Excellence in the Emergency Department: How to Get Results Indiana Rural Health Association Stephanie Baker, RN, MBA, CEN March 3, 2011 Why is this Important? What does improved results mean to: Patients/Families Physician Employees Community Emergency Department Hospital What Do Improved Results mean to Patients and Families? Pain is being managed Call lights are being responded to in a timely manner Patient needs are met “proactively” Patients are kept informed and actively involved in their plan of care Improved communication with families Patients understand their home care instructions Patients feel like we care, not like an inconvenience What Do Improved Results mean to Physicians? Less turnover of staff Better working systems Better relationships with referring hospitals Decreased complications and complaints Decreased litigation Greater peace of mind Increased fulfillment of physician mission to provide better patient care What Do Improved Results mean to Employees? Know and feel better about where they work- pride in workplace More effective and efficient team when work force is stable Feel systems and processes work better Tools and equipment to do the job Ability to consistently perform core responsibilities More specific reward and recognition Renewed passion for their work Better work-life balance What Do Improved Results Mean to the Community? Better access to care for patients Better place to work for employees Healthier community Better place for physicians to practice medicine High quality care at a competitive cost What do improved results mean to the ED and the Hospital? Improved Clinical Quality Outcomes Reduced litigation and risk More positive community representation Increased volumes / revenue Improved Market Share Positioned well for Pay for Performance Allows for survival -- accountable for metrics Healthcare Flywheel® Bottom Line Results Prescriptive To Do’s (Transparency and Accountability) Purpose, worthwhile work and making a difference SelfMotivation WHY ® 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 performers Move low performers up or out Standardization Accelerators Aligned Process Processes that are consistent and standardized throughout the company Software “Vision without execution is h a l l u c i n a t i o n .” Thomas Edison Top Ten Challenges in Execution 1. Leaders / Others underperforming and still receiving a good evaluation (Accountability) 2. Change not connected to why (Alignment) 3. Lack of necessary urgency (Alignment) 4. Leaders do not have the skills to assure a solid implementation. (Action) 5. Too many changes -- too soon (Action) 6. Push Back by leaders, staff and physicians (Accountability) 7. Not familiar with what “right” looks like (Action) 8. Lack of frequency (Action) 9. Inability to transfer best practices (Action) 10. Poor processes (Action) Key Evidence Evidence - Defined ev·i·dence /ˈɛv ɪ dəns / Show Spelled [ev-i-duh ns] noun, verb, -denced, -denc·ing. –noun 1. that which tends to prove or disprove something; ground for belief; proof. 2. something that makes plain or clear; an indication or sign Studer Group Partners Outperform the Nation by an Average of 20 Percentile Points across HCAHPS Measures Percentile Rank Comparison: Studer Group Partners vs. Non‐Partners Patients who gave a rating of 9 or 10 (high) Yes, patients would definitely recommend the hospital 23% 22% Source: The graph above shows a comparison of the average percentile rank for Studer Group Partners that have received EBL coaching since Oct 2007 and non‐partners for each composite; updated 10.11.10 Our Partners Outpace Peers in HCAHPS Improvements at a Speed Nearly Three Times Faster Than the Nation. Source: The graph compares the change In one year in “top box” results achieved by Studer Group partners vs. non‐partners. Change is from Jan‐Dec 2008 to Jan‐Dec 2009. As Hospital’s ED Percentile Ranking Increases, So Does Its HCAHPS “Overall” Percentile Ranking Studer Group Partners Perform Better Than the Nation in All Core Measures Studer Group Partners vs. National Average in Compliance with Evidence‐Based Clinical Core Processes 100% 93.9% 90% 96.1% 94.5% 93.5% 91.4% 90.0% 89.0% 87.6% 83.3% 78.6% 80% 70% Children's Asthma Heart Attack or Chest Pain National Average Heart Failure Pneumonia Surgical Care Improvement Project SG Avg (EBL Since Oct 2007) Why is The Focus On the ED? 45-80% of hospital admissions come through the ED Why is this important? #1 - Reimbursement “Here you go… thought you might like this” #2 Workforce Shortage - Nurses Physician Workforce Shortage www.aamc.org/workforce Reason #3 - Malpractice Relationship between patient