Transcript Powerpoint

Hardwiring A Culture of Always
And Impacting The Patient Perception Of Quality Care
April 6, 2016
Copyright © 2015 Studer Group. Please do not quote or disseminate without Studer Group authorization
“Rate honesty and ethical standards of
people in these fields”
100
90
80
70
60
50
40
30
20
10
0
% Responses "High" and "Very High"
85
75
70
70
62
58
53
52
41
38
28
24
10
8
Gallup Poll: http://www.gallup.com/poll/159035/congress-retains-low-honesty-rating.aspx
Copyright © 2015 Studer Group. Please do not quote or disseminate without Studer Group authorization
Overall Objectives
1. Describe the CAHPS family of surveys, Value-Based
Purchasing and the link to clinical quality
2. Identify five areas that create moments of truth used to
judge service and quality
3. List four strategies to impact the patient perception of
quality care, especially the Communication with Nurses
Composite
4. Outline the Readmissions Program and the Transitions of
Care Composite including strategies to impact results
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Start With A WIN – You Are A High-Performing State
Low to High State Performance “Percent of Patients that Rate the Hospital a 9 or 10”
#11 but was #7 in 2011
Lowest States
Average Top Box
57%-67%
VI
DC
NY
NJ
AK
NM
MD
NV
FL
WV
DE
MT
WY
Middle Low States
Average Top Box
68%-71%
ND
CA
CT
MA
PA
VA
GA
WA
AR
RI
HI
AZ
OR
Middle High States
Average Top Box
71%-73%
NC
MS
TN
VT
IL
MO
MI
SC
KY
AL
OK
OH
NH
Highest States
Average Top Box
73%-77%
TX
MN
IN
UT
ID
CO
ME
WI
IA
LA
NE
KS
SD
4
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Organizations Coached by Studer Group
Outpace in HCAHPS Improvements
Average Improvement in Top Box in One Year
Studer Group Partners vs. Non-Partners
Willingness to Recommend
1.2
0.4
Room Clean
1.5
0.7
HCAHPS Composite
Responsiveness of Staff
1.7
1.2
Quiet at Night
2.4
1.2
Pain Management
1.3
0.4
Overall Rating
1.8
1.3
Nurses Communication
1.1
Doctors Communication
0.4
1.4
0.9
Discharge Instructions
2.1
Communication of Meds
2.3
2.7
1.4
0.0
0.5
1.0
1.5
2.0
Average Change in Top Box in One Year
SG Partner Change 1Q12-4Q12 to 1Q13-4Q13
Non-Partner Change 1Q12-4Q12 to 1Q13-4Q13
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2.5
3.0
Family of CAHPS Surveys





Hospital CAHPS
Home Health Care CAHPS
In-Center Hemodialysis CAHPS
Clinician and Group CAHPS
Family Eval of Hospice Care




Health Plan CAHPS
OAS CAHPS
ED CAHPS
Child CAHPS
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HCAHPS Questions
Composite
Nursing
Communication
Doctor
Communication
Responsiveness
of Staff
Pain
Management
Communication
of
Medications
Discharge
Information
Care Transitions
NA
NA
Question Summary
Response Scale
Nurse courtesy and respect
Nurses listen carefully
Nurse explanations are clear
Doctor courtesy and respect
Doctors listen carefully
Doctor explanations are clear
Did you need help in getting to bathroom? 2
Staff helped with bathroom needs
Call button answered
Did you need medicine for pain? 2
Pain well controlled
Staff helped patient with pain
Were you given any new meds? 2
Staff explained medicine
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
Yes No (screening question)
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
Yes, No (screening question)
ALWAYS, Usually, Sometimes, Never
ALWAYS, Usually, Sometimes, Never
Yes, No (screening question)
ALWAYS, Usually, Sometimes, Never
Staff clearly described side effects
Did you go home, someone else’s home, or to
another facility? 2
Staff discussed help need after discharge
Written symptom/health info provided
Staff took pt/family preferences into account
I had good understanding of managing health
I understood the purpose of medications
ALWAYS, Usually, Sometimes, Never
Own home, Someone else’s home, Another
facility (screening question)
YES, No
YES, No
Area around room kept quiet at night
ALWAYS, Usually, Sometimes, Never
Room and bathroom kept clean
ALWAYS, Usually, Sometimes, Never
DEFINITELY YES, Probably Yes, Probably No,
Strongly Agree, Agree, Disagree, Strongly Disagree
Strongly Agree, Agree, Disagree, Strongly Disagree
Strongly Agree, Agree, Disagree, Strongly Disagree
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NA
What is “Top Box”?
HCAHPS Scales
Always
Usually
Sometimes
Never
Definitely Yes
Probably Yes
Probably No
Definitely No
Yes
No
10
9
8
7
6
5
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4
3
2
1
0
Current HCAHPS Data
9
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Key Drivers - Correlations
10
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What is the evidence that links the patient
perception of care to readmission rates?
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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.
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-2012-001570
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Emergency Department Patient Experience With
Care Survey (EDPEC Pilot Completed)
 Communication by Provider Type








