Personalizing, Humanizing and Demystifying the Healthcare Environment

1.  Personalizing, Humanizing and Demystifying the Healthcare Environment  Susan B. Frampton, PhD President Planetree

2. Learning Objectives Industry changes supporting patient-centered environments of care Defining features of patient centered environments Recognizing impact of the built environment Making the connection to quality and safety in healthcare facilities

3. How it all began� �It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.� -Florence Nightingale, 1859

4. Hospitals in the Modern Era Specialty Hospitals Outpatient Services Technology Surge Efficiency at the expense of compassion

5. Patient-centered Principles A patient is an individual to be cared for, not a medical condition to be treated . . . Each staff member is a caregiver . . .

6. The new accountability for patient-centered care ��establish a Hospital Value-Based Purchasing (VBP) program in Medicare that moves beyond pay-for-reporting on quality measures, to paying for hospitals �actual performance��beginning in FY2012�measures would focus on heart attack (AMI); heart failure; pneumonia; surgical care activities; and patient perception of care. � Language included in the Affordable Care Act Engaging patients is the most efficient way of addressing the challenge of accountable care. Engaging patients is the most efficient way of addressing the challenge of accountable care.

7. CMS Transition to Value Based Purchasing Transition from pay-for-reporting to pay-for-performance Current = 100% payment for reporting 2011-2012 = Data Collection/performance year 2012-2013 = Hospital payments adjusted based on performance 1% in FY13, 1.25% in FY14, 1.5% in FY15, 1.75% in FY16, 2% in FY17 HCAHPS 30% of overall VBP score (combination of actual scores and improvement from baseline to current year) CMS Core Measures 70% 7 We cannot afford NOT to focus on patient centered care; hospitals assign resources to the things leadership believe are important for the success of the org; PCC and high pt satisfaction will impact the bottom line.We cannot afford NOT to focus on patient centered care; hospitals assign resources to the things leadership believe are important for the success of the org; PCC and high pt satisfaction will impact the bottom line.

8. Patients are Choosing Based on Experience 8 These elements of patient engagement are important and many are being measured on HCAHPSThese elements of patient engagement are important and many are being measured on HCAHPS

11. Designing Environments to Support Patient-Centered Care What does it mean to you? Some people think of it as the amenities�these are nice, and it can have an important impact on reducing anxiety and making people more comfortable. But it�s really these other items is what patient-centered care is about � it is the foundation for quality and safety. Joint Commission reports on root causes for sentinel events each year, and communication is the most frequent root cause listed. What does it mean to you? Some people think of it as the amenities�these are nice, and it can have an important impact on reducing anxiety and making people more comfortable. But it�s really these other items is what patient-centered care is about � it is the foundation for quality and safety. Joint Commission reports on root causes for sentinel events each year, and communication is the most frequent root cause listed.

12. Challenges in the nursing environement, not just physical, but communicaiotn. All staffing is affected, no surprise, with the nursing shortage. This also talks about key issues in diesign as well. Challenges in the nursing environement, not just physical, but communicaiotn. All staffing is affected, no surprise, with the nursing shortage. This also talks about key issues in diesign as well.

13. 22% of 193 reported a �recent unsafe experience� More than half of the events were classified as �service quality incidents� 30% related to waits and delays 21% related to poor communication 12% related to environment factors Conclusion: �Patients may perceive that these inconveniences signal problems with the overall process of care� Source: �Patient-Reported Safety and Quality of Care in Outpatient Oncology�, Joint Commission Journal on Quality and Patient Safety; 33:2, 2007 Research that is starting to come out about how patients view safety..there has been a tendency to dismiss patients because we tend to think they can�t tell the difference between safety and customer service. Research that is starting to come out about how patients view safety..there has been a tendency to dismiss patients because we tend to think they can�t tell the difference between safety and customer service.

