Responsiveness

1. Responsiveness February 13, 2013 Carrie Brady, JD, MA cbradyconsulting@gmail.com Ashka Dave adave@aha.org David Schulke dschulke@aha.org

2. AHRQ/HRET Patient Safety Learning Network (PSLN) Project • This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET). • HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education. • AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

3. The Patient Experience of Care is Fundamental to Clinical Improvement • Understanding the patient experience of care is not an add-on activity: it should be used as a fundamental element in your other improvement efforts. • For those working on the HRET Partnership for Patients Hospital Engagement Network (HEN) or another HEN, your work will benefit directly from your efforts to improve the patient experience of care (e.g., readmissions, ADEs). • Lessons you learn in this HCAHPS Learning Network will help you succeed in the HEN project because— • Patient-centered care is a driver of clinical outcomes • Employee and patient engagement are 2 sides of one coin • HCAHPS assesses key factors in ADEs and readmissions

4. HCAHPS Curriculum 2012-13All Web conferences are scheduled for 12-1pm Eastern • December 7, 2012: Fundamentals of HCAHPS • December 18/19, 2012: Using HCAHPS Data Effectively • January 16, 2013: Nurse Communication • February 13, 2013: Responsiveness • March 13, 2013: Medication Communication • April 24, 2013: Discharge Information • May 15, 2013: Physician Communication and Engagement • June 5, 2013: Pain Management • July 17, 2013: Clean • August 14, 2013: Quiet

5. HCAHPS Technical Assistance Faculty • Carrie Brady, MA, JD • HRET’s primary HCAHPS faculty • Former senior Connecticut Hospital Association staffer • Previously a vice president at Planetree • Exemplary hospital peers • Sharp Memorial Hospital, San Diego, CA • Verna Sitzer, MN, RN, CNS, Manager, Nursing Innovation and Performance Excellence • Laurie Ecoff, PhD, RN, NEA-BC, Director, Research, Education, and Professional Practice • At the 90th percentile nationally in responsiveness

6. Research Update Based on a reviewof 55 studies: “[P]atient experience is consistently positively associated with patient safety and clinical effectiveness across a wide range of disease areas, study designs, settings, population groups and outcome measures.” Doyle C., Lennox L., Bell D., A Systematic Review of Evidence on the Links Between Patient Experience and Clinical Safety and Effectiveness, BMJ Open, 2013;3e001570.Available at no charge at: http://bmjopen.bmj.com/content/3/1/e001570.full.pdf+html

7. HCAHPS Responsiveness Domain During this hospital stay: • After you pressed the call button, how often did you get help as soon as you wanted it? • How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? Source: CMS Summary of HCAHPS Survey Results and HCAHPS Percentiles December 2012 Public Report (April 2011 – March 2012 Discharges) www.hcahpsonline.org • 66% “Always” is the national average • Third lowest scoring HCAHPS domain • Medication communication and quiet are lower • Best performing hospitals in the country (95th percentile) get 83% or more “Always”

8. Thinking About Responsiveness

9. Reactive Responsiveness:Consider Staff Perception • Nursing staff from four hospitals asked to complete a survey on call lights • Survey questions related to: • Reasons for use of lights • Number of calls per hour • Average length of time to answer call • Opinion on call lights

10. Nursing Staff Opinions on Call Lights Nearly half of the nurses in the study did not perceive answering call lights as a critical aspect of their role. Source: Tzeng Huey-Ming. “Perspectives of staff nurses of the reasons for and the nature of patient-initiated call lights: an exploratory survey study in four USA hospitals” BMC Health Services Research 2010, 10:52.

11. Reactive Responsiveness: Patient Perception

12. Elapsed v. Perceived Time

13. Response • Initial acknowledgment • In person or through speaker • Manage attitudes • Identify “words that don’t work” (e.g. short-staffed) • Set expectations

14. Waiting • When patient need cannot be met immediately (e.g. because physician order is required): • explain to the patient what next steps are necessary • update the patient as each step in taken • estimate how long it will be before the next step and why

15. Expanding the Reactive Team • Engage every staff member in responding to call lights (e.g. “no pass zones”) • Emphasize that each call light could be an urgent patient safety issue – you won’t know until you answer it • Provide direct access to services (e.g. number on white board) • Consider experiential learning techniques • Sit (fully clothed) on bed pans in a staff meeting • Hold an ice cube while it melts