Doctors Listening to Your Concerns
Doctors Using Words and Terms You Could Understand
Doctors Involving You in Decisions about Your Care
Doctor's Understanding and Caring
Doctor's Instructions/Explanations of Treatment/Tests
Nurses' Responsiveness to Your Needs and Requests
Nurses' Understanding and Caring
Nurses' Instructions/Explanations of Treatments/Tests
 Instructions for Care at Home
 Hospital Staff's Courtesy and Friendliness to You
 Timeliness/Throughput
 Transitions of care
 Pain Management
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Outpatient/Ambulatory Surgery Patient Experience
of Care Survey (OAS-CAHPS)
 New Composite Measures:
 About Facilities and Staff (Questions 3, 4, 5, 6, 7, and 8)
 Communications about procedure (Questions 1, 2, 9, 10, 11, and 12)
 Preparations for Discharge and Recovery (Questions 13, 14,
15, 16, 17, 18, 19, 20, 21, and 22)
 Global Items remain the same:
 Overall rating of facility (Question 23)
 Patient willingness to recommend (Question 24)
Note: There is a Surgical Survey created by American College of Surgeons , but it focuses on the surgeon, not the facility
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15
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Overview – Value-Based Purchasing (VBP)
What is VBP?
Why is it
important?
How will it be
used?
Another word for Pay-for-Performance, this is a
program intended to transform healthcare by
fostering a joint clinical and financial accountability
system.
This new payment system changed CMS from a
“passive payer” of services into an “active purchaser”
of value which is high quality, affordable, safe
healthcare.
Hospitals will be reimbursed based on their
performance, not just reporting, of quality metrics,
including the patient perception of quality.
If you perform “better” – you’ll be paid more
Better = patient-centered, efficient, quality care
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We Are In FY2018 Performance Period
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Tool
Efficiency Domain Measures COST (Value)
 MSPB-1 Medicare Spending per
beneficiary
 A claims-based measure that include
risk-adjusted and price-standardized
payments for all Part A and Part B
services provided from 3 days prior to
a hospital admission (index
admission) through 30 days after the
hospital discharge
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Downloads/NPC-MSPB-09Feb12-Final508.pdf
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Patient Perception and Medicare Spending per
Beneficiary
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5.75% at risk in FY2016 for Performance
• Value Based Purchasing 1.75% of base DRG (Increases to 2.0% in
FY2017)
• Rewards for good performance, Penalties for poor performance
• Credit is given for improvement
• Readmission measures cannot be included in VBP.
• HAC measures are eligible for inclusion in VBP.
• Readmissions Reduction Program 3.0% of base DRG
• Penalties for excess readmissions as determined by CMS
• Can only be penalized, no bonus. Up to 3% of base DRG at risk
• No credit is given for improvement
• Hospital Acquired Conditions (HAC) Reduction Program 1%
• 1% penalty for hospitals deemed as having “worst” performance.
• •No credit for improvement
• •HAC measures are also in VBP
20
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Nurse Communication Drives VBP Results
Both Clinical Process of Care and Patient Experience of Care VBP Scores Are
Influenced by the Quality of Nurse Communication
Average VBP Clinical Process of Care
Domain Score
by Hospital Ranking in Nurse
Communication
63.0
62.0
60.6
61.0
61.2
59.0
58.0
73
70
Patient Experience Domain Score
Clinical Process of Care Domain Score
64.0
59.0
80
64.2
65.0
60.0
Average VBP Patient Experience of Care
Domain Score by Hospital Ranking in
Nurse Communication
60
50
50
40
40
26
30
20
10
57.0
56.0
0
0-24th
25-49th 50-74th 75-99th
Percentile Percentile Percentile Percentile
0-24th
25-49th 50-74th 75-99th
Percentile Percentile Percentile Percentile
Hospital Ranking in Nurse Communication
Hospital Ranking in Nurse Communication
Copyright © 2015 Studer Group. Please do not quote or disseminate without Studer Group authorization
Overall Objectives
1. Describe the CAHPS family of surveys, Value-Based
Purchasing and the link to clinical quality
2. Identify five areas that create moments of truth used to
judge service and quality
3. List four strategies to impact the patient perception of
quality care, especially the Communication with Nurses
Composite
4. Outline the Readmissions Program and the Transitions of
Care Composite including strategies to impact results
Copyright © 2015 Studer Group. Please do not quote or disseminate without Studer Group authorization