satisfaction, complaints and lawsuits Physicians with lower patient satisfaction results are more likely to have patient complaints (RR 1.79;95% CI 1.38-2.33; p<.001) Each one point decrement in patient satisfaction scores is associated with a – 6% increase in complaints (RR 1.06, 95% CI 1.03 – 1.08;p<.0001) 5% increase in risk management episodes (RR 1.05, 95% CcI 1.01 – 1.09;p< .008) Lower performing physicians were at greater risks for lawsuits (RR = 2.10;p 95% CI 1.13 – 3.90; p<.019) 75% of complaints were related to communication issues Stelfox HT, et al, The American Journal of Medicine 2005; 118: 1126 – 1133 Reason #4 - The Transparent Environment –Quality On-Line Pay for Performance . . . Coming Soon to Your Neighborhood Value-Based Purchasing (VBP) = a specified percentage of hospital payment would be conditional on performance – Reimbursement currently: 100% public reporting – Reimbursement FY 2013: 50% performance 50%public reporting – Reimbursement FY 2014: 100% performance Calculating Reimbursement – Will need to either be at 50%ile or show improvement from previous score to earn points for that dimension Reason #5 – Communication = Compliance = Quality Physician communication correlates STRONGLY with adherence rates by patients in acute and chronic disease. There are now over 100 observational and 20+ experimental studies published demonstrating the correlation of communication (patient satisfaction) with compliance. Compliance with treatment regiments has significant influence on quality measures in chronic disease and outcomes. Medical Care: August 2009 - Volume 47 - Issue 8 - pp 826 Quality/Service/Efficiency Relationship Between Employee Turnover and Patient Care Mortality Index = Clinical Quality Employee Turnover = Service Excellence LOS = Operational Efficiency It’s Getting Harder to be Great The Best Definition of Madness is To keep doing things the same way and expect different results . . . How Are You Feeling About All of This? How We Need to Feel CHANGE Patient Safety, Satisfaction, and Quality All Depends on Patient Flow Quality and Safety Source: Studer Group and CEP ED Revenue Potential with a 1 Hour reduction in Throughput with Unmet Demand… 40,000 ED Visits X 1 Hr LOS reduction= 40,000 Hrs of ↑ED Capacity/ Year 2-3 Hours/Visit = 20,000-13,000 potential new visits 20,000 new visits X $100/Visit = $2,000,000 in new revenue for the group 20,000 new visits x $400/Visit = $8,000,000 in new revenue for the hospital This potential revenue increase does not include the increase in inpatient revenue at $3,000-$7500 per admission Walkaways- LWBS’s and AMAs: The Financial Implications of Throughput Improvements Average $100 MD income for every walkaway Average $400 in hospital income for every walkaway For a 50,000 visit ED= $50,000 in new MD revenue (no increased overhead) for every 1% reduction in LWBS/LWBTs A 1% reduction in walkaways = $200,000 in new outpatient hospital revenue Hospital Admissions and Your ED 20 admissions per day x $5,000/admission (on average)= $36,500,000/year coming in through your ED What if you increased admissions by 5% = what increase would this have on revenue? 30 admissions/day x $5,000/admission (on average)= $54,750,000/year coming in through your ED 1 more admission per day (365) X $3,000-$7500/ patient admission Go ahead, find out your numbers and then do the math for your facility… (AHRQ-only 6.2% of admissions through the ED are uninsured) =$1,095,00-$2,737,500/year Thinking About ED Patient Flow Optimizing Patient Intake and Throughput: Segmenting Patient Flow Into Incoming Patient Streams… The Life Cycle of a Patient Visit Arrival Triage Input (Patient Intake) Bed assigned Physician contact Throughput Disposition Output (Departure) Admit Discharge The view from the gurney up: “Vertical” vs. “Horizontal” Patients Vertical Patients Ambulatory Arrive by Triage Well Younger Perceived urgency or convenience factor Value (Starbucks or McDonalds) – Speed – Convenience – Financial – Other non-medical factors Horizontal Patients Stretcher bound Ambulance Arrival Sick Older Perceived serious or lifethreatening Condition Value (Traditional Healthcare) – Speed – Safety – Preservation of Life/Limb Segment Your ED’s Patient Flow into Incoming Patient Streams Triage Brief RN Assessment: ESI Evaluation / Evaluation of Acuity Low Acuity Pathway ESI Levels 5, 4, + some 3s Moderate Acuity Pathway Most ESI Level 3s High Acuity Pathway ESI Levels 1 + 2 Keeping Your Vertical Patients Vertical and Moving Treat and Release Patient Intake Area Results Waiting Area Patients enter intake area -Focused Evaluation and Treatment -Move to results waiting area. -Triage