Transforming Care at the Bedside across Wisconsin

1. Transforming Care at the Bedsideacross Wisconsin Monthly Webinar for January The 90 day Challenge! Please mute or phone by using *6. Un-mute to speak by using *7 Please mute your computer speakers and call into the phone line

2. Welcome to Today’s Call Please confirm your hospital is in attendance (if you miss roll call – please e-mail Stephanie by 4 pm)

3. Today’s Agenda • Announcements • Site Visit Update from Judy • CNO Reports and Innovation Logs 2. 90 Day Challenge Slides 3. Upcoming Webinars

4. TOPIC: SICU Pain Improvement Score DATE: Jan. 3, 2014 HOSPITAL: Froedtert Hospital Milwaukee Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • 1) more attainable goal for the TCAB group for a 90 day challenge • 2) Difficult to do a “quick fix” on a long term problem in short time span • 3) SICU will continue to strive for improved pain score (look at follow up) 2013 SICU Avatar Score • What was your 90 day aim? • Increase Avatar pain score by .2% from 85.85 to 86.05 in 90 days. For ICUs, Avatar is similar to HCAPS score but consists of only four questions. The question related to pain is “Given my medical condition, I was satisfied with how well my pain was controlled in SICU” “Given my medical condition, I was satisfied with how my pain was controlled in SiCU” Root Cause(s)? • What is the cause of the problem? • There are only four questions related to a patient’s stay in the ICU. The “N” ( total number of returned survey )is low. One negative reply affects the total score. • Difficult to totally relieve pain in certain populations (trauma, intubated waiting to be extubated, brain injury requiring neuro assessments) • Pain reassessment not documented as indicated by audits Follow Up • What are the next steps? • Posting trend of Avatar pain score • Re-education at: staff meetings, newsletter, posting in report room • Utilization of pain info on white board in patient room’s: laminated pain verbiage on white board along with pain score • Developing a “script” to reflect the Avatar pain question on survey • Updating patient education booklet to reflect Avatar statement

5. BEDSIDE REPORT JANUARY 2014 Fort Healthcare Lessons Learned Aim Statement: Measure • It does not take longer to do bedside report. • Patients and families like it and feel like they are participating in their plan of care. • Increase in “near-misses” caught in a timely manner (ex.; Iv abx not infusing, bed alarm off, scd’s off, infiltrated IV sites, etc.) • In 90 days increase patient safety and communication through consistently doing bedside reporting. Place Run Chart or Graph here Follow Up Root Cause(s)? • Leadership to continue patient rounding for patients feedback on bedside report. • Implement Inpatient Services Folder containing information about bedside report to be given to patients on admission. • UBC to continue to encourage staff to participate in bedside report. • Monitor if decrease in patient falls • Monitor clarity events for near-misses. • Lack of patient participation in plan of care. • Inefficiency of staff time during shift change. • Safety issues related to clarity events.

6. TOPIC: Nursing Vitality Scores DATE:01/07/2014 HOSPITAL: Agnesian Healthcare (SAH) Lessons Learned Measure Aim Statement: • What will be done differently as a result of this improvement process • 1.What will be done differently as a result of this improvement process • •Work on projects that are quick wins if the end date is 3 month. • •Bring in the other disiplines early to get their feedback. • •Increase awareness for the associates working through the process. Often reminders of the change implimented. • 1.Increase Vitality score by 1-2% Root Cause(s)? Follow Up • 1.What is the cause of the problem? • •Associates not working as a team • •Staff turn-over • •Too many “hoops” to implement changes • •IT issues with Advanced Care Documentation • What are the next steps? • Implement Break Buddies on all the units. • •Work with volunteer Services to implement a partnership to help with patients that need to talk or want companionship. • •Encourage nurses to use the new medication sheets routinely. • •Continue to try to get a Compliment Hotline started

7. TOPIC: Pain Menu DATE: 1.7.2014 HOSPITAL: Froedtert- Community Memorial Ortho Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • More feedback from patients versus just asking yes/no questions. • What was your 90 day aim? • To increase patient’s awareness of ALL pain options, both pharmacological and non pharmacological. During post discharge phone calls we have asked patient’s if they felt they understood all pain options provided to them. Root Cause(s)? • What is the cause of the problem? • Being an orthopedic unit, pain management is always a concern. Pain control is also a strategic goal for our organization. Ortho TCAB wanted to do something that would focus on improving patient’s pain while they were inpatient and even when they go home. Follow Up • What are the next steps? • Continue to use the pain menus and spread the word to the rest of the hospital