What Do High Performers Do Differently?
They create a “Culture of Always…
“Culture means
creating consistency
and alignment in
human behavior that is
also in alignment with
a certain way of
thinking and living.”
Quint Studer
23
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Partner Up
No Pass Zone initiative
is in place
You are a CNA walking
down the hall of the med
surg unit. A call light is
going off. The IV pump is
beeping and the family is
looking out the doorway.
The CNO is walking in
front of you and saunters
right by.
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We Don’t Speak Up in Healthcare
 62% of nurses see coworkers taking
shortcuts that may endanger care
 80% staff have observed disruptive
behavior
 48% of providers believe coworkers
show poor clinical judgment at times
 10% of nurses, physicians, and other
clinicians directly confront
colleagues about performance
concerns.
Silence Kills: The Seven Crucial Conversations for Healthcare, 2005, AACN and VitalSmarts. A
national study of 1700 healthcare workers.
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The Culture Is Reflected in Memorable Moments
of Truth
MOT
MOT
MOT
MOT
 Moments of Truth are
events, observations,
and interactions that
create impressions.
 Moments of Truth create
impressions in five
areas.
MOT
MOT
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Memorable Moments #1: Tangible
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Memorable Moments #2: Responsiveness
Hourly Rounding Behavior
Expected Results
Use Opening Key words
Demonstrates respect and
reduces anxiety
Accomplish scheduled tasks
Contributes to efficiency
Address 4 P’s (pain, personal needs, position and
patient education)
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 leave’
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
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Memorable Moments #3: Reliability
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Memorable Moments #4: Assurance
Focus on the “A” and “I” to
show courtesy and respect to
people.
Focus on the “D” and “E” to
keep people informed.
Focus on “T” to show gratitude
and “The Promise” to
communicate your commitment to
providing excellent service or care.
30
Tool
A
Acknowledge
I
Introduce
D
Duration
E
Explanation
T
Thank You
The Promise
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Discussion – Building Skill in Coaching AIDET
Skills Lab Video
What did they do well in
this skills lab?
How did the employee
feel?
How are they going to build
skill of the staff?
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Memorable Moments #5: Empathy/The Little Things
 “Would you like me to close
the door to keep your room
quiet?”
 “While we do all we can,
we are a hospital and some
noise is inevitable as we
are caring for patients. I
brought you some ear
plugs…
 “I brought your sister a
pillow.”
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A Culture of Engagement/Empathy – ALWAYS?
Sample Verbatim patient comments
 One nurse avoided my call button, I could hear her talking at the
nurses station.
 I HATED going to the bathroom and nobody emptying the toilet pan.
 I felt like an inconvenience and she probably didn’t appreciate
getting a patient at the end of her shift. She told my husband that
she didn’t know why the doctor ordered the IV and was basically
disagreeing with him. That was unprofessional.
 Dr. very nasty to family members if she didn't want to answer
questions - she shouldn't have asked if anyone had questions.
 Had to remind staff members to sanitize their hands before
examining me... not good.
 Sent home with medications and no instructions.
33
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34
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Physician Empathy
"Our results show that physicians with high empathy scores
had better clinical outcomes than other physicians with lower
empathy scores"
•
Empathy
•
Higher Empathy 
Good Control
Lower Empathy 
Poor Control
good control*
(A1c<7.0 percent)
good control*
(LDL<100mg/dL)
moderate control*
(A1c≥ 7.0% and
A1c≤ 9.0%)
moderate control*
(LDL≥ 100 and ≤
130 mg/dL)
poor control*
(A1c>9.0 percent)
poor control*
(LDL>130 mg/dL)
Hojat, M., Louis, D.Z., Markham, F.W., Wender, R., Rabinowitz, C., & J.S. Gonnella. (2011). Physicians’ empathy and clinical outcomes for diabetic patients. Academic
Medicine, 86(3), pages 359-364.
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Sacred Time: First Two Minutes of Any Interaction
“Welcome to the third floor where all of our nurses are specially
trained to handle heart issues such as yours. I have been a
nurse for five years, all of it here at this hospital. We are proud
of the care we provide here on this unit. I will take about five
