Transcript Rounding for Outcomes

Evidence-Based
Leadership
Digging Deeper
Rounding on Employees
Rounding on Patients
Hourly Rounding
Why Are We REALLY Here Today?
To create a place where
employees and physicians want to
work and patients choose to
receive their healthcare
To deliver on the Institute of
Medicine’s six Aims (safe, timely,
effective, efficient, equitable,
patient-centered care)
To implement strategies that get
staff back to the bedside, increase
effective communication, and
provide harm-free patient/family
centered care with good outcomes
including a safe transition home
Rev 4.8.11
Execution Framework
Evidence-Based LeadershipSM
Foundation
STUDER GROUP®:
Objective
Evaluation
System
Leader
Development
Aligned Goals
Implement an
organizationwide
staff/leadership
evaluation
system to
hardwire
objective
accountability
(Must Haves®)
Create
process to
assist leaders
in developing
skills and
leadership
competencies
necessary to
attain desired
results
Must
Haves®
Performance
Gap
Aligned Behavior
Agreed upon
tactics and
behaviors to
achieve goals
Re-recruit high
and
middle/solid
performers
Move low
performers up
or out
Standardization Accelerators
Aligned Process
Processes that
are consistent
and standardized
Process
Improvement
PDCA
Lean
Six Sigma
Baldrige
Framework
Software
Sustained Culture Change/Standardization
Requires Behavior Change
Reliability
Reliability and
and
Standardization
Standardization
Performance
Insight
Insightand
and
results
results
Instability
Instability
Year
Year11
Technical
Technical
Improvements
Improvements
Year
Year22
Year
Year33
Behavioral
Behavioral
effect
effect
(can five front
(can
five
line users
front
clearlyline
users
clearly
articulate
the
process and
articulate
do
thethey know
WHY?)
process?)
Time
Time
HCAHPS – Hospital Consumer Assessment
of Healthcare Providers and Systems
What is
HCAHPS
A standardized survey tool to measure the patient’s
perception of quality care provided during their
experience while a patient at an acute-care hospital.
The patient perception of care is publicly reported with
Why is it other quality metrics on the Hospital Compare website.
important? www.hospitalcompare.hhs.gov
The information will be used to provide meaningful data
How will it for improvement efforts, for comparisons between
be used? hospitals to help consumers choose a hospital and will be
linked to reimbursement through the Value-Based
Purchasing program.
Articulation demands simplicity!
Patient Perspective of Clinical Quality
Communication with doctors
Their perception
Communication with nurses
of your
Responsiveness of hospital staff
performance is a
Pain management
reportable and
Communication about medicines
tangible
Discharge information
reflection
Cleanliness of hospital environment
of your
Quietness of hospital environment
reputation
Overall rating of hospital
Willingness to recommend the hospital
Clear Connection between Patient-Centered
Care and Clinical Quality Outcomes
Compared Hospital Quality Alliance (HQA) scores for the Quality
of Clinical Care to HCAHPS Global Rating for 2,429 hospitals
HCAHPS Rating
AMI
CHF
PNA
Surgery
Lowest quartile
93.5
82.7
88.5
82.8
Second quartile
94.5
85.2
90.1
84.3
Third quartile
94.6
85.9
90.7
85.2
Highest quartile
95.3
86.0
90.8
85.7
P value for trend
<0.001
<0.001
<0.001
<0.001
Source: Jha et al. New England Journal of Medicine 359, no. 18 (2008): 1921-1931.
Patients’ Perception of Care = Quality
Vascular Catheter-Association Infection
Engage Patient and Families in Reducing
Infections
During bedside report, listen for reasons that
catheter is still present
Ask your nurse about procedures to prevent
central line infections
Tell nurse if bandage over central line is loose,
soiled or wet or skin is red/inflamed
Watch that doctors/nurses wash hands
Make sure visitors do not touch catheter or
tubing
Keep catheter ends clean and dry
If go home with catheter, teach-back
appropriate care
High Patient Perception of Care Equals
Lower Preventable Readmissions
1/5 of Medicare Beneficiaries are
readmitted within 30 days with an
annual cost of $17.4 Billion
2.6%
Acute
MI
3.1%
Heart
Failure
2.3%
Pneumonia
Source: The American Journal of Managed Care; Relationship Between Patient Satisfaction With Inpatient Care and Hospital
Readmission Within 30 Days; 2011; Vol. 17(1)
Expanded HCAHPS Survey (Jan 1, 2013 Discharges)
3 Care Transition Items (4-point Agreement Scale)
(Strongly Disagree, Disagree, Agree, Strongly Agree)
During this hospital stay, staff took my preferences and
those of my family or caregiver into account in deciding
what my health care needs would be when I left.