8. TOPIC: Bedside Report DATE: January 2014 HOSPITAL: Westfields Hopsital Lessons Learned Aim Statement: Measure • This is still a work in progress • Readdress the importance of this newly adapted bedside report and the impact it has on patient satisfaction • What was your 90 day aim? Our focus was to continue with bedside reporting and each 30 days we would reevaluate, make necessary adjustments and continue forward. We wanted to include what our patient satisfaction scores were Root Cause(s)? • Patient satisfaction is high, not enough nursing staff support • Old habits die hard – continuing with more verbal report • Not enough understanding of importance to patient and family for bedside report Follow Up • Encourage staff to continue with bedside report • Revisit new word/ phrases to use when taking care of same patient over time

9. TOPIC: Hourly Rounding DATE: 12-19-13 HOSPITAL: St Croix Regional Medical Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • Found through our call light study that the majority of the call lights were due to patients needing to use the bathroom, IV pump alarms and bed or tab alarms. • It was difficult to match the RN and NA so that their schedules and job duties matched the rounding schedule. • What was your 90 day aim?. • To Develop a plan for Implementing Purposeful Hourly Rounding on the Med-Surg unit. Root Cause(s)? What is the cause of the problem? Unsuccessful Implementation of Hourly Rounding in the past. Was not a team approach, but focused as a Nursing Assistant responsibility. Follow Up What are the next steps? 1- Develop 6 teams of RN’ s and aides that work together on the weekends to do another trial of rounding to find more barriers or successes to our rounding. 2- Develop a rounding schedule for the staff to be able to visualize with times to keep on track.

10. TOPIC: Observation Patients and Problems Associated with the Use of Home Meds DATE: January 3, 2014 HOSPITAL: Aurora Lakeland Medical Center Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • Formation of an interdisciplinary team to address designated storage area and process for ensuring that the patient is discharged with their home meds. • What was your 90 day aim? Implement a process for the identification and administration of home meds in the observation patient. This is to include the appropriate storage of the meds and subsequent return to the patient at discharge while the patient is hospitalized. Root Cause(s)? Follow Up • What is the cause of the problem? • What are the next steps? Creation of a formal process to address the issues/barriers of home meds in the observation patient

11. TOPIC: Medication Education DATE: 1/06/14 HOSPITAL: Mayo Clinic Health System La Crosse Lessons Learned Aim Statement: Measure • On admission each patient will receive a medication information sheet with common medications listed, what they are used for and possible side effects in an easy to understand format in their admission folder. • It is the nurses responsibility each shift to look at the education sheet, highlight and educate about any medications the patient is taking. • The patient is able to take that education sheet home with them. • Data varies, depends on number of respondents, takes around 3 months to be accurate. Watch for consistency. • Increase HCAHPS scores for teaching patients what new medications they are taking are for from 75% to 79% and teaching patients about side effects of medications they are on in a way they can understand from 48% to 50%. Root Cause(s)? • There was no standard way to educate patients about new medications they were taking and side effects of medications they were taking. • Completed HCAHPS education for staff at unit meeting and completed and A3 with RN’s at each unit meeting. Follow Up • Approval from hospital Education Council • Brand education sheets. • Educate all staff. • Add education sheets to admission folders.

12. TOPIC: Increase Time at the Bedside DATE: 12/28/2013 HOSPITAL: Aurora Sinai Lessons Learned Aim Statement: Measure • 1.) Focus again on supplies and equipment. Are they available, in working condition and readily accessible. • 2.) Need to continue to enforce real time charting in rooms. • 3.) Need to work on bedside reporting at shift change. Some staff are willing to try it and adopt it, while others still are reluctant. • 4.) Hourly rounding has been adopted and is working. • 5.) Implement rounding with MD’s and nursing staff when rounding on patients. • Will repeat time study in one month and see if the inventions we have placed above will increase our time at the bedside to 65%. • Aim was to increase time at bedside to 60%. • Goal was met, 61% of RN’s time was spent at the bedside Root Cause(s)? 1.) Supplies and equipment issues 2.) Time management 3.) Poor shift to shift report/ transition 4.) Reluctance to change 5.) MD’s rounding on patients without nursing staff Follow Up Test Cycles 1.) Re-introduced Bedside reporting with RN’s and purposeful rounding -Staff willing to adapt and adopt 2.) Hourly rounding -Adopted and working 3.) Re-addressed supplies and equipment issue