minutes to walk through a couple things you can expect from
us. We will be responsive to your needs and you can expect us
in here about every hour and we will ask you about your pain, if
you are comfortable and if we can help you to the bathroom.
We will also include you, and your family if you want, in our
change of shift report. One of our leaders will round on you
every day to make sure we are providing excellent care. We
will tell you more about what you can expect from us but now
let’s hear about what excellent care will look like to you…
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Nine Factors Of Engagement
Chapter 4
Nine factors of engagement
1. Actively listening
2. No multi-tasking
3. Eye contact
4. Tone of voice
5. Speed of speech
6. Empathetic touch
7. Appropriate use of humor
8. Physical position
9. Energy mirrors the needs of the patient/family
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Listen Carefully Exercise
Pair Up – decide who will speak first
Think about a caring moment – a time in which you
were cared for or you cared for someone else. Does
not have to be patient related, can be at any time in
your life. Tell your story for 2-3 minutes
Listener - you may provide only “mirroring
statements” and other gestures to demonstrate deep
listening
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Overall Objectives
1. Describe the CAHPS family of surveys, Value-Based
Purchasing and the link to clinical quality
2. Identify five areas that create moments of truth used to
judge service and quality
3. List four strategies to impact the patient perception of
quality care, especially the Communication with Nurses
Composite
4. Outline the Readmissions Program and the Transitions of
Care Composite including strategies to impact results
Copyright © 2015 Studer Group. Please do not quote or disseminate without Studer Group authorization
Execution Framework: Evidence-Based
LeadershipSM
LEADER EVALUATION
MUST HAVES®
STANDARDIZATION
Implement an organization-wide
leadership evaluation system to
hardwire objective accountability
Rounding, Thank You Notes, Employee
Selection, Pre and Post Phone Calls, Key
Words at Key Times
Agendas by pillar, peer interviewing, 30/90 day
sessions, pillar goals
PERFORMANCE GAP
Leader Evaluation Manager®
Validation MatrixSM
Provider Feedback SystemSM
Studer Group Rounding
Patient Call ManagerTM
LEADER DEVELOPMENT
Create process to assist leaders in
developing skills and leadership
competencies necessary to attain
desired results
Re-recruit high and middle performers,
Move low performers up or out
40
ACCELERATORS
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High Impact Recommendation for Improvement
# 1 – Use Key Words At Key Times
WHY? Key words reflect a communication style that
improves the quality of information provided by every
person in every interaction. This makes care safer,
patients less anxious and informed about their care.
 Identify key times (defining moments that occur during
times of vulnerability that create memorable
experiences (positive or negative)
 Train and validate all employees on the concept of
“managing up” and the “WHY” of fundamentals of
communication (AIDET℠)
 Narrate your care
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Narrating Your Care… Sounds So Cold
• The voice from the wall above
answers the call light “can I help
you?”
• “Have a seat, we will call you when
we are ready for you”
• “We will put you on a stretcher here in
the hallway until they have a bed
ready for you upstairs”
• “You will have to set up a payment
plan before you leave.”
42
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From “Blind Trust” To “Informed Trust”
Addressing Patient Fears
1. Infection
Correlates with actions:
2. Incompetence
3. Death
4. Cost
5. Mix-Ups
6. Needles/pain
7. Rude doctors and nurses
8. Prognosis
9. Communication issues
10. The unknown
• “For your safety”
• AIDET®
• Responsive to needs/hourly
rounding
• Explain things/bedside report
• Keep informed
• Manage pain
• Treat with courtesy/respect
• Multi-disciplinary rounds
• Explain in ways can
understand/include family
• Listen carefully
- Colleen Sweeney, “The Empathy Project”
43
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Seek first to understand what is most
important to them.
44
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Use words that patients/customers NEED
and WANT to hear.
45
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Verify understanding with “Teach-Back”
Verifies they understand what you said
Use appropriate language
• Caring tone of voice/attitude
• Plain language/ no jargon
• Reiterate the two most important things
• “Can you tell me what are the two most important things
you heard to take care of your incision when you go home?”