Orders -Dx/Rx Protocols -MLP in Triage -MD in Triage -Super-Track -Fast-Track -Team Triage -Results Back -Treatment Complete -Discharge Bed Turns and Results Waiting 6 Hour ALOS=4 patients per bed per day 4 Hour ALOS=6 patients per bed per day A key rate limiting server A key component of care A key “member” of your team …Park bench… or MVP? ED Patient Flow is Predictable: Classic ED Patient Flow Curves Emergency Department Admission Times : 1 Hour Increments 400 350 300 250 Number 200 Of Pts 150 100 50 0 0:00 1:00 2:00 3:00 FY2004 Q- 1 154 149 120 81 4:00 5:00 83 79 6:00 7:00 8:00 99 153 166 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 269 253 277 235 260 274 268 294 307 332 352 345 299 278 211 FY2005 Q- 1 160 119 107 83 71 76 85 106 156 208 226 230 260 243 260 260 304 286 302 333 287 270 260 198 [Trend-Star Data : Q-1 FY04 & 05 Volume Variation by Day of Week Volume varies significantly by day of week – 10%+ variation between heavy and light days Saturday, Sunday and Monday are heavier days When matching capacity with demand, varying staffing by day of week is essential Our Emergency Departments are the ultimate reality show… We can do this… Must Haves to Hardwire a Culture of Safety and Service Why Do We Want To Do This? ….because this could be hard….. Service is Married to Quality, Safety and Flow 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 will be publicly reported Why is it with other quality metrics on the Hospital Compare important? website. www.hospitalcompare.hhs.gov The information will be used to provide meaningful data How will it for improvement efforts as well as provide comparisons be used? between hospitals to help consumers choose a hospital. HCAHPS Questions Composite Nursing Communication Doctor Communication Responsiveness of Staff Pain Management Communication of Medications Discharge Information 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 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 NA Willingness to Recommend ALWAYS, Usually, Sometimes, Never DEFINITELY YES, Probably Yes, Probably No, Definitely No NA Hospital Rating Question 0 to 10 point scale (percent 9 and 10 reported) Always Never Sometimes Usually Always Research Patients’ rating of quality is more predicted by their rating of the quality of communication than technical care. * Annals of Internal Medicine 75% of patients admitted to the hospital were unable to name a single doctor assigned to their care. *Archives of Internal Medicine 91% of patients want to be addressed by name and 78% of patients wanted their physician to shake hands YET physicians use the patients’ name less than 50% of the time. * Annals of Internal Medicine * Mayo Clinic Proceedings Nursing Communication: The Most Bang for Your Buck The Nursing Communication Composite is the one most highly correlated with overall hospital rating. 1. During this hospital stay, how often did nurses treat you with courtesy and respect? 2. During this hospital stay, how often did nurses listen carefully to you? 3. During this hospital stay, how often did nurses explain things in a way you could understand? Key Tactics: What You Must Know to Improve Your HCAHPS Results Rounding for Outcomes On staff and providers On patients Hourly Rounding Rounding in Reception Area Post Visit Phone Calls AIDETSM Chapter Two: HCAHPS Handbook; The Fundamentals: What You Must Know to Improve Your HCAHPS Scores; pgs 23‐44 Leader Rounding on Providers and Staff What All Types of Rounding Have in Common Proactively engaging, listening to, communicating with and supporting our most important customers (family, staff, doctors, patients, partners, and other departments) The exact opposite of an open door policy Engagement: The 12 Items That Matter Q12. Q11. Q10. Q09. Q08. Q07. Q06. Q05. Q04. Q03. Q02. Q01. This last year, I have had opportunities at work to learn and grow. In the last six months, someone at work has talked to me about my progress. I have a best friend at work. My associates or fellow employees are committed to doing quality work. The mission or purpose of my company makes me feel my job is important. At work, my opinions seem to count. There is someone at work who encourages my development. My supervisor, or someone at work cares about me as a person. In the last seven days, I have received recognition for doing good work. At work, I have the opportunity to do what I do best every day. I have the materials and equipment I need to do my work right. I know what is expected of me at work. Total Number of Hours Absent by Engagement Levels Work force with higher levels of engagement were absent for fewer hours than less engagement