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

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. AHRQ is a federal agency within the U.S. Department of Health and Human Services (DHHS) whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. HRET is a charitable and educational organization affiliated with the American Hospital Association whose mission is Transforming health care through research and education. HRET’s vision is to leverage research and education to create a society of healthy communities, where all individuals reach their highest potential for health.

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

HCAHPS Curriculum 2012-13 All 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

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

Research Update Based on a review of 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

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”

Thinking About Responsiveness Reactive Proactive Pervasive

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

Nursing Staff Opinions on Call Lights Opinion on Call Lights % positive responses Most of the reasons for call lights are meaningful 77% Most of the call lights require nursing staff’s attention and care 52% Most of the call lights pertain to patient safety 49% Answering call lights prevents you from doing the critical aspects of your role 53% 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.

Reactive Responsiveness: Patient Perception Elapsed Time Perceived Time Time Initial Acknowledgment Resolution of Request Response Informed Uninformed Waiting

Elapsed v. Perceived Time

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

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

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

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)

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

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

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

Sharp Memorial Hospital The magazine's top 10 most beautiful facilities were: 1. Sharp Memorial Hospital (San Diego, Calif.) 2. Henry Ford West Bloomfield Hospital (Bloomfield, Mich.) 3. Matilda International Hospital (Hong Kong, China) 4. Florida Hospital Waterman (Tavares, Fla.) 5. The City Hospital (Dubai, United Arab Emirates) 6. UPMC Hamot Women's Hospital (Erie, Pa.) 7. Bumrungrad International Hospital (Bangkok, Thailand) 8. St. Rose Dominican Hospitals-Siena Campus (Las Vegas, Nev.) 9. The London Clinic (London, England) 10. Children's Hospital of Pittsburgh (Pa.) http://healthexecnews.com/the-25-most-beautiful-hospital-designs-in-the-world

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

Quality of Solution

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

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

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

Q: Analyze Why are customers pressing their call buttons?

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

Q: Improve Plan Strategy Set expectations for responding to call lights Rules and tools for responsiveness Round effectively 7 Ps for responsiveness Educate Care Partner/Family Instructions on how to get help Standardize whiteboard Electronic whiteboard Leverage technology Nurse call system upgrade

Q: Improve Badge Card Bulletin Board Sign

Q: Improve Electronic Whiteboard

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

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.

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

E: Effective Results

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

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

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

HCAHPS Curriculum 2012-13 All 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