14. Do Medical Inpatients Who Report Poor Service Quality Experience More Adverse Events and Medical Errors? Med Care. 2008 Feb;46(2):224-228. CONCLUSIONS: Patient-reported service quality deficiencies were associated with adverse events and medical errors. Patients who report service quality incidents may help to identify patient safety hazards. Patients ARE in fact able to identify safety problems�for example, �needle stick.� Med Care. 2008 Feb;46(2):224-228. Links Do Medical Inpatients Who Report Poor Service Quality Experience More Adverse Events and Medical Errors? Taylor BB, Marcantonio ER, Pagovich O, Carbo A, Bergmann M, Davis RB, Bates DW, Phillips RS, Weingart SN. From the *Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts; �Harvard Medical School, Boston, Massachusetts; �Beth Israel Medical Center, New York, New York; �Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and �Center for Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts. PURPOSE:: Service quality deficiencies are common in health care. However, little is known about the relationship between service quality and the occurrence of adverse events and medical errors. We hypothesized that patients who reported poor service quality were at increased risk of experiencing adverse events and medical errors. SUBJECTS AND METHODS:: Patients were interviewed during and after their admissions regarding problems experienced during the hospitalizations. We used this information to identify service quality deficiencies. We then performed a blinded, retrospective chart review to independently identify adverse events and errors. We used multivariable methods to analyze whether patients who reported service quality deficiencies (obtained by patient report) experienced any adverse event, close call, or low risk error (ascertained by chart review). RESULTS:: The 228 participants (mean age 63 years, 37% male) reported 183 service quality deficiencies. Of the 52 incidents identified on chart review, patients experienced 34 adverse events, 11 close calls, and 7 low risk errors. The presence of any service quality deficiency more than doubled the odds of any adverse event, close call, or low risk error (adjusted odds ratio = 2.5; 95% confidence interval = 1.2-5.4). Service quality deficiencies involving poor coordination of care (adjusted odds ratio = 4.4; 95% confidence interval = 1.4-14.0) were associated with the occurrence of adverse events and medical errors. CONCLUSIONS:: Patient-reported service quality deficiencies were associated with adverse events and medical errors. Patients who report service quality incidents may help to identify patient safety hazards.Patients ARE in fact able to identify safety problems�for example, �needle stick.� Med Care. 2008 Feb;46(2):224-228. Links Do Medical Inpatients Who Report Poor Service Quality Experience More Adverse Events and Medical Errors? Taylor BB, Marcantonio ER, Pagovich O, Carbo A, Bergmann M, Davis RB, Bates DW, Phillips RS, Weingart SN. From the *Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts; �Harvard Medical School, Boston, Massachusetts; �Beth Israel Medical Center, New York, New York; �Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and �Center for Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts. PURPOSE:: Service quality deficiencies are common in health care. However, little is known about the relationship between service quality and the occurrence of adverse events and medical errors. We hypothesized that patients who reported poor service quality were at increased risk of experiencing adverse events and medical errors. SUBJECTS AND METHODS:: Patients were interviewed during and after their admissions regarding problems experienced during the hospitalizations. We used this information to identify service quality deficiencies. We then performed a blinded, retrospective chart review to independently identify adverse events and errors. We used multivariable methods to analyze whether patients who reported service quality deficiencies (obtained by patient report) experienced any adverse event, close call, or low risk error (ascertained by chart review). RESULTS:: The 228 participants (mean age 63 years, 37% male) reported 183 service quality deficiencies. Of the 52 incidents identified on chart review, patients experienced 34 adverse events, 11 close calls, and 7 low risk errors. The presence of any service quality deficiency more than doubled the odds of any adverse event, close call, or low risk error (adjusted odds ratio = 2.5; 95% confidence interval = 1.2-5.4). Service quality deficiencies involving poor coordination of care (adjusted odds ratio = 4.4; 95% confidence interval = 1.4-14.0) were associated with the occurrence of adverse events and medical errors. CONCLUSIONS:: Patient-reported service quality deficiencies were associated with adverse events and medical errors. Patients who report service quality incidents may help to identify patient safety hazards.