• “Before we have our bedside report, let’s spend five
minutes reviewing what we accomplished together over the
last twelve hours.”
46
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Intentionally Moving From “Blind Trust” To “Informed
TRUST”
1.
2.
3.
Seek to understand what is important to them
The only way to know is to ask
Use words that patients/customers Need and
Narrate your care and tell “their story”
Verify understanding with “Teach-Back”
Verifies they understood what you said
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Want to hear
High Impact Recommendation for Improvement
# 2 – Engage and Educate ALL Employees
WHY? We must engage the hearts and minds of all staff to
promote effective communication and coordination of care.
With a scale of Always, every interaction impacts the patient
perception of quality care.
 Accountability for Leaders
 Round on Employees
 Thank you Notes
 Accountability for Staff
 Rejuvenate the behavior standards and be aggressive about
managing people who do not uphold the values
 Expand HCAHPS education to all staff and ensure they
understand their role in a culture of always
Copyright © 2015 Studer Group. Please do not quote or disseminate without Studer Group authorization
Engaged Work Environments Is Critical
• Engaged – work with passion and feel a
profound connection to their company,
drive innovation and move the company
forward
• Not-engaged – essentially “checked-out”
or sleep-walking through their day, putting
time in but not energy or passion in their
work
• Actively dis-engaged- not only unhappy
at work but actively acting out their
unhappiness. Every day these workers
undermine what their engaged coworkers accomplish.
Nurse
Engagement
Survey
22%
9%
26%
43%
Engaged
Content
Ambivalent
Disengaged
Source: Gallup and JONA. Vol. 41. No. 6. June 2011
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Rounding For Outcomes on Employees,
Physicians and Internal Customers
Proactively, engaging, listening to,
communicating with, building relationships with
and supporting your most important customers.
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 can I do to make this a better place to work?
What can I do to be a better leader for you?
Thank you for making a difference!
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Tool
Engaged Employees And Workforce Safety
1. Am I treated with dignity and
respect by everyone, every
day, in each encounter?
2. Do I have what I need:
education, training, tools,
financial support,
encouragement, so I can
make a contribution to this
organization that gives
meaning to my life?
3. Am I recognized and thanked
for what I do?
Download at Lucian Leape Foundation
www.npsf.org/lli
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Tool
High Impact Suggestion for Improvement
# 3 – Nurse Leader Rounding on Patients
WHY? Rounding is the best way to PROACTIVELY connect
with patients to ensure the delivery of quality care, validate
staff behaviors, and recognize employees living the values.
 Every patient – every day with documentation of themes
 Reduces variance in frequency of behaviors and ensures they
are hardwired (real-time recognition or coaching)
 Links to actionable information to drive results
 Hourly rounding
 Bedside handover
 White/care boards complete
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The Why Four Goals EVERY Day
Round on staff to communicate
1. I care about the quality of care we provide
2. I appreciate the quality of care you deliver (or not)
4 Goals with each interaction
1. Create an empathetic connection with patients;
manage their expectations
2. Proactively assess quality of care using focused,
probing questions to determine gaps and obtain
actionable information
3. Harvest compliments and manage up
4. Service recovery (if needed)
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Tool
The How Two Key Questions After The Round
1. What have you learned about the care being
delivered to the patients you have rounded on?
2. What MUST you do with that information?
• Recognition
• Coach/development of staff
• Process improvement
• Environmental safety
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Discussion – Skills Lab Video 2
Your role is to coach the nurse leader in this video to a higher level of
performance on nurse leader rounding. Her two focus areas are pain
management and responsiveness of staff.
• What did she do well?
• What are coaching opportunities to raise performance?
55
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Leader Rounding – Key To Accountability
1.
Use opening key words and/or actions to introduce yourself and manage
up others. Refer to the white board and ensure is updated.
2.
Ask 2-3 questions about specific initiatives:

We focus on meeting your needs, and with that in mind, the staff are
to be in the room every hour asking about pain, position and
bathroom needs. Has this been your experience?

In the last 24 hours, have you had to use your call bell to ask for
pain medicine?

What do you think about our new process of bedside shift report
where we include you, the family, in the care plan?
3.
Conduct environmental assessment. Use closing key words and/or
actions including setting expectation that a caregiver will return within the
hour.
4.
Review patient’s rounding log for compliance. Provide immediate
feedback to staff – both with celebrations / recognition and coaching
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High Impact Recommendation for Improvement
# 4 – Hardwire The Nursing Care Model
Hourly Rounding®
1.
2.
3.
4.
5.
6.
7.
8.
Use opening Key words: Round
Perform scheduled tasks
Perform 3P’s
Additional Comfort measures
Environmental assessment of room
Closing Key words
Tell when you will return
Log the round
Nursing and
Patient Care
Excellence
Individualized Patient
Care
1.
2.
3.
4.
Ask what 2-3 things will ensure excellent care
Write on board
Used by all members of the care team
Ask each shift to reinforce listening
Bedside Shift Report
1. AIDET® introduction
2. Communication of current state and plan of
care
3. Teach back reinforcement of important
patient care information such as drug side
effects
Post visit calls
1. Questions designed to assess patients
progress at home
2. Listening with more than your ears
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Bedside Shift Report (Chapter 11)
• What is it?
The process of handing-over care delivery from one nurse to another at
change of shift at the patient bedside when appropriate. This
process incorporates other concepts such as “managing up”, AIDET
communication, teamwork and creating a safe patient environment.
All necessary patient information is exchanged in the patient room
such as patient identifiers, safety checks, medications, tests etc.
This addresses basic patient rights by keeping them patient informed
and involved in their care.
• Why do it?
Safe hand-over’s are the responsibility of every nurse. This process
“transfers trust” to the oncoming caregiver and reduces patient
anxiety.
Through a real-time exchange of information, the patient and their
family/caregiver is involved in their care as well as teamwork and
accountability are strengthened with the care-giver team.
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Standardize Communication Process
Utilizing the SBAR(T) communication framework:
S
B
A
R
T
Manage up next care giver; utilize
SITUATION
AIDET℠; environmental assessment
Update on patient’s chief complaint;
pending tests/treatments; special
BACKGROUND
needs; explain plan to patient/family;
medications and side effects
Quick physical assessment including
pain scale; check IV sites and pumps
ASSESSMENT
for accuracy
Validate orders and plan of care
RECOMMENDATION including anticipated disposition.
Ask patient if they have pain,
understand plan of care, have any
THANK YOU
questions or concerns.
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CMS Patient Family Engagement Metrics
Best Practice Category
PFE Metric
Instruction: For each of the following items, indicate if the hospital does this or does not do this.
If you do not know, indicate so.