employees Percentage of Hand Hygiene Incidents by Workgroup Engagement Levels Departments with higher levels of engagement also have a higher % of acceptable hand-hygiene incidents than lesser engaged departments Annual Department Patient Satisfaction Percentile Ranks by Engagement Levels Departments with higher engagement levels also had higher annual Patient Satisfaction Percentile Ranks Rounding for Outcomes – Staff and Providers Concern and Care Align Questions to Fit Desired Outcomes of the Organization What is Working Well People to Recognize Systems to Improve (hit those Q12!) Tools and Equipment Follow-up Be Prepared Round on high performers first! Have data with you, data speaks louder than opinions Know how you will answer tough questions Assure that rounding stays positive! Use a log for validation to be sure you do not forget important things, note trends, and validate rounding was done Validation: Staff / MD Rounding Log What is working well? Staff / doctors to recognize? Any systems need improvement? Do you have the tools and equipment to do the job? Anything else I can do for you right now? Rounding for Outcomes www.studergroup.com Stop Light Report Impact of Rounding on Willingness to Recommend as a Place to Work Oregon Integrated Health System; 8700 employees Better Leaders Rounding on Staff and Physicians * Results are one year following implementation of Leader Rounding on Staff and Physicians; Staff and physicians rounded on at least monthly had the highest satisfaction levels. Leader Rounding on Patients Leader Rounding on Patients Best way to validate behaviors for an “Always” culture. Are we do doing it effectively? Are we doing it consistently? Are we focused on the right outcomes? Are the tactics truly hardwired? Nurse and Physician Leader Rounding is the single best way to connect with patients to reinforce care, verify nursing behaviors, and recognize staff members. Rounding with Patients and Families Set expectations/validate Behavior Identify patient and family needs Align Questions to Fit Desired Outcomes of the Organization Document needs Give instructions on what to do if they do not get the care they expect Explain any post visit calls or surveys Recognize and Coach Staff Leader Rounding on Patients (Clinical) Four Goals of Leader Rounding on Patients: 1. Manage the patient's expectations 2. Service Recovery 3. Harvest Recognition/Manage/Up 4. Gather information for coaching/Manage Staff Performance Leader Rounding on Patients (Clinical) Two key questions: 1. What have I learned? 2. What must I do with that information? Question: What do we do with the information we get from patient rounding? Nothing Fix it for them Yell and scream Coach and mentor Service recovery and reassurance How to Ensure Consistent Behaviors Rounding : the continuous feedback loop Round on Patient and Family Patient and Family Round on Staff www.studergroup.com EMCA-551 Leader Rounding on Patients “Did a Nurse Manager Visit You During Your Stay?” n= 561 n= 604 n= 601 n= 608 Tactic and Tool Implemented: • Leader Rounding on Patient n= 106 n= 104 n= 105 n= 96 Source: Arizona Hospital, Total beds = 355, Employees = 4,000, Admissions = 10,188; updated 2Q2010 Leader Rounding on Patients – ED Round vs. No Round 100 98.6 97.7 90 96.8 88.5 84 96.2 93.2 95.7 80 % Excellent Rank 70 60.2 60 48.3 50 Yes 36.9 40 No 30 20 10 11.8 9.2 8.6 1.3 6.7 0 4Q08 1Q09 2Q09 3Q09 4Q09 Source: Southwest Washington Medical Center; ED visits = 81,799 1Q10 3Q10 4Q10TD Leader Rounding on Patients HOW MANY OF YOU HAVE EVER LEFT A DISTRACTED SPOUSE TO BABYSIT? Did you round on him?? Did you round on his “patients”??? Leader Rounding on Patients Leader Rounding on Patients Reception Area Rounding Best Practice- Hourly- Keep a log Owned by triage nurse but others can assist Goal is to keep patients informed Use “Close the Gap” behaviors Keep it simple! Reception Area Rounding Decreased Patients Leaving without Medical Advice 5 Tactic and Tool Implemented: % of patients leaving without medical advice 3.9 Leader Rounding on Patients Hourly Rounding (reception and treatment areas) with IPC 4 3 1.9 2 Implemented April 2007 0.9 0.9 1 0 FY 06 FY07 FY08 FY 09 (YTD) Source: Miami Hospital, Total beds = 584, Employees > 1,500 employees, Admissions = 32,522 Reception Area Rounding Reduced Left Without Being Seen • • • • 10 % LWOBS 9 7.5 8 7 ROI: $2,206,336 reduction (2008 – 2009) Annual Adult visits = 64,000 Average net revenue = $1567 LWOBS reduced from 5.2% to 3.0% 7 5.2 6 5 3.06 4 3 Tactic and Tool Implemented: 2 Leader Rounding on Patients 1 Hourly Rounding (reception and treatment areas) with IPC 0 FY 06 FY07 FY08 FY09 YTD