A variety of teams exist in the healthcare environment, and many of them can offer substantial contributions to the catheter-associated urinary tract infections prevention program. The central focus of CAUTI prevention lies with the clinicians who work directly with the patients at the unit level.
Achieving any meaningful change starts with assembling a strong unit-based team. The Comprehensive Unit-based Safety Program (CUSP) is a framework for improvement that can be combined with any existing local quality improvement model or initiative. Funded by theAgency for Healthcare Research and Quality, CUSPs have been used on the national level to improve safety culture and reduce harm to patients, including preventing CAUTIs and CLABSIs.
The CUSP Toolkitincludes tools and resources to help unit-based teams address the following key components:
Understand the science of safety
Assemble the team
Engage the senior executive
Identify defects through sense-making
Implement teamwork and communication
CUSP works on the premise that culture is local to the unit level, and unit-based teams can build a framework for improvement and safety that will engage frontline staff in the process of change. It promotes the concept of the "science of safety," which means designing systems that use standardization, defect analysis, and input from team members to improve patient care. To effectively create those systems with diverse input, a multidisciplinary CAUTI prevention team should be assembled. Nurses, physicians, clinical educators, infection preventionists, patient safety officers, senior executives, and any ancillary or support staff who have a role in preventing CAUTIs should all be considered.
When building the team, it is critical to select the right people to fill key positions. By recruiting champions and leaders who understand concepts related to CAUTI prevention, safety culture, and quality improvement, frontline staff will be more easily engaged and active in the unit-based activities. Below are key roles in a unit-based CAUTI prevention team:
Project leader: The project leader is responsible for overseeing the CAUTI prevention team. He or she coordinates activities and meetings, documents CAUTI prevention efforts, promotes unit staff engagement in CAUTI prevention efforts, solicits feedback, and coordinates efforts with other teams within the hospital. The project leader can be a nurse or physician with both the clinical knowledge of CAUTI prevention best practices and the available time to dedicate to the project lead role.
Physician champion: The physician champion is a person with a knowledge of and passion for CAUTI prevention. He or she must be able to serve as a leader to engage other physicians in unitb ased interventions, educate medical staff about urinary catheter best practices (e.g., appropriate Chapter 5 indications for insertion), and provide feedback to physicians who need coaching on CAUTI practices. Among his or her peers, the champion is a role model for the multidisciplinary approach to CAUTI prevention.
Nurse champion: The nurse champion is one who is able to engage other nursing staff in CAUTI prevention. He or she must be must have clinical expertise in urinary catheter care practices and a deep knowledge of catheter-related policies and procedures. Nurse champions promote the use of teamwork and communication tools on the unit, and they must be able to educate and provide feedback to nurses who need coaching on CAUTI prevention practices.
The senior executive: The senior executive is a senior leader in the organization and is responsible for helping the team set safety goals, prioritize CAUTI prevention efforts, and secure resources. Senior leaders should meet with the team and frontline staff regularly and communicate the team’s mission and goals to other stakeholders within the organization.
The nurse manager: The nurse manager of the unit works closely with the project leader and champions to engage frontline staff in the CAUTI prevention activities. He or she helps coordinate the training and education of staff related to urinary catheter use practices. The nurse manager also helps orient new staff to CAUTI prevention policies and procedures.
The infection preventionist/quality improvement advisor: The infection preventionist or quality improvement advisor supports the CAUTI prevention team by providing CAUTI and catheter use data for teams to review. He or she acts as a consultant to guide teams in the implementation of evidence-based practices, as well as assisting teams in reviewing CAUTI cases to identify an event’s root causes and facilitate the design and implementation of improvement strategies (e.g., small tests of change models).
Based on their local needs and settings, CAUTI prevention teams may identify various individuals to be on the team. Maintaining flexibility and openness to modifying the team structure allows it to expand and contract depending on the situation and team’s overarching goals.
Coding specificity, education, and CMS monitoring are key for capturing Hierarchical Condition Categories.
This article was originally published June 27, 2018, on HCPro's Revenue Cycle Advisor.
Although Hierarchical Condition Categories (HCC) are not new, the risk-adjustment methodology is beginning to surface more frequently in both the acute and primary settings.