Does=1

Does not=0

Unknown=u
Point of Care
1.
Prior to admission, hospital staff provides and discusses a discharge planning
check list with every patient that has a scheduled admission, allowing questions or
comments from the patient or family (e.g., the planning checklist may be similar to
the CMS Discharge Planning Checklist).
2.
Hospitals conduct both shift change huddles for staff and do bedside reporting with
patients and family members in all feasible cases.
3.
Hospital has a dedicated person or functional area that is proactively responsible for
Patient and Family Engagement and systematically evaluates Patient and Family
Engagement activities.
4.
Hospital has an active Patient and Family Engagement Committee (PFEC) OR at least
one former patient that serves on a patient safety or quality improvement committee
or team.
5.
Hospital has one or more patient(s) who serve on a Governing and/or Leadership
Board and serves as a patient representative.
Policy & Protocol
Governance
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Hourly Rounding® (Chapter 10)
 What is it?
 A plan to proactively interact with patients every hour
during the day using focused key words to assess needs
(pain, position, personal needs and patient education)
and achieve goal of “always” delivering quality care in a
safe environment
 A care model to help return care to the bedside
 Why do it?
 Quality of care (Reduce falls 50% and HAPU 14%)
 Gives nurses control (reduce call lights 37.8%)
 Improves patient perception of care (+12 pts)
 It is just good patient care
 There is no other initiative that impacts the patient
perception of quality care as this ONE does
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Track Actions And Outcomes
62
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Responsiveness: Correlates to Quality
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Eight Behaviors of Hourly Rounds – More Than 3 P’s
Hourly Rounding Behavior
Expected Results
1.Use Opening Key words
Creates efficiency
“checkin’ on ya” won’t suffice
2. Accomplish scheduled tasks
Contributes to efficiency
3. Address 3 P’s (pain, potty, position)
Quality indicators – falls, decubitis, pain
management
4. Address additional comfort needs
Improved patient satisfaction on pain,
concern and caring, efficiency
5. Conduct environmental assessment
and ensure bed technology is correctly
utilized
Contributes to efficiency, teamwork
6. Ask “Is there anything else I can do for
you before I go, I have time?”
“Call me if you need me” decreases
efficiency.
Improves patient satisfaction on teamwork
and communication
7. Tell each patient when you will be back
Contributes to efficiency
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“Explain” What Hourly Rounding Is and WHY We
Do It…
“On this unit, one of our care team
members will be coming in to see
you every hour during the day.
You will see either me or Jackie,
our certified nurse assistant. I
have worked with Jackie for two
years and she is excellent. We
will be checking on your comfort
such as we will make sure we are
helping manage any pain you
might have, help you change
position, help you to the bathroom
and make sure you have
everything you need.” We call this
hourly rounding and we do it to
make sure you are safe and we
are always meeting your needs.”
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Discussion
Hourly Rounding
has been “rolled
out” with an
expectation that
they will sign the
log with their
initials when in
the room.
You are the manager of the
med-surg unit. During
rounds, you see the log has
not been signed for three
hours yet the patient says
that the staff have been
checking on them at least
every hour. (this is a low
performer)
How do you coach them?
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Discussion
At 10 AM the next
day, you round on
their patients and
there is no
documentation of
hourly rounding.
The patient states
they haven’t seen
their nurse since 7
AM.
 Describe what has been
observed
 Explain the impact of the
behavior
 Show or tell what needs
to be done
 Know the consequences
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Important difference in employees:
 “I couldn’t” vs. “I didn’t” vs. “I won’t”
 If “I couldn’t”
―Do they have the tools and equipment?
―Do they have the knowledge and skills?
 If “I won’t”
―Do they understand why it is important?
―Do they understand consequences?
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Tip From Experts: Clearly Define Consequences
1. As a leader, do you have concerns regarding your staff performance and
lack of outcomes?
Is it ‘Skill’?
• Does your staff know how to do the job?
• Have they been trained properly?
• Do you have confidence that they have the know-how?
2. Once you are sure its not a ‘Skill’ issue, then you must assess if it’s a ‘Will’
issue
• Have clear expectations been defined (mandatory)?
• Have you exhausted efforts to coach them fully & effectively?
3. If you determine it is ‘Will’, need to move to performance counseling,
including consequences
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Barriers to Effective Communication
 We don’t INVITE feedback
 We don’t send the mail to the right address
 Letting too much time go by
 Ignoring problems, and hoping they will go away
 Giving a softened form of correction
 Giving general vs. specific feedback
 Not getting the facts before deciding action
 Not indicating the consequences
 Not acting on stated consequences
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Overall Objectives
1. Describe the CAHPS family of surveys, Value-Based
Purchasing and the link to clinical quality
2. Identify five areas that create moments of truth used to
judge service and quality
3. List four strategies to impact the patient perception of
quality care, especially the Communication with Nurses
Composite
4. Outline the Readmissions Program and the Transitions of
Care Composite including strategies to impact results
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Readmissions Reduction Program
Tool
• In FY 2016, the maximum penalty remains at up to 3 percent of inpatient
payments based on each hospital's readmission rates for acute
myocardial infarction, chronic heart failure, pneumonia, chronic
obstructive pulmonary disease (COPD) and elective total hip/total knee
arthroplasty.
• The three-year measurement period for FY 2016 is July 1, 2011 through
June 30, 2014. CMS finalized its proposal to formally adopt an
extraordinary circumstance exception (ECE) policy for hospitals, which
aligns with the existing ECE policies in place for the IQR and VBP
programs and now policies in place for the HAC program.
• CMS estimates that 2,666 hospitals will have their base operating DRG
payments reduced by their proxy FY 2016 hospital-specific readmissions
adjustment, resulting in approximately $420 million in payment reduction
72
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Evidence-Based Problem