16. Be Proactive • Implement consistent purposeful rounding* by nursing staff • Tell patients when you will return • Plan for continual coverage • Plan for toileting • Especially for patients on diuretics or high fluids *See Halm M. Hourly Rounds: What Does the Evidence Indicate? Am J Critical Care 2009;18: 581-584 (hourly rounding decreased call lights in 5 of 6 studies described)

17. Expanding the Proactive Team • Provide multiple points of contact • e.g. leadership rounding, non-clinical staff serving as patient ambassadors • Encourage all staff to identify patient needs • Engage family and friends as partners • Provide guidance for family on how to meet certain patient needs • Has the added benefit of helping prepare family for involvement in post-discharge care

18. Pervasive • Being aware of and responding to patient/family needs is second nature (e.g. wayfinding) • The organization is responsive to staff • e.g. regular rounding on staff with follow-up, shadowing, trading places • Staff have their own “call buttons” • e.g. “All Hands on Deck” initiative

19. Case Study Exemplar: Sharp Memorial Hospital Responsiveness to Call Bells Verna Sitzer, MN, RN, CNS Laurie Ecoff, PhD, RN, NEA-BC

20. Sharp Memorial Hospital http://healthexecnews.com/the-25-most-beautiful-hospital-designs-in-the-world

21. Effectiveness Formula Responsiveness Task Force Effectiveness formula: Q x A2 = E Quality of the solution Acceptance & Accountability Effective results

22. Quality of Solution

23. Q: Define Who are our customers and what are their requirements? Patients- “always” get help as soon as they want it

24. Q: Measure How is the process currently performing in meeting our customer requirements?

25. Q: Analyze What is causing us to not meet customer requirements?

26. Q: Analyze Why are customers pressing their call buttons?

27. Q: Improve • What is the strategy to meet customer requirements and does it work? • Address root causes: • Set Expectations for responding to call lights • Round Effectively • Standardize Whiteboard • Educate Care Partner/Family • Leverage Technology

28. Q: Improve

29. Q: Improve Badge Card Bulletin Board Sign

30. Q: Improve Electronic Whiteboard

31. Q: Improve • Nurse Call System Upgrade • Direct alerting to caregiver • Nurse locator • Call/information transfer • Detailed reporting

32. A2: Acceptance of Solution • Elevator Speech • This project is about improving patients’ HCAHPS score on: During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? • It’s important because HCAHPS scores that don’t meet target affect financial reimbursement via value-based purchasing. $$$ is currently at stake. • Success looks like patients’ perceiving that after they press the call button, they “always” get help as soon as they wanted it. The goal is HCAHPS scores of 90 or greater. • We need you to understand the new strategies, use the tools developed by your peers, and give feedback on ways we can further improve responsiveness.

33. A2: Accountability for Solution • Charge nurses, leads, managers monitor rounding by asking patient 3 questions: • Have staff been in your room every hour to check on you and meet your needs? • Have you been shown the whiteboard and does it have all the information you need? • Do you or your family members know who to call and how to call for help? • “Pulse Check” monthly reporting to Task Force

34. E: Effective Results

35. E: Control • What is the plan to consistently meet customer requirements? • Integrate into new employee orientation • Revise Rounding competency • Monitor implementation strategy at defined intervals • Report responsiveness data to direct-care providers • Implement and evaluate technological aids • Continue to seek best practices

36. Questions and Discussion Ways to Get Involved in the Discussion Follow operator’s instructions to ask a question Type your question in chat Use the HRET listserv or discussion board to ask questions or share your experiences

37. Wanted: HCAHPS Success Stories If you have a success story to share in any HCAHPS domain, please email Ashka Dave at adave@aha.org

38. HCAHPS Curriculum 2012-13All Web conferences are scheduled for 12-1pm Eastern • December 7, 2012: Fundamentals of HCAHPS • December 18/19, 2012: Using HCAHPS Data Effectively • January 16, 2013: Nurse Communication • February 13, 2013: Responsiveness • March 13, 2013: Medication Communication • April 24, 2013: Discharge Information • May 15, 2013: Physician Communication and Engagement • June 5, 2013: Pain Management • July 17, 2013: Clean • August 14, 2013: Quiet