15. �What symptoms of poor design in health care facilities could contribute to medical errors?� �Virtually any characteristic of the environment can have a supportive or detrimental effect on human performance and hence, on patient safety.� Kenneth N. Dickerman and Paul Barach, �Designing the Built Environment for A Culture and System of Patient Safety � A Conceptual, New Design Process in Advances in Patient Safety,� in Agency for Healthcare Research and Quality, New Directions and Alternative Approaches, Volume 2: Culture and Redesign, 2008.

16. Making Connections Elements of design can help establish connections between patients and providers At Waverly Health Center, this is displayed in each outpatient surgery suite and the circles are marked to show the patient and family who their caregivers for the day will be. It is about relationships, and how they are developed between staff and the patient � and not only can the human interactions support this, but the physical design of a space can as well. At Waverly Health Center, this is displayed in each outpatient surgery suite and the circles are marked to show the patient and family who their caregivers for the day will be. It is about relationships, and how they are developed between staff and the patient � and not only can the human interactions support this, but the physical design of a space can as well.

17. Infection Prevention �In a survey of health care workers, 75 percent stated that rewards or punishments would not increase hand-washing, but 80 percent said that easy access to sinks and hand-washing facilities would.� �Keeping Patients Safe: Transforming the Work Environment of Nurses� 2004 Page 243 We very often think we can mandate through policy and procedure, but even if you educate or apply punitive measures you can�t make people do it. But staff know that if they have easy access to a sink or hand-gel dispensers they are more likely to use them. We also need to get codes and regulations to adjust the codes to Page 243 We very often think we can mandate through policy and procedure, but even if you educate or apply punitive measures you can�t make people do it. But staff know that if they have easy access to a sink or hand-gel dispensers they are more likely to use them. We also need to get codes and regulations to adjust the codes to

18. Infection Prevention Page 243 We very often think we can mandate through policy and procedure, but even if you educate or apply punitive measures you can�t make people do it. But staff know that if they have easy access to a sink or hand-gel dispensers they are more likely to use them. We also need to get codes and regulations to adjust the codes to Page 243 We very often think we can mandate through policy and procedure, but even if you educate or apply punitive measures you can�t make people do it. But staff know that if they have easy access to a sink or hand-gel dispensers they are more likely to use them. We also need to get codes and regulations to adjust the codes to

19. Patient Falls �[T]he majority of falls of hospitalized patients occur in the patient�s room, usually in association with elimination needs.� �Keeping Patients Safe: Transforming the Work Environment of Nurses� 2004 Page 249Page 249

20. Design and Fall Prevention �Patient falls can be avoided. Poor placement of handrails and small door openings are two primary causes of patient falls. Many falls can be reduced through providing well-designed patient rooms and bathrooms and creating decentralized nurses� stations that allow nurses easier access to at-risk patients.� Agency for Healthcare Research and Quality �Transforming Hospitals: Designing for Safety and Quality� 2007 Reducer strips and wheelchairsReducer strips and wheelchairs

21. Lack of Storage Space �Because of a lack of adequate storage space, medication carts, wheelchairs, isolation carts, and dietary carts are often found in the hallway, blocking travel for both patients and caregivers and introducing safety hazards (falls, fire, public access to medications and supplies) in the environment.� �Keeping Patients Safe: Transforming the Work Environment of Nurses� 2004 Page 249 Junk in hallway Can�t find what you need in an emergency situation. Difficult to maneuverPage 249 Junk in hallway Can�t find what you need in an emergency situation. Difficult to maneuver

