Transcript GPU RN Coverage Anesthesia Day

Combining Art and Science in the
Co-Creation of Value for Patients & Staff
Susan Shaw, MS, RN
Director, Clinical Operations
Children’s Hospital Boston
June 18, 2009
Children’s Hospital Boston – Overview
• Primary pediatric teaching hospital of Harvard Medical School
• American Nurses Credentialing Center (ANCC) Magnet
Recognition for nursing excellence
• 396-bed comprehensive center for pediatric health care
• One of the largest pediatric medical centers in the United
States, offering a complete range of health care services for
children from birth through 21 years of age
• Records approximately 22,600 inpatient admissions, and more
than 527,500 outpatient visits annually in 204 specialized
clinical programs
• Perform 23,000 surgical procedures and 170,000 radiological
examinations every year
• 56,000 Emergency Department visits annually
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Care and Service
While the technical competence of health care is well established and, at
times, breathtaking in its accomplishments, it is no longer enough to
ensure that patients are satisfied, regardless of whether the missing
element is called customer service, patient satisfaction, caring
competence, beneficence, or good old-fashioned bedside manner. Taken
together, these three facts point to the need for combining technical
expertise with service excellence in health care to improve clinical care,
as well as the patients’ perception of that care.
(Mayer & Cates, Service Excellence in Health Care, JAMA, June 2009)
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Vision: Life Changing Care, World-Changing Research
Mission
Strategic Goals
care
Justifiable
Costs
Foundation For Success
education
research
Excellent
Care
community
Clinical
and
Research
Innovation
State-of-theart
infrastructure
Talent
destination
Innovative
and
sustainable
organization
Financial
sustainability
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Strategy Map
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Definition of Value
Quality + Service + Innovation
Value = _____________________________________
Cost
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New Definition of Patient Experience Emerging
Family Centered Care
Patient Experience
• Family centered care is a philosophy that
promotes the inclusion of the patient and
family in the care decisions of the
patient.
• Embraces the family as a care partner,
with the goal of putting the needs of the
family first.
• Strategic shift in focus from operations to
the customer
• Has family centered care at its core, but
extends beyond a philosophy of care
• Focuses on viewing each encounter with
the organization through the customer’s
eyes
• Valuable approach when customer
relationships are complex and involve
multiple “touch points” or points of
contact.
• Experience Mapping
Not a process map, but an evaluation of
initial patient/family expectations and
experiences of the continuum of services
provided.
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Background
•
Healthcare is characterized by complexity and fragmentation, with discrete
silos of information controlled by separate entities. This frequently leaves
patients with a sense of frustration as they negotiate the system (Gulati,
2007).
•
A study recently completed at the University of Pittsburgh Medical Center
(2007) found that 30 departments impact a single patient on the day that
he/she undergoes surgery (World Health Congress, 2007).
•
The integration of patient experience information (solicited and voluntary) is
critical to bridging operational silos and providing a comprehensive approach
to management of the patient experience (Russell & Otley, 2003).
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Recent Analysis of CHB Patient Experience
• De-identified existing satisfaction data over a 2-year time period
(August 1, 2006 through July 31, 2008) were examined to identify
key satisfaction issues across survey results.
• Content analysis: the text is coded, or broken down, into
manageable categories and examined using one of content analysis'
basic methods: conceptual analysis or relational analysis.
• Conceptual analysis: examine presence of identified categories
with respect to patient satisfaction
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Major Themes
Environment of Care
Accommodations, Infrastructure – includes staffing, availability of equipment,
supplies/equipment failure, service delivery.