When I left the hospital, I had a good understanding of
the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose
for taking each of my medications.
(Health Literacy, Family Involvement and Teachback)
Source: http://www.caretransitions.org
New HCAHPS Questions (Jan 1, 2013 Discharges)
Demographic Items in the “About You” section
1. During this hospital stay, were you admitted to
this hospital through the Emergency Room?
(Yes/No)
2. In general, how would you rate your overall mental
or emotional health?
(Excellent, Very Good, Good, Fair, Poor)
For additional details on these new HCAHPS items from CMS, please
see Page 5 of the HCAHPS Quality Assurance Guidelines v7.0:
http://www.hcahpsonline.org/qaguidelines.aspx.
National Average Top Box Results have
Improved Over Time for Each Composite
HCAHPS Answer Description
National
Avg.
1Q074Q07
National
Avg.
1Q084Q08
National
Avg.
1Q094Q09
National
Avg.
1Q104Q10
National
Avg.
1Q114Q11
National
Avg.
Increase
2007-2011
Percent
Increase
2007-2011
Overall rating of 9 or 10 (high)
63
64
66
68
69
6
9.5%
Quiet at night
54
56
57
58
59
5
9.3%
Responsiveness of Staff
60
62
63
64
65
5
8.3%
Communication about Medicines
58
59
60
61
62
4
6.9%
Room Clean
68
69
70
72
72
4
5.9%
Nurses Communication
73
74
75
76
77
4
5.5%
Discharge Information
79
80
81
82
83
4
5.1%
Pain Management
67
68
69
69
70
3
4.5%
Definitely Recommend
68
68
69
70
70
2
2.9%
Doctor Communication
79
80
80
80
81
2
2.5%
National Average Year to Year Change in Top Box Results
has declined over time
Patient Experience, Safety, Effectiveness
The data presented display that patient experience
is positively associated with clinical effectiveness
and patient safety, and support the case for the
inclusion of patient experience as one of the
central pillars of quality in healthcare. It supports
the argument that the three dimensions of quality
should be looked at as a group and not in isolation.
Clinicians should resist sidelining patient
experience as too subjective or mood-oriented,
divorced from the ‘real’ clinical work of measuring
safety and effectiveness.
Source: 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;3:e001570.doi:10.1136/bmjopen-2012
Value Based Purchasing FY 2014
Core Measures
(45% Weight)
1.25% Base
operating
DRG
payments
HCAHPS
Composites
(30% Weight)
Outcomes
Note: Implementation FY 2014
Source: OPPS VBP Final rule 11.1.11
(25% Weight)
Performance
attainment and
improvement
will
determine total
hospital
reimbursement
2013 and 2014
Process of Care Measures
Green = increased threshold from 2013
Red = decreased threshold from 2013
Measure ID Measure
2013 National 2014 National
Threshold
Threshold
2013 National
Benchmark
2014 National
Benchmark
Fibrinolytic Therapy Received Within 30 Minutes of Hospital
AMI–7a Arrival
0.6548
0.8066
0.9191
0.9630
Primary PCI Received Within 90 Minutes of Hospital Arrival
0.9186
0.9344
1.0000
1.0000
0.9077
0.9266
1.0000
1.0000
Blood Cultures Performed in the Emergency Department Prior
to Initial Anti-biotic Received in Hospital
0.9643
0.9730
1.0000
1.0000
Initial Antibiotic Selection for CAP in Immunocompetent Patient
0.9277
0.9446
0.9958
1.0000
0.9735
0.9807
0.9998
1.0000
0.9766
0.9813
1.0000
1.0000
0.9507
0.9663
0.9968
0.9996
0.9428
0.9634
0.9963
1.0000
N/A
0.9286
N/A
0.9989
0.9500
0.9565
1.0000
1.0000
0.9307
0.9462
0.9985
1.0000
0.9399
0.9492
1.0000
0.9983
AMI–8a
HF–1 Discharge Instructions
PN–3b
PN–6
Prophylactic Antibiotic Received Within One Hour Prior to
SCIP–Inf–1 Surgical Incision
SCIP–Inf–2 Prophylactic Antibiotic Selection for Surgical Patients
Prophylactic Antibiotics Discontinued Within 24 Hours After
SCIP–Inf–3 Surgery End Time
Cardiac Surgery Patients with Controlled 6AM Postoperative
Serum Glucose
SCIP–Inf–4
NEW
Postoperative Urinary Catheter Removal on Post Operative
SCIP–Inf–9 Day 1 or 2
SCIP–Card–2
Surgery Patients on a Beta Blocker Prior to Arrival That
Received a Beta Blocker During the Perioperative Period
Surgery Patients with Recommended Venous
SCIP–VTE–1 Thromboembolism Prophylaxis Ordered
Surgery Patients Who Received Appropriate Venous
