Change (2011 - 2012)+1.6 -0.3 +3.1 +3.3 +3.2 +1.3 +0.4 +1.3 +1.4 +1.0 +1.1Innovation Change Units 2012 (2011 - 2012)80.8 82.0 70.6 49.8 60.2 64.0 73.3 65.7 92.3 78.5 90.3+4.5 +0.5 +4.2 +6.2 +5.2 +1.7 +3.7 +6.8 +2.7 +2.4 +2.4KEY 2012 Score exceeds that of entire hospital Rate of Improvement Exceeds that of the entire hospital - 38 - 39. HCAHPS Results Q2 YTD MGH-wide vs. Phase 2 Innovation Units 2013 YTDSurvey Measure2013 Quarter 2 YTDMGH Overall Phase 2 Units MGH Overall Phase 2 UnitsNurse Communication Composite Doctor Communication Composite Room Clean Quiet at Night Cleanliness/Quiet Composite Staff Responsiveness Composite Pain Management Composite Communication About Meds Composite Discharge Information Composite Overall Rating Likelihood to Recommend80.6 81.7 74.2 50.1 62.1 63.5 71.180.4 81.5 74.6 50.3 62.4 62.8 72.281.3 82.1 75.6 52.3 63.9 65.0 71.965. 81.8 77.0 53.2 65.1 64.6 74.2 69.491.3 80.1 90.490.8 79.8 90.292.5 80.1 91.392.1 80.5 92.2* 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: 6.26.13KEY Phase 2 Units Score exceeds that of entire hospital - 39 - 40. HCAHPS Indicator Results - Quiet at Night How has Quiet at Night (Top Box %) been evolving over time? Our patients Upper/lower natural process limit% of maximum achie vable score 52504846Quiet Times Launched4442Q3-2011Q4-2011 Info BoxOrganization: MGH Survey: HCAHPSPlus Date Range: Range: 7/1/2011~6/30/2013Q2-2012 Cases Per Point Cases Per Point 4 8 32 64 256 512 2048 4096Q4-201216 128 1024 8192Date Range Date Range By Month By Quarter By 6 Months By Year * Period incompleteQ2-2013 41. HCAHPS Indicator Results - Nurse Communication How has Nurse Communication (Top Box %) been evolving over time? Our patients Upper/lower natural process limit% of maximum achievable score 8482807876Q3-2011Q4-2011 Info BoxOrganization: MGH Survey: HCAHPSPlus Date Range: Range: 7/1/2011~6/30/2013Q2-2012 Cases Per Point Cases Per Point 4 8 32 64 256 512 2048 4096Q4-201216 128 1024 8192Date Range Date Range By Month By Quarter By 6 Months By Year * Period incompleteQ2-2013 42. HCAHPS Indicator Results - Discharge Information How has Discharge Info (Top Box %) been evolving over time? Our patients Upper/lower natural process limit% of maximum achievable score 94 93 92 91 90 89 88Q3-2011Q4-2011 Info BoxOrganization: MGH Survey: HCAHPSPlus Date Range: Range: 7/1/2011~6/30/2013Q2-2012 Cases Per Point Cases Per Point 4 8 32 64 256 512 2048 4096Q4-201216 128 1024 8192Date Range Date Range By Month By Quarter By 6 Months By Year * Period incompleteQ2-2013 43. 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 44. Anything else I can do for you? Rick Evans Senior Director Service Excellence Massachusetts General Hospital and Mass General Physicians Organization [email protected] 617-724-2838