Source: Miami Hospital, Total beds = 584, Employees > 1,500 employees, Admissions = 32,522 Emergency Department Satisfaction Emergency Department Satisfaction 84 70 Percentile 60 50 Tactic and Tool Implemented: 40 Hourly Rounding (reception and treatment areas) with IPC Leader Rounding on Patients 40 30 20 8 11 10 0 FY06 FY07 FY08 FY09 YTD Source: Miami Hospital, Total beds = 584, Employees > 1,500 employees, Admissions = 32,522 AIDET Advantages of AIDET SM Decrease anxiety with increased compliance Decreased Anxiety + Increased Compliance = Improved clinical outcomes and increased patient and physician satisfaction AIDET – Emergency Department Outcome Source: Hazel Hawkins Emergency Department; discharge date Impact on Safety and Quality Better Change in Percentile Ranks Ease of obtaining test results (60.0%) CP instructions for follow‐up care (80.0%) CP information about medications (73.5%) CP efforts to include in decisions (73.3%) CP concern for prob/condition (84.2%) Access to care (46.5%) Overall Patient Satisfaction (53.0%) Post AIDET Pre AIDET 0 10 20 30 40 50 60 Percentile Rank 70 80 90 100 Source: Oklahoma University; OUP Hematology/Oncology Clinic & Infusion Center; 10 providers & 22 staff, take care of 15,000 clinic visits & 10,000 chemotherapy infusions per year Post AIDET Results- Major Hospital- EmCare Qualitick Patient Satisfaction Results- Jan 2011 Were you kept informed of your wait time? Yes: 76%, No: 7%, Did not wait: 17% Would you recommend the ED to provide care to your family or friends? Yes: 97% No: 3% “AIDET allowed us to improve the interpersonal relationships between doctors and nurses and all other staff members, as well as our patients. It has brought a much higher level of camraderie and helps the entire organization work toward a common purpose. We now move as one”. Chris Loman, ED Medical Director Major Hospital, Shelbyville, IN Post AIDET/Hourly Rounding Results- Logansport Memorial- EmCare Qualitick Patient Satisfaction Results- 2010 Kept informed of your wait time? Yes: 85%, No: 5%, Did not wait: 10% Would you recommend the ED to provide care to your family or friends? Yes: 96% No: 4% Explanations and Instructions given? Very Satisfied: 68%, Satisfied: 26% “You can provide outstanding care, but if they didn’t feel communicated with, it didn’t matter”. Jeanette Huntoon, Chief Executive Nurse Studer Group Five Fundamentals AIDETSM Focus on the “A & I” to show courtesy and respect by all physicians, nurses and staff. Focus on the “E” to explain medications and diagnosis. A Acknowledge I Introduce D Duration E Explanation T Thank You Communication and Malpractice Claims Risk of most malpractice suits is predicted by practitioners’ inability to communicate well with their patients Specific physician behaviors that significantly increased the likelihood of malpractice suits include: Lack of respect Not listening to the patient Not providing adequate feedback Hickson, GB, et al. NC Med.J 2007: 68:362-364 Levinson W, et al. JAMA 1997; 277: 553 – 559 Acknowledge A Acknowledge Key message: You are important Eye Contact Acknowledge everyone with patient Smile, look like you love what you are doing The importance of the Greeting 78.1% of patients wanted their physicians to shake hands 91.3% of patients wanted to be addressed by their name Makoul G, Zick A, Green M, Annuals of Internal Medicine 2007;167: 1172 – 1178 Introduce I Introduce First Generation Name Title Patients name Next Generation Your role in the team of care givers Your years of experience, credentials Other information to MANAGE UP Manage Up! Duration D Duration Key Message: I anticipate your concerns How long will the visit take? How long will the test, procedure, wait actually be? How long will it take to get the results? How long to see the doctor? Explanation E Explanation Listen to the patient’s story Active Listening Clarifying questions Empathy Explain the treatment plan Using language that patients can understand Use key words “Do you need more explanation”? Thank You T Thank You Key Message: I appreciate the opportunity to care for you Closing key words Thank you for choosing Fairview Park. Thank you for waiting. Thank you for trusting us to care for you. What other questions do you have? Validation of AIDET Key Words for Push Back “What about this is not right for our patients?” “It’s a new day” “I hear you …..” It always seems impossible until it is done.” Nelson Mandela Never Underestimate the Difference You Can Make ~ Quint Studer ~ Thank You ! [email protected] Stephanie Baker, RN,MBA, CEN [email protected] 619-977-2579 www.studergroup.com
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