Quality of Care (Care and Treatment of patient)
Care of patient during stay, Unsatisfactory treatment, Lack of support, Did not involve patient in
decisions about care, IV starts/lab draws, Medication errors, Patient safety, Pain management
Communication
Quality of information (inadequate explanations, conflicting information), inadequate
instructions,, Unresponsiveness, Fragmentation of care
Respect and Caring (Staff Attitudes and Behaviors)
Insensitivity, poor attitude, discounting patient/family opinions, unprofessional conduct,
courtesy, ability of providers to work together
Timeliness
Access, Availability, Scheduling, Delays in treatment, Delay in receiving reports or results,
timeliness of admission and discharge processes
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Complaint Data 2006-2008
Physician/Clinical Treatment
Operations
Clinical Care
YEAR 1
YEAR 2
Billing/Payment
Communication
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Time Between Control Charts
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Example: Emergency Department (2004)
•
•
•
•
Significant increase in patient complaints
Decrease in staff morale (MDs, RNs, AAs)
Increased patient waiting times
Increased “Left Without Being Seen” (LWBS)
Senior Leadership held local leaders accountable for
improvements…development of ED Improvement Plan
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Elements of Improvement Plan
• Patient Satisfaction Survey
• Increased efforts at “immediate bedding” lead to creative exam room space
(“pull system”)
• Referring MD Oversight Committee: ED sub-group
• Leader/Patient rounds
• Left Without Being Seen
• Service Excellence Program
• Expanded post-discharge follow up calls
• Clinical Operations Group established
• Fast-track system developed and optimized
• Registration process enhancements (pre-reg, bedside reg)
• Increased awareness of and access to chain of command around patient
satisfaction
• Student consultation
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Significant Drivers of Service for Patients/Families
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High Level View of ED Dashboard
Whole
System
Whole
System
Measures
Safe
Safe:
Adverse event rate
Effective: Unplanned return visits resulting in admission
Patient Centered:
Timeliness:
Efficient:
% visits where care is rated excellent
ED length of stay
Charges by ESI level (resource use)
Equitable: Metrics stratified by race/ethnicity/ payer
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The 3 C’s (Clear Concise Communication) Campaign
Techniques to help families ask the appropriate questions to get the answers they need about their child's care
Goals
•
•
•
•
A collaborative improvement project that targets patient-centered information
management
Create a mechanism to support optimal parent-provider communication
Analyze the parent comments
Measure the impact of the improvement effort on parents’ experiences with
emergency care
Details
• Patient-centeredness and parent-provider communication
• Existing literature on efficacy for a parent-completed needs assessment during
ED care
• Opportunity to use existing satisfaction survey to measure the impact of an
intervention
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Specific Questions Asked
Theme Theme
Diagnosis
Example
Evaluation/Treatment
Does she need surgery?
Will he need a cast?
Can I get an x-ray to make sure nothing is wrong?
Pain/Pain management
What is causing her pain?
How can we stop this pain?
Medication
Is she going to be on any medications?
Does she need a stronger med?
Can I give something to reduce the cough?
Anticipatory guidance
What do we need to look out for?
How can we help her feel better?
What do we do when this occurs?
Example
What is wrong with his throat?
Does he have a pneumonia?
Does she have an infection?
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Primary Outcomes for 3C Implementation
Summary measure of parent-provider communication
• Did the doctor listen to what you said about your child?
• Was everything done for your child that you think should have been
done?
• Was your child’s problem explained to you in a way that you could
understand?
• Did the doctor listen to what your child said?
• Before leaving the ED, were you told signs to watch for?
• Thinking about your involvement in care, would you have liked more
involvement in decisions regarding your child?
• Did the doctor and nurse say different things?
• Were there times that you needed help but did not get it?
Primary outcome for content analysis
• Percentage of completed forms determined to have potential value to
a treating clinician
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ED Example – Patient Satisfaction Survey
100
90
93.3%
90%
92.13%
91.66% 90.37%
90% 90.83%
85.83%
89.17%
87.97%
80
85%
88.33% 83.33%
60
50
40
30
20
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Excellent
1
Q
tr
2008
Very Good
Q
tr
4
Q
tr
3
Q
tr
2
Q
tr
1
2007
Q
tr
4
Q
tr
3
Q
tr
2
2006
Q
tr
1
Q
tr
3
Q
tr
2
2005
Q
tr
1
0
Q
tr
4
Percent
70
2009
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Lessons Learned
• The 3C campaign had a measurable and positive impact on ED
communication behaviors as reported by parents
- 0.028 points per day improvement
- 2.8 points (95%CI 0.1, 5.5) per 100 days
• Successfully improved communication in the ED, even as workflow and
clinicians were challenged by potentially disruptive technologies
• Potential value for ED clinicians in the information shared by parents on
written needs and expectations form at the outset of pediatric ED care
• The potential value of information is consistent across varying levels of
patient acuity and ED visit types
What was the reason for 3C success?