HCCs can be a prospective approach to paying providers or health plans for the care provided to patients, explains Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer of First Class Solutions, Inc. in Maryland Heights, Missouri.
Here are three strategies for improving physician documentation and compliance around HCC capture:
Consider coding specificity
Often, Dunn says, HCC payment is driven by the number of conditions that the provider monitors, evaluates, assesses, or treats (MEAT).
“Chronic conditions are especially important to MEAT and, therefore, code and claim,” says Dunn, a member of the advisory board for HIMB.
The codes submitted by the hospital and physician office contribute to the HCCs that patients may accumulate during the year. Dunn says that reimbursement for the patient’s accumulated HCCs is based on the risk adjustment factor (RAF) and the conversion factor for the year, otherwise known as the denominator.
Coding specificity is a major part of HCCs because less than 10,000 ICD-10 codes qualify for the 79 HCCs, says Dunn. But specificity also heightens the need for outpatient clinical documentation improvement (CDI).
“This serves as an ideal opportunity for coding professionals to take on this concurrent role in physician practices,” says Dunn. “Outpatient CDI should occur while the physician has the patient’s current status fresh in mind. Unlike inpatient CDI, the review of the record should take place on the same day rather than waiting until the next business day.”
Educate physicians, staff
The coding professional’s knowledge of coding requirements is especially important when educating scribes who may work in the practice. The scribe can help capture some of the specificity—in real time—when he or she is with the physician and the patient, Dunn notes.
Education is also important for physicians and the entire staff, says Dawn Diven, BSN, RN, CCDS, CDIP, a CDI specialist at West Virginia University Medicine.
“You have to educate staff on what HCCs are and how they impact the patient’s chart,” she says.
Physicians need to understand that the purpose is not to upcode or capture as many as HCCs as possible, Diven says. It’s about accuracy. Sometimes accuracy may mean less reimbursement, she notes. Other times it may mean some Patient Safety Indicators on the inpatient side.
“We make sure that in CDI everything is about accuracy; there is no pressure to move a DRG to make more money,” she says. “If you focus on the chart and what is exactly going on with the patient on the outpatient setting and inpatient side, why they are here and what is exactly going on, all the MCCs, CCs, HCCs, and reimbursement will take care of themselves.”
The team at West Virginia University Medicine also discussed compliance and what is appropriate in the outpatient setting. They looked at charts and pulled the history and physical, plan of care, and assessment to explain to physicians where they need to document and what terminology they need to use so the coder can accurately capture the correct code.
Look to CMS for data, guidance
There currently isn’t federal data on HCC details and capture rates, but CMS is expected to release that information at some point to provide a better picture of what is happening across the industry.
Some MA companies and organizations may issue reports on the data they collect, However Sonia Trepina, MPA, director of ambulatory CDI services at Enjoin CDI, a physician-led clinical documentation integrity company, cautions HIM directors to be aware that insurance companies, like health systems, could interpret guidelines differently in accordance with their own internal policies, therefore creating variances in data sets of HCC capture information.
“There is vagueness out there when it comes to risk adjustment, so the industry needs to be very clear on what gets counted toward an HCC versus what does not get counted and why,” she says.
About 75% of workplace assaults occur in healthcare and social service sector each year, and violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries.
The Joint Commission (TJC) is the latest healthcare heavy-hitter to call for better protection of healthcare workers, announcing on Tuesday the creation of Sentinel Event Alert 59, which addresses violence—physical and verbal—against healthcare workers.
The purpose of the new alert is to help hospitals and other healthcare organizations better recognize workplace violence directed by patients and visitors toward healthcare workers and better prepare healthcare staff to address workplace violence, both in real time and afterward, TJC writes in this latest Sentinel Event Alert publication.
Sentinel Event Alert 59 has some overlap with Alerts 40 and 57—which were released in 2008 and 2017, respectively, and focused on the development and maintenance of safety culture—and therefore were not addressed in this alert.
Per the Occupational Safety and Health Administration (OSHA), about 75% of workplace assaults annually occurred in the healthcare and social service sector. Violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries, according to the Bureau of Labor Statistics (BLS).