Thromboembolism Prophylaxis Within 24 Hours Prior to
SCIP–VTE–2 Surgery to 24 Hours After Surgery
Concurrent Interventions – High Performing HEN
Evidence-Based
Leadership
Digging Deeper
Rounding on Employees
Rounding on Patients
Hourly Rounding
Warning Sounded on Demoralized Workforce
American Medical News. March 25, 2013
Rounding on employees and asking questions about
basic safety of the workplace demonstrates respect
Injury rate in healthcare is 5.6/100 FTE (33% higher than
all private industry)
7/10 doctors see disruptive behavior once/mo and 11%
said it happens daily
70% of doctors and others feel rushed in office setting
50% of doctors have symptoms of burnout
Evidence-based leadership trends themes and
finds solutions
Source: Through the Eyes of the Workforce: Creating Joy, Meaning and Safety in Health
Care. Lucian Leape Institute at the the National Patient Safety Foundation. March
Retained Staff is Correlated with Lower LOS
and Lower Mortality Rates
Session Outcomes
Increased understanding of the Evidence-Based
Leadership (EBL model) and expectations
including:
 Rounding
Senior Leader
Staff
Patient
Hourly
Customer
“Leader rounding is
not optional.
It has to be looked
at as seriously as
correct medication.”
Quint Studer
Define the Term “Hardwired” Rounding
90% of leaders rounding with the prescribed
frequency, utilizing good skills, to elicit
actionable reward/recognition and process
improvements that are documented and
followed up on.
These are trended and reported to give a more
global organizational perspective.
Rounding on Staff: Leader WIIFM
Rounding questions
Foster team development, take a pulse of the
Department & provide insight into
staff skills & behaviors
1.
2.
3.
4.
5.
6.
7.
8.
9.
Personal Connection
What is working well?
Anyone I can recognize? Why?
What systems or processes are not working well?
What can we do to improve them?
Do you have the tools you need to do your job?
What’s one way we can improve…
Is there anything you need from me?
Thank you for making a difference!
Rounding for Outcomes – Direct Reports
Who Rounds?  Leader With
Hire/ Fire responsibility
How Often? (minimum)
With <40 Direct reports 
Monthly
With 40-80 Direct Reports 
Every other month
With over 80 direct reports 
Quarterly
Rounding on Employee Worksheet
Focused Huddle
Daily Safety
Daily core measure patients
Weekly HCAHPS actions
Evidence-Based
Leadership
Digging Deeper
Rounding on Employees
Rounding on Patients
Hourly Rounding
Nurse Leader Rounding Improves
Patients’ Perception of Nursing Quality
Increase in Percentile Ranking for HCAHPS Measure "Nurses Always
Communicated Well" Following Implementation of Nurse Leader Rounding
1st Qtr after
Implementation
4%
Avg Percentile Rank Improvement Among Partners Implementing Nurse Leader Rounding
0%
National Average Percentile Rank Improvement
2nd Qtr after
Implementation
3rd Qtr after
Implementation
4th Qtr after
Implementation
5th Qtr after
Implementation
6th Otr after
Implementation
4%
0%
9%
5%
11%
5%
16%
5%
25%
10%
Source: The graph above shows a comparison of average percentile rank improvement using the Studer Group partner database compared to CMS data
based on 3Q09-2Q10. N = 12 hospitals that implemented in 2008.
Leader Rounding on Patients
“Did a Leader Visit You During Your Stay?”
100
90
90
98
99
99
90
Percentile
80
70
55
60
Yes
44
50
No
40
30
20
10
0
Overall
OB
Card
Neuro
7th floor
Source: Sacred Heart Press Ganey Data, Jan 1, 2012 – Dec 31, 2012
8th floor
9th floor
Leader Rounding on Patients
“Did a Staff Member Visit You Hourly?”
100
95
99
96
92
90
90
99
83
90
80
Percentile
70
60
Yes
50
No
40
30
20
10
0
Overall
OB
Card
Neuro
7th floor
8th floor
Source: Sacred Heart Press Ganey Data, Jan 1, 2012 – Dec 31, 2012
9th floor
ICU
HCAHPS Data
“Answered Yes to Both Questions
100
99
99
98
Percentile
98
97
97
97
96
Yes
95
94
93
92
91
90
Yes
Overall
WTR
Staff took pref into acct
Listen carefully
99
98
97
97
Source: Sacred Heart Press Ganey Data, Jan 1, 2012 – Dec 31, 2012
Leader Rounding on Patients
What is it?