22. Challenge the False Choice between Patient Safety and Design �Soft Suicide Prevention Door� National Association of Psychiatric Health Systems, �Design Guide for the Built Environment of Behavioral Health Facilities� Edition 3.0 (2009) Page 25. Dr. Phil Wilner � we are not choosing between the two, we are blending it�we need to find ways to do this, in a creative, patient-centered AND safe way.� Door � A �Soft Suicide Prevention Door� (SSPDoor) has been developed that eliminates many of the hanging hazards associated with a typical door. The door may be easily removed by staff and used as a shield against an attacking patient and can have a photograph printed on its faces . This door cannot be locked or latched in any manner. 56. Patient Toilet Door Soft Suicide Prevention Door Integrated Facility Products; Security Outlet Cover P. O. Box 382 Voorhees, NJ 08043-0382 609-504-7507 http://www.4ifp.com Page 25. Dr. Phil Wilner � we are not choosing between the two, we are blending it�we need to find ways to do this, in a creative, patient-centered AND safe way.� Door � A �Soft Suicide Prevention Door� (SSPDoor) has been developed that eliminates many of the hanging hazards associated with a typical door. The door may be easily removed by staff and used as a shield against an attacking patient and can have a photograph printed on its faces . This door cannot be locked or latched in any manner. 56. Patient Toilet Door Soft Suicide Prevention Door Integrated Facility Products; Security Outlet Cover P. O. Box 382 Voorhees, NJ 08043-0382 609-504-7507 http://www.4ifp.com

23. Safe Involvement of Family/Friends in the ICU Griffin�s ICU corridor � keeps family close by (nurses are able to lock the door when family entering would be unsafe, such as during a delicate procedure)Griffin�s ICU corridor � keeps family close by (nurses are able to lock the door when family entering would be unsafe, such as during a delicate procedure)

24. Key Factors in Personalizing the Healthcare Environment Privacy Noise Control Views and Access to Nature Wayfinding Therapeutic Distractions

25. Privacy Patient rooms Registration Family Consult Rooms Staff spaces

26. Single Bed Rooms are Better Medicine

27. Noise, Stress and Healing

28. Staff Stress Walking Fatigue Noise Access to support functions

29. Control of Noise Decentralization of nursing stations Materials (ceiling, flooring, doors) Carts and equipment Overhead paging

30. Music Music decreased the use of analgesics and hastened recovery from surgery in a study of 90 hysterectomy patients - Nilsson, et al., 2001 Music programs timed to a surgical procedure produced significant reduction in the amount of perceived pain and decrease in the level of stress hormones in the blood - Robertson, 2001 Studies of neonates also provide strong evidence for the benefits of music to promote weight gain and reduce stress, resulting in a shorter length of hospital stay - Caine, 1991

31. Patient Music Survey

33. Access to Nature Daylight Gardens Therapy Patios and Gardens Dining Areas It has also been shown that patients in brightly lit rooms have a shorter length of stay compared to patients in dull rooms. Beauchemin and Hays (1996) found that patients hospitalized for severe depression reduced their stays by an average of 3.67 days if assigned to a sunny rather than a dull room overlooking spaces in shadow. It has also been shown that patients in brightly lit rooms have a shorter length of stay compared to patients in dull rooms. Beauchemin and Hays (1996) found that patients hospitalized for severe depression reduced their stays by an average of 3.67 days if assigned to a sunny rather than a dull room overlooking spaces in shadow.

34. Improve Wayfinding Reduce stress Provides for welcoming, friendly environment Common verbiage & multi-lingual Architectural and art cues

35. The Healing Power of the Arts �The excellent staff has nourished my body The flowers and art have nourished my soul I am not confined to these four walls My eyes rest on a water color of Marin Beach I step through the frame Walk hand in hand with peace and serenity And therein lies the healing.� From the very first Planetree unit in California�this is pre-HIPAA, so people actually signed their names!From the very first Planetree unit in California�this is pre-HIPAA, so people actually signed their names!

36. Therapeutic Distractions Artwork � positive scenes Outdoor views What the patient sees Respite areas

37. Positive Distractions:Humor and Entertainment Health benefits of �a good laugh� include: greater optimism, socialization and cooperation among patients; decreased dependence on tranquilizers and pain-relieving medication; and less burnout among health professionals - Fry WF, 1992 Exposure to a humor video resulted in decreased levels of epinephrine (adrenaline)(raises the heart rate and blood pressure) and cortisol (suppression of the immune system).