13. TOPIC: Medication Education Sheet DATE: 1/7/2014 HOSPITAL: Tomah Memorial Hospital Lessons Learned Aim Statement: Measure 1. What will be done differently as a result of this improvement process More medication education will be given to patients which will help increase our HCAHPS scores and help decrease readmissions. *When we predicted our goals for improvement we did not take into consideration the lag time for HCAHPS scores to be received. We hope to see results with the incoming scores in the next couple months. • What was your 90 day aim?. • By Dec. 31st we will improve patients understanding of new medication and increase at least 15% in HCAHPS Scores. HCAHPS Question Root Cause(s)? • What is the cause of the problem? • Our HCAHPS survey scores for questions 16, 17 and 25 concerning patient medication education were unsatisfactory. Our unit feels as though we could always do more medication education with patients. Some reasons we haven’t been up to par is due to poor education material and not a lot of time to teach. Follow Up • What are the next steps? • Finish respiratory education sheet. • Develop more medication education sheets for other classes of drugs or diagnoses. • Adopt, adapt, or abandon quiet time/teaching time.

14. TOPIC: Bedside Shift Reporting DATE: 1/2/2014 HOSPITAL: Froedtert Health: CMH - Med Lessons Learned Aim Statement: Measure • Increased patient involvement in plan of care enhances overall patient satisfaction with nurse communication. • Identify barriers to bedside report prior to implementation. Ours was time, once this was decreased it was an easier transition. • You need a few dedicated staff to keep the ball rolling and people motivated to continue bedside report. • 1. By December 31, 2013, 75% of patients will answer yes to a question about participation in planning their care. • According to collected data, 100% of patients called feel involved in their plan of care since implementation. Root Cause(s)? Pre TCAB Kardex Bedside • Patients felt separate from the care they were receiving. Care was done “to them” not “with them”. • Some important information was being missed on patients that were staying for long periods of time. Follow Up • Auditing compliance and use of bedside shift report

15. TOPIC: Patient Partnership/ Activity Log DATE: Jan. 2014 HOSPITAL: Midwest Orthopedic Specialty Hospital Lessons Learned Aim Statement: Measure • Not enough staff participation. Patients too sedated DOS to make use of the log. • Need more communication & reminders to staff. Patients are better able to work on logs when m ore alert on POD 1. • Audit results more frequently so changes can be made to meet goals. Improve partnership with patients by use of an activity log to prevent post-op complications. (IS, flex/ext. ankle exercises, CPM time, up in chair,) In 90 days, 50% of patients will actively be working on the log during audits. Follow Up Root Cause(s)? • Continue to audit more frequently and provide staff feedback. • Add to SCIP checklist • Monitor HCAHPS , Press Ganey, & HAC reports. • The activity log had been included in Welcome Folders several years ago to engage patients in tracking activity goals, but had not been utilized. **Activity Log

16. TOPIC: Break Buddies DATE: September 2013 HOSPITAL: MCHS-Eau Claire Lessons Learned Measure Aim Statement: • What will be done differently as a result of this improvement process • Assure break buddies are assigned at every shift-Staff are not actively taking breaks unless held accountable by break buddy • Show staff data at monthly staff meetings to support the use of break buddies • What was your 90 day aim? • In 90 days, increase the number of staff that take a lunch break with a goal of 99% Root Cause(s)? • What is the cause of the problem? • *Workload • *Turnovers of patients (d/c, admits, tx) • *Interruptions Follow Up • What are the next steps? • * Data collection

17. Patient Education Discharge Teaching 01/08/2013 Milwaukee VA Medical Center Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • Discharge teaching will begin upon admission instead of the day of discharge. Also, there will be specified teaching topics individualized to each veteran based on their medical conditions and teaching needs. • What was your 90 day aim?. • Our aim is to pilot a new process for implementing patient discharge teaching upon admission. It will be a detailed process followed by all staff on the unit. Root Cause(s)? • What is the cause of the problem? • Currently, there is no standardized process for determining discharge teaching needs or timeframes for completing discharge teaching. Follow Up • What are the next steps? • The next steps are to implement the pilot, obtain feedback from staff, and make adjustments based upon these recommendations prior to full implementation.