Why is it
important?
How will it
be used?
Structured process to ensure we create a quality, safe and compassionate
environment and resolve issues by obtaining “just in time” feedback from
patients and families.
•
•
•
•
•
•
•
•
•
•
•
Furthers mission to deliver patient-centered care
Builds relationships and provides emotional support
Improves clinical outcomes and quality of care
Promotes patient safety and a culture of safety
Increases efficiency and discovers opportunity to reduce “waste”
Raises patient engagement and perception of quality
Proactively addresses service recovery opportunities
Sets expectations of quality care in that area
Validates behaviors and raises the performance bar of all staff
Allows opportunity for reward and recognition
Builds leader skills
Nurse leader rounds on 100% patients daily to obtain feedback on quality,
care and validation of staff expected behaviors. Staff then
coached/recognized and actions taken to address improvement
opportunities. Support Departments round as appropriate.
Nurse Leader Rounding on Patients
Rounding questions
are focused on ensuring quality care ,
solving for gaps and validating staff
performance
1. Prep with Nurse
2. Personal Connection
3. AIDET®
4. Focus on key drivers of satisfaction
5. Validate staff behaviors – AIDET®, Hourly Rounding®, etc.
6. Identify staff to be recognized
7. Check Bathroom
8. Is there anything you need from me?
9. Thank you
10.What did I learn about the QUALITY of care for that patient?
11.Log findings
12.Review finding with Nurse – Coach & Reward & Recognize
Key Points on First Round
Expectations
Person of authority
Manage up and reduce anxiety
Goals of unit/department – what they can expect
and what processes are in place like bedside
report, hourly rounding, checking arm bands, etc.
Ensure family is comfortable and involved as the
patient requests
Provide contact information
Validate behaviors are apparent
“How WELL are we doing….”
Keeping you informed?
Keeping your room clean?
Explaining test and treatments?
Explaining what will occur after discharge?
Managing your pain?
Responding to your requests for assistance?
Addressing your questions and concerns?
Washing our hands?
Plan for the Day, Plan for the Stay
Plan for the Day
Patient goal for the shift
Patient and family included in
care and decisions
Reinforces learning
Plan for the Stay
Anticipated discharge date
and what needs to happen
before patient can go home
Engages primary caregiver at
home as well as patient
Contributes to reduced LOS
http://www.mc.vanderbilt.edu/reporter/index.html?ID=11199
Start Discharge Planning at Admission
Discharge Readiness Tool
Introduced by admission
nurse
Updated daily until discharge
Suggested questions
Medications
Activity/Home Needs
Diet
Worsening symptoms
Follow-up
M in the Box: Step 1
If a new med ordered during the
shift, the nurse will explain the
medication and possible side
effects to the patient.
Then, puts the letter “M” in the
box drawn on the board.
“Mrs. Smith, I’m writing the M in the box to remind
both of us that you had a new medication and I
have communicated to you the reason for the
medication and any possible side effects.”
M in the Box: Step 2
Later, during bedside shift
report, the off- going nurse
points out the “M in the Box”
“Dr. Jones ordered Mrs. Smith a new medication”.
“Mrs. Smith, do you remember the name of the new
medication?
Can you tell me why Dr. Jones ordered it for you?
Can you also tell me one of the side effects of the
medication?”
M in the Box: Step 3
The off-going nurse checks back with the oncoming nurse
“As you heard, Mrs. Smith is aware of her new
medication and possible side effects.”
“I will erase the “M in the box”, so that you can fill it
in if another new medication is ordered for Mrs.
Smith during your shift.”
The process continues each shift until the patient is
released. If no new medication is ordered the box
should be empty.
Simple Tactic, Profound Results
Safety: Engage patient in monitoring for side
effects/reactions; Opportunity for “teach-back”
Patient engagement: verbal and visual, two-way
communication with patient about all new
medications and any possible side effects
HCAHPS: Hardwire explanation of medication and
side effects
Challenge – multiple medications
Important Discharge Phone Call
%tile
ranking
increased
30 - 60
when d/c
call made!
Start Discharge Planning at Admission
Sets expectation for followup call including
appropriate phone number
“Is there anything that
makes it hard for you to
care for yourself at home?”
Customized to high-risk for
readmission diagnosis or
specialty units (CHF, AMI,
PN, Mother/Baby, etc.)