38. Smells Unpleasant odors stimulate anxiety, fear and stress. Pleasing aromas reduce blood pressure, slow respiration and lower pain perception levels. Pleasant fragrance lowered patient-rated anxiety during magnetic resonance imaging - Redd, et al.,1994

39. Patients Can Tell the Difference A recent study found that hospitals in the highest quartile of performance on the HCAHPS hospital environment questions (clean/quiet) had a lower incidence of selected infections due to medical care. The Relationship Between Patients� Perception of Care and Hospital Quality and Safety Thomas Isaac, MD, MBA, MPH Alan M. Zaslavsky, PhD Paul D. Cleary, PhD Bruce E. Landon, MD, MBA presented at CAHPS User Group Meeting December 2008 (available at https://www.cahps.ahrq.gov) HOSPITAL CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS This is not a published study, but will be released some time this year, - the patients are saying that these hospitals are cleaner and quieter�an AHRQ patient safety indicators include infections.. The data confirms that the hospitals are in fact, cleaner and quieter, and the patients notice this. HOSPITAL CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS This is not a published study, but will be released some time this year, - the patients are saying that these hospitals are cleaner and quieter�an AHRQ patient safety indicators include infections.. The data confirms that the hospitals are in fact, cleaner and quieter, and the patients notice this.

40. The Proof

42. Patient-Centered Hospital Designation Program Recognition program for hospitals, behavioral health facilities and long-term care communities that have implemented patient- and resident-centered care in a comprehensive manner Recognized by Joint Commission on Quality Check

43. Designation Criteria Domains Structures and Functions Necessary for Culture Change Human Interactions/ Independence, Dignity and Choice Patient/Resident Education and Community Access to Information Family Involvement Nutrition for Healing Healing Environment: Architecture and Interior Design Arts Program/ Meaningful Activities and Entertainment Spirituality & Diversity Integrative Therapies/ Paths to Well-Being Healthy Communities/ Enhancement of Life�s Journey Measurement

44. Healing Environment Criteria VI.G: The organization is able to demonstrate sustainable and �green� approaches to construction and renovation and promotion of environmentally-friendly practices in the operation of the facility.

45. Planetree Designated Sites � # of responses Surgical: 10 Pneumonia Care: 10 Heart Failure Care: 8 Heart Attack Care: 5Planetree Designated Sites � # of responses Surgical: 10 Pneumonia Care: 10 Heart Failure Care: 8 Heart Attack Care: 5

46. Using the most recent full year of HCAHPS data (2009), statistical comparison of HCAHPS scores was conducted between Planetree Designated hospital and non-Planetree Hospitals. To conduct the comparison, independent group t-tests were utilized, which compare means of the same variable between two groups (e.g., score on Medication Communication in Planetree Designated vs. non-Planetree hospitals).� With data from 10 designated hospitals and 3778 non-Planetree hospitals, findings show Planetree designated hospital perform significantly better than the CMS national average. This slide shows Planetree Designated hospitals perform significantly better on all five of these scores at the traditionally used 95% confidence level, meaning we can be 95% confident these differences are not due to chance. Planetree Designated hospitals perform significantly better on Responsiveness at the 90% confidence level, meaning we can be 90% confident these differences are not due to chance. Using the most recent full year of HCAHPS data (2009), statistical comparison of HCAHPS scores was conducted between Planetree Designated hospital and non-Planetree Hospitals. To conduct the comparison, independent group t-tests were utilized, which compare means of the same variable between two groups (e.g., score on Medication Communication in Planetree Designated vs. non-Planetree hospitals).� With data from 10 designated hospitals and 3778 non-Planetree hospitals, findings show Planetree designated hospital perform significantly better than the CMS national average. This slide shows Planetree Designated hospitals perform significantly better on all five of these scores at the traditionally used 95% confidence level, meaning we can be 95% confident these differences are not due to chance. Planetree Designated hospitals perform significantly better on Responsiveness at the 90% confidence level, meaning we can be 90% confident these differences are not due to chance.

48. THANK YOU! Susan B. Frampton, PhD President sframpton@planetree.org