18. TOPIC: Team Vitality DATE: 1/1/14 HOSPITAL: Spooner Health System Lessons Learned Aim Statement: Measure a) Staff will stop chatting and wait until the end of report for each patient to ask questions. b) Staff will ask how well a patient is known thereby preventing leaving out pertinent information to new nurses c)Recommend to expand use of whiteboards in patient room to communicate further info ie: fall risk, activity level, diet, etc. d)Recommend use of white board for staff in report room. Percentage of 5/5 responses Shift Change Patient Handoff mo/yr Info. Exchange Info Exchange 10/12 32 24 03/13 25 5 10/13 25 15 (Will not have results of test until next survey) • What was your 90 day aim?. • Increase % of nurses who score 5/5 to the questions regarding communication between shifts and hand-off communication on the Team Vitality Survey. Root Cause(s)? • What is the cause of the problem? • a) Hand off from ED to floor feels rushed, not enough time to ask questions. • b)Distraction is a large issue during report and at handoff., especially when sidebar conversations take place. • c)unable to find reporting RN in a timely manner to ask questions after listening to taped report. • d)Information is not always thorough during report. • e) Some staff give oral report and others tape report. Follow Up • What are the next steps? • a) Coach/teach staff to use SBAR during report. • b) Nursing Management to be approached regarding option of assignments, role of charge nurse, use of staff white board. • c) Continue to investigate pro’s/con’s of taped vs. verbal report.

19. TOPIC: Bedside Report DATE: Jan 2014 HOSPITAL: Mercy Hospital Lessons Learned Aim Statement: Measure • Share testimonials from nurse to nurse about benefits of change process • Temperature check of unit and team prior to implementing change process • Encourage and praise • Share progress with other departments Place Run Chart or Graph here • Increase bedside report compliance by 50% on all shifts through standardizing bedside report process Root Cause(s)? • Miscommunication • Lack of confidence • Fear of change in process • Misunderstanding of process Follow Up • Continue temperature check • Onboarding of new staff • Problem solving and intervention • Remain open to improvements

20. TOPIC: Medication Education DATE: 1/2014 HOSPITAL: Richland Hospital Lessons Learned Aim Statement: Measure • Standard Teaching Documents being used for our most used medications. • Nurses are now able to see medication education that is being done with patients. • Better follow through on medication education based on the above. To improve patient understanding of meds and to increase HCAHPS scores by 10% in the category “Communication about Meds” Root Cause(s)? Test Cycles -Nurses doing routine med teaching and patients not realizing med teaching being done. Need to come up with a tool to use so patients realize education is taking place and so nurses can still complete teaching in a timely manner. -Hard to find documentation on medication education previous nurses have done with patient • Gathered Data: TCAB developed a med question sheet to gauge how well patients know their meds. • Stole Shamelessly: Obtained med teaching sheets from another TCAB team. • Applied to Our Patient Population: Looked at our primary population and diagnoses and created med teaching sheets for our unit. • Colloborated with Pharmacy and EMR: Worked with our pharmacy director to produce medication education sheets and EMR to build documentation screens into Meditech. Follow Up • Implementation of Medication Teaching Tool • Continue EMR involvement as they work to build a more efficient way to document med teaching in Meditech • Monitor HCAHPS for improvement

21. TOPIC: Increase ambulation to decrease falls DATE: 1/7/2014 HOSPITAL: William S. Middleton Memorial VA Hospital Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • Consistent documentation of ambulation in a specific section of the nurse shift summary note as identified by nursing and other disciplines caring for the patient. • Increased awareness which will increase staff commitment to patient ambulation • What was your 90 day aim? • Increase purposeful patient ambulation and staff awareness of the need to ambulate through standardized documentation. Root Cause(s)? • What is the cause of the problem? • Nurses had different perceptions on where ambulation should be documented • There was no guide of measurement in the hallway to assist staff with documentation of distance Follow Up • What are the next steps? • Evaluate effectiveness in ambulation program for those patients that are high fall risk

22. DATE: 1/9/13 TOPIC: Break Buddies HOSPITAL: St. Elizabeth Hospital Lessons Learned Measure f • What will be done differently as a result of this improvement process? • Continue to engage associates in a supportive manner and listen to their ideas • Management coach associates who habitually miss their meal break • Staff need to use scripting with patients to inform them of the staff break time and meet needs prior to taking their break • Share the results with associates regularly to track progress Aim Statement: • What was your 90 day aim?. • 1. Decrease # of No-Lunch punches by 50% • 2. Decrease dollars paid to employees for no-lunch punches by 50% Follow Up Root Cause(s)? • What are the next steps? • Punching in and out during lunch break to ensure all employees have a 30 minute uninterrupted break • Staff MUST hand-off phones for break so we’ll purchase an extra phone to use on breaks for personal calls • Spread our progress with other Ministry hospitals • What is the cause of the problem? • Staff kept their phones with them on break and were constantly interrupted when trying to have a 30 minute break • Staff needed to hand their phones off to someone so they could actually take a break • Staff required education on fatigue and the importance of taking a break Cycle 1: 2 RNS Cycle 2: 4 RNS paired Cycle 3: 6 RNS paired Cycle 4: 6 RNS & 2 TCS paired Cycle 5: 6 RNS, 4 TCS, UC paired