Rounding by Assignment
Care giver focused which
enables focused validation of staff
behaviors & coaching for
improved outcomes
 Safety
 Hourly Rounding
 White Boards
 Pain education
 Core measure patients/bundle
 Discharge planning
 Patient/Family education
 Empathy
Aligns staff very quickly when
round by assignment
Sample Patient Rounding Log
Complete daily
Store in binder
Review for trends
Share “trends from
rounding” monthly with
direct report during
supervisory meeting
Use to write thank you
notes and R/R
Sample Patient Rounding Summary Weekly
Complete weekly
Used to track
organization wide
compliance with % of
patients rounded on
Share “trends from
rounding” monthly with
direct report during
supervisory meeting
Use to write thank you
notes and R/R
Coaching Tips – Organizational Compliance and
Correlation With Other Quality Metrics
Lessons Learned About Rounding on Patients
Schedule rounding as if it is a standing meeting
No meeting zone – TBD with staff input
This is not a TASK – this is evidence-based leadership
Don’t underestimate the value of proactively offering
service recovery
Post rounding questions in the lounge so staff are aware of
priority focus
Documentation on rounding tool/log is critical – not
optional
Census sheets may be used – keep a summary log of key
information
This is for the patients comfort, not ours
Coaching Tip: Role of the Leader
Train in skills lab and validate in real-time
Reward top performance and coach opportunities
Reinforce the WHY, connect to safe patient care
Track impact and communicate results
• Patient satisfaction by unit and HCAHPS
– Nurse communication, pain, responsiveness
• Falls, pressure ulcers, and other core measures
• Call lights
Audit the rounding logs
Round on patients to confirm behaviors
Post results from rounding – thank you notes
Communicate results in Supervisory Monthly Meeting
Hourly Rounding
A process to proactively interact with patients every hour during
the day using focused key words to assess needs (pain, position,
personal needs and patient education). A care model to help
return care to the bedside and a process to help achieve our
goal to “always” deliver exceptional clinical quality care in a safe
and compassionate environment.
What is it?
•
Why is it
important?
How will it
be used?
•
•
•
Evidence supports a decrease in patient anxiety, falls, skin
breakdown, and nursing steps as well increased patient
satisfaction
It allows nurses to provide more care at the bedside
It is just good patient care
There is no other initiative that impacts the patient perception of
quality care as this ONE does.
While in the patient room performing regularly scheduled tasks,
include 6 additional behaviors to proactively address the patient
needs and promote safety. Support areas address patient
environment and see what patient may need.
8 Behaviors of Hourly Rounding
Hourly Rounding Behavior
Expected Results
Use Opening Key words
Demonstrates respect and reduces anxiety
Perform scheduled tasks
Contributes to efficiency
Address 3 P’s (pain, personal needs,
position)
Impacts quality indicators – falls, HAPU, pain
control and responsiveness
Address additional comfort needs
Improved patient perception of pain control,
responsiveness and caring
Conduct environmental assessment
Focuses on culture of safety and clean,
healing environment
Ask “Is there anything else I can do for
you before I go, I have time?”
Builds a proactive, efficient care model and
improves patient perception of care
Tell patients when a team member will
be back
Contributes to efficiency and builds teamwork
Document the round on log in patient
room
Shows visible commitment to excellent quality
care
Hourly Rounding Logs
Non- negotiable if you want to
achieve desirable results
Is a visible representation to
patient/family of excellent, safe,
quality care
During rounds, nurse leaders
ensure logs represent hourly
rounding behaviors are
completed (R/R top performers)
Sustained results – can
consider taking logs down but
remember this if for the patients
Hardwired: 100% of Key Support Departments
Round on Inpatient Units
If not directly serving
patients, we are serving
someone who is…
How can my department
help improve the patient
perception of care?
Reward and recognition
Link to quality
Track and trend issues
Posted monthly
Rounding on Internal Customer Process
Schedule
Rounding
Appointment*
Next Rounding
Round on
Customer
Follow up on
identified
actions
Complete
Preference
Card
Review preferences
with staff
Post Cards in
department
Schedule next
Rounding
Copy Preference
Card & leave with
leader
Preference Card
• Customize service
to meet customer
priorities
• Align customer
priorities with
reality of resources
• Educate staff
• Prioritize
• Organize work flow
Verification
• Synthesize
Rounding
information
• Trend process
issues
• Review at MM
“If you have
accountability
with no
consequences,
you have no
accountability.”
Coaching Tips
Identify areas you support that are high impact
Round in these areas weekly
Schedule the time
Rotate the others so you connect with all departments
served on a regular basis
Define which leaders will be rounding on which areas
Validate areas of focus
Determine how progress will be communicated
Follow up and follow through
Capture the WINS
Don’t be defensive