TJC cites both of those facts in this Sentinel Event Alert publication and adds that TJC data show 68 incidents of homicide, rape, or assault of hospital staff members over the past eight years—and that’s mostly only what hospitals voluntarily reported.
TJC is calling for each incident of violence or credible threat of violence to be reported to leadership, internal security, and—if necessary—law enforcement, and TJC also wants an incident report to be created. Under its Sentinel Event policy, TJC says that any rape, any assault that leads to death or harm, or any homicide of a patient, visitor, employee, licensed independent practitioner, or vendor on hospital property should be considered a sentinel event and requires a comprehensive systematic analysis.
Additionally, TJC says it’s up to the healthcare organization to specifically define unacceptable behavior and determine what is severe enough to warrant an investigation.
CMS is clearing up recent confusion on what medical providers can text each other. The agency confirmed care team members are allowed to text patient information over a secure messaging app. However, texting medical orders is still verboten.
Some providers have taken to secure messaging platforms as a way to contact providers during emergency, to consult on medical cases, or send photos of the patient. The confusion started on December 18 after an article by theHealth Care Compliance Association (HCCA) cited emails CMS had sent to two hospitals saying that “texting is not permitted.” People thought this meant “texting is never permitted” instead of “texting medical orders isn’t permitted.”
“Secure texting is an integral part of a community platform for organizations,” one manager told the HCCA. “If you pull secure texting out of that pathway, you have disrupted a huge chain of communications that will have a broader effect.”
Luckily, CMS explained this wasn’t the case in its newest S&C memo, and that it knows the value of instant messaging in the workplace.
“CMS recognizes that the use of texting as a means of communication with other members of the healthcare team has become an essential and valuable means of communication among the team members,” wrote David R. Wright, director of CMS’ Survey and Certification Group.
“In order to be compliant with the CoPs or CfCs, all providers must utilize and maintain systems/platforms that are secure, encrypted, and minimize the risks to patient privacy and confidentiality as per HIPAA regulations and the CoPs or CfCs. It is expected that providers/organizations will implement procedures/processes that routinely assess the security and integrity of the texting systems/platforms that are being utilized, in order to avoid negative outcomes that could compromise the care of patients.”
Despite sustained attention from hospital leaders, wait times in the University of California, San Francisco (UCSF) ED were considerably longer than desired. Knowing that longer wait times means poor patient satisfaction and a higher risk of poor health outcomes, a team of resident physicians set out to find innovative strategies to decrease wait time.
This article first appeared in Strategies for Nurse Managers.
What they found can probably be applied to many quality improvement projects: education, buy-in, and incentives work.
Most importantly, remembering that people run the show, not systems, processes, or data, is critical to success.
“Don’t count out the human aspect,” advises Gene Quinn, MD, MS. Quinn and 10 of his fellow residents participated in the health systems and leadership track of their residency. The track—a two-year program developed by Arpana Vidyarthi, MD, and currently run by Read Pierce, MD, both faculty in UCSF’s Department of Medicine—allows selected residents to spend part of their training preparing for leadership careers in health systems improvement. ”A large portion of that [track] is quality improvement and patient safety training,” says Quinn. The group focused on decreasing ED door-to-floor time, or the time from stepping into the ED to hospital admission, as part of the Quality & Safety Innovation Challenge (QSIC). Launched in 2010 by the UCSF Department of Medicine, QSIC invites trainees, staff, and faculty to work as teams over the course of six to nine months to design and implement innovative solutions aimed at improving patient care. The project won a Permanente Journal Service Quality Award.
“You’re really having to rally a lot of different subcultures and groups with their own ideas and values and their own ways of doing things. You are trying to get them all excited about one specific thing and work together,” says Quinn. “It’s extremely difficult but really important for sustainability. You have to get people behind the project to make any sort of meaningful change.”
Assessing the problem
The group used Lean methods, process mapping, Failure Modes and Effects Analysis, and stakeholder interviews to pilot strategies that changed the work flow and culture of the admissions process.