• The tool itself
• The multi-modal strategy of improvement
• The “modeling” of the behavior
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Patient Experience Initiatives
Development of Patient Experience Committee, charged with:
• Defining care from the patient perspective
• Understanding the survey tools currently in use system-wide to assess the patient
experience
• Evaluating survey results
• Assisting with the development of initiatives to improve the patient experience
• Providing regular reports of the patient experience survey results to senior leadership
Ambulatory Survey
• ECES
• Service Recovery
• “Extra Mile” Initiatives
Human Resources Partnership
• Employee Satisfaction Survey
• Employee Selection & Development
• Employee Recognition
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Extra Mile Initiatives
Service Improvement Initiative Adoption in the Ambulatory Areas:
• Team huddles/daily briefings
• Visit checklist, patient info, fact sheets
• Customer service communication, concierge, greeter
• Department communication
• Staff meetings, department orientations
• 3 C’s questionnaire (Clear, Concise, Communication)
• Rounding (management, team, provider)
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Exceptional Care Exceptional Service (ECES)
Our Commitment
If there is one promise we all make here at Children's Hospital Boston,
it's to serve. Each other. Our patients. Their families. Our community.
And those who practice throughout the region and partner with us in care.
We are a family of 11,000 united by optimism, devotion and innovation. We pledge to
foster a culture of exceptional care and exceptional service that supports these standard
EXCELLENCE. We believe that expectations are meant to be exceeded
RESPECT. We treat others with empathy and compassion. We appreciate our differences
COMMUNICATION. We speak honestly. We listen carefully. We respond thoughtfully and promptly
COURTESY. We are friendly, professional, welcoming and kind
ENTHUSIASM. We are upbeat and positive, and will go the extra mile
TEAMWORK. We work together. We rely on one another's support and trust
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Employee Experience
•
Employee survey – improvement in all ECES benchmarks (FY06-08)
- Added 2 new courtesy questions to benchmark in FY10
•
ECES Core Training at New Hire Orientation weekly
•
Standards & Values added to job description for new applicants as well as the HR website
Patient Experience
•
Service Recovery Program developed and rolledout to all Ambulatory areas (May 2008-present)
-
•
18 areas currently participating
Car Seat Carrier program developed and
implemented (September 2008) in main lobby
•
-
Carriers signed out on 176 occasions
-
Also available in Waltham
ECES
Successes
Ask me! Program
•
-
18% increase in participation from FY08
to FY09
-
Informational brochure created
Outpatient Satisfaction Survey Round Tables
(FY07-09)
Employee Recognition
•
ECES ‘Employee of the Month’ program (administered by HR)
•
21 employees recognized to date
•
‘Way to Shine!’ program in development (multidisciplinary team)
•
Yearly Ask me! celebrations
Staff Training & Management
Support
•
8,100 staff trained to date (2007-2009)
•
8 Management Boosters developed (available on
web site)
•
3 Additional ECES training modules developed and
rolled-out (administered by HR L&D)
•
Workshops/Focus groups in 7 different areas
throughout the hospital (focusing on staff courtesy,
teamwork, communication)
• Support Services, Patient Services, Satellites
and Ambulatory areas
Other
• ECES Strategy Team
• 30 members representing all areas of
institution
• Ongoing organization-wide communication in Small
Talk, Children’s News and ECES Website
• Support all departments implementing ECES
initiatives/projects/recognition
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CHB Patient Portal: IndivoHealth
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There Is Still More Work To Do…
Next Challenge… How do we do it all?
• Balance vision, strategies and goals
• Integrate care, service AND innovation
• Take the “magic” at the bedside or local program and
standardize it across the institution
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