23. TOPIC: Nurse Server Stocking DATE: January 2013 HOSPITAL: WFH-Franklin Lessons Learned Measure Aim Statement: • Important to make sure that locking mechanisms on nurse servers are easy to use. • Our keyholes were not easy to use so for new construction looking at a different options for locking mechanisms. • What was your 90 day aim?. To decrease amount of time that is spent between running and gathering supplies by stocking the nurse server. Root Cause(s)? • What is the cause of the problem? • Nurse servers were not stocked with the most frequently used supplies so staff would spend a greater amount of time hunting and gathering instead of spending it with patients. Follow Up • What are the next steps? Is to gather our post implementation step data week of January 13th.

24. TOPIC: Fall Prevention DATE: Jan 8 HOSPITAL: Aurora Memorial Hospital - Burlington Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process • There will be guidelines based on the Morse fall scale of 45 or greater that the beds will be set as follows. • Brake on, Bed plugged into nurse call system, side rails up, bed in low position, bed alert on and programed to zone two, ibed on. All alarms are programed into every staffs phone and if the alarm goes off everyone goes. • Fall tree on the unit with leaves placed with every day there is no falls, if a fall occurs all the leaves will come off. • We will have no falls for 100 days. Place Run Chart or Graph here Root Cause(s)? • What is the cause of the problem? • Increase in falls from July thru September that doubled our yearly fall total. Did not meet our goal of no falls with injury and to reduce falls my 50% from previous years total. Follow Up • What are the next steps? • Bed audits to ensure all the above criteria are met • No further falls for the 100 days we set for out goal.

25. TOPIC: Medication Education DATE:11/1/13 HOSPITAL: Calumet Medical Center Lessons Learned Aim Statement: Measure • Time consuming- needs to be done prior to discharge • Provider compliance is a challenge • Written info appreciated by patients • Pt education is easier and consistent with medication cheat sheet. To improve and be consistent with medication education and documenting purpose of med in patient copy of med list at least by 50% in 90 days. Manual audit of patient copy of med list at discharge to reflect purpose HCAHPS: Understood the purpose of medication Root Cause(s)? • Patient don’t always know their meds and its purpose – potentially impacting compliance. • Pt education is inconsistent and lacking ( purpose, side effects and when best to take) Follow Up • Manual audit for med-purpose and reinforce • Work with providers to improve documentation • Encourage use of med-educ cheat sheet for consistency, validate on rounding with patient

26. TOPIC: Discharge teaching DATE: 1/7/14 HOSPITAL: Hayward Area Memorial Hospital Lessons Learned Aim Statement: Measure • What will be done differently as a result of this improvement process? • A randomized audit of charts was done for the month of November and December to audit for documentation of “teach back” on discharge. This audit found nursing used teach back in 38% of the randomized chart review in November and 39% in December. • Nursing will be re-educated on the teach back method and the importance. • What was your 90 day aim? • Increase patient satisfaction with discharge education as evidenced by an increase in HCHAPS scores by 12/31/13.flkasjflkdjflkjsdfkljf Root Cause(s)? • What is the cause of the problem? • Nursing was instructing the patient on discharge, in regards to signs and symptoms and medications. However, the patient was not always understanding what was being taught. Therefore, when the patients returned home, the HCAHPS scores reflected that the patient did not feel that teaching was done to prepare them for self care at home. Follow Up • What are the next steps? • To continue to audit the use of teach back and trend HCAHPS scores related to patient understanding of medications and discharge instructions. • Re-educate Nursing on “teach back” method.

27. Summarizing Lessons Learned from the 90 Day Challenge

29. Keep the data flowing…. We will be wrapping up the data collection with the March 30th due date. We really want a complete data set so that we can accurately reflect the improvement you all have worked for.  You can always check your current data on the Quality Center data portal