Research shows that patients remember and understand less than half of what clinicians
explain to them
(Communicating with patients: improving communication satisfaction,
and compliance 1988)

58% of patients discharged don’t know their diagnosis and don’t understand their care plan
(Mayo Clinic Proceedings, 2010)

81% of patients requiring assistance with basic functional needs at home failed to receive a
home care reference and 68% said no one talked to them about home care ( Rost,
Predictors of recall of medication regimens and recommendations for lifestyle change in
elderly patients 1987)

30% less likely to be re-admitted if included in care plan about discharge before leaving
(AHRQ Re-Engineering Discharge)

36% of Americans are below an average health literacy level
http://nces.ed.gov/pubs2006/2006483_1.pdf

12-34% of primary care givers did not have a discharge summary when patient came to first
office visit post-hospitalization
ahrq.gov
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Care Transitions and Discharge Information
Rooted in Communication
• During this hospital stay, did doctors nurses or other hospital staff talk
with you about whether you would have the help you needed when you
left the hospital?
• During this hospital stay, did you get information in writing about what
symptoms or health problems to look out for after you left the hospital?
• 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.
74
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Differing Perspectives (Staff/Patient)
Clinicians and hospital staff
Patients and family members
• Are taught that discharge starts
at admission but may not do this
often
• Can feel as if they are being forced out of the
hospital when you raise the idea of discharge starting
at admission
• May not start to think about discharge until later in the
stay
• May prioritize clinical care (e.g.,
wound care) at home
• May prioritize functioning and quality of life
(e.g., activities and diet)
• May not know all the questions they should ask or what
they need to know when they are home
• Have limited time for discharge
planning
• May not understand all the written information they
receive related to discharge
• May feel rushed on the day of discharge
• Want patient to succeed at home
• Want to know the name and phone number of the one
person to call if they have problems
AHRQ Strategy 4: IDEAL Discharge Planning (Tool 4)
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Tool
76
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1. Improve Initial Communication With Key
Stakeholders – Patient/Family
Tool
At ADMISSION
Identify “Key Learner”
Explain preparation for
discharge is continuous
Share tools
Discharge Checklist
Discharge Folder
Discharge Home Pass
“Post-Discharge Tool” (National Patient Safety Foundation [NPSF])
http://www.npsf.org/wp-content/uploads/2011/10/Post-Discharge-Tool.pdf
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2. Improve DAILY Communication With Providers
and Patient/Helpers at Home
 Bedside Handover
 Nurse Rounds With Docs
 Multi-disciplinary team
rounds
 Case Management
 Anticipated DC date
 Help/Tools at Home
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3. Improve Discharge Communication With
Standardized Tools
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Discharge Phone Calls (Chapter 9)
WHY? A telephone call made to a patient within 24-72
hours after an interaction with Inpatient, Outpatient or ED
services will help ensure a safe transition home and
reduce unnecessary re-admissions.
 Goal is 100% of patients receive a discharge phone call
 Did your discharge instructions answer all your questions?
 Is there anything preventing you from taking your medications as
ordered?
 Track attempt/complete rate and trended info associated
with quality outcomes/readmissions
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Validate: Are we Calling who we Need to Call?
81
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Impact of Patient Call Manager℠
on Patients Overall Rating of Hospital
When a Call was Received, Top Box Results for “Patients Rate Hospital a 9 or 10” Increased by 30%,
Enough to Move Department from the Lowest Quartile to the Highest
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Readmission Reduction
Post-Visit Calls
Patients that received a post visit call
3 days after discharge had a lower
re-admission rate
Source: South Carolina Academic Medical Center
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Did We Accomplish Our Objectives?
1. Describe the CAHPS family of surveys, Value-Based
Purchasing and the link to clinical quality
2. Identify five areas that create moments of truth used to
judge service and quality
3. List four strategies to impact the patient perception of
quality care, especially the Communication with Nurses
Composite
4. Outline the Readmissions Program and the Transitions of
Care Composite including strategies to impact results
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