Process mapping was a huge undertaking, as there are a number of steps involved in admitting a patient who presents to the ED, including:
Initial registration
Triage
Placing the patient in an ED bed
Consulting with the ED physician
Ordering lab tests
Admission decision
Deciding whether to admit a patient is a process in itself. The ED physician must call an admitting service, which in a large hospital can be one of a number of departments, including internal medicine, multiple subspecialty surgery services (e.g. neurosurgery, vascular surgery, etc.), and psychiatric. The appropriate level of care must then be decided. Providers must also consider whether the patient needs telemetry, additional monitoring, or is ill enough to justify admission to the ICU.
Admission orders are then written, but of course a bed must first be available and ready for the patient, which involves environmental services staff.
"That’s quite a lot of things that actually have to happen,” says Quinn. “ED wait times were a major quality improvement focus for the hospital.”
“When we started the project, our ED door-to-floor time was much higher than our goal and above the average for a number of peer institutions,” he admits. “It has a lot of different effects on us; obviously, it’s not good for patient safety—there’s some evidence to suggest you’re more likely to have a complication the longer you wait down in the emergency room before being admitted.”
There was another issue, too: The emergency medicine residency program participants knew that long wait times could affect their training goals and, ultimately, the accreditation of their program.
The group of residents took a multitiered approach to curbing wait times, including interviews with all levels and types of staff from multiple departments.
“We spoke with the pediatrics department, admitting services, the emergency room, as well as a lot of people in administration who have been trying to work on the issue previously,” says Quinn. “We didn’t just speak with doctors; we spoke with nurses who are actually doing a lot of this work, the front desk, with triage, emergency room clerks, and with environmental services who clean the rooms. Out of that, we had a lot of insights.”
Education and buy-in
After conducting extensive research, the team broke down what needed to be done into three categories:
Work flow. Looking critically at work flow had been done before, says Quinn. But this time, the focus was on how the process worked, and whether it worked well. The team asked how to make orders easier to write, how to get laboratory tests sent earlier to facilitate timely results and begin the decision-making process earlier. Essentially, the team focused on ensuring that top priority was given to the work directly involved in making an admission decision.
“If the patient needs advanced tests that may take a while but don’t actually affect that original decision that the patient goes up to the hospital, then perhaps it can be done once the decision has been made to admit so that the work to get a patient a bed can be started,” says Quinn. The team also focused on avoiding bottlenecks for needs such as telemetry.
Culture. “When we talk about culture, it really has to do with the people,” says Quinn. He notes that some departments have a long history of butting heads, which has to be recognized. “For example, admitting services and ED services certainly have a long history together; they have very different cultures that can create barriers to working together efficiently.”
The team worked to make the admitting process more collaborative and less adversarial. “As long as we foster a culture of collaboration, it’s better for patient safety and door-to-floor times as well,” says Quinn.
Incentives. Quinn notes that incentives are often broadly defined to include disincentives, but focusing on positive reinforcement rather than punishment is a more sustainable model. The term “incentive” usually invokes thoughts of money; however, sometimes a good reason is all the incentive you need.
“Most of the providers that were actually doing this didn’t understand why ED door-to-floor time was important; all they knew was that they were told by administration that the time needs to go down,” he says. “If you’re told that, you’ll work to make the time go down for a little while, but you’ll miss what the time represents, which is increased patient safety and making sure there are fewer poor outcomes.”
Understanding the culture is critical to incentives. The fact that providers care about their patients and the outcomes of their efforts acts as its own incentive, and presenting it as such was a simple (and cost-effective) matter of education.
Providers also care about patient satisfaction knowing patients often have the choice to go to other hospitals, so the team made sure providers understood door-to-floor time is also tied to patient satisfaction.
Data sharing was another incentive that was tightly tied to education. Providers were given reports on their individual door-to-floor times.
“Without any feedback, it sort of becomes this nebulous concept where you’re not really sure if you’re doing any good,” says Quinn. “Most people think they’re probably doing well but have no idea what their time is.”
A good example of this powerful tool was how the process improvement actually added a step. Previously, before the team was involved, a one-page order set was added to the process of ED door to floor. The idea was to have this quick order set to get the information needed for admission; later, the provider fills out a five-page order set. But although the one-page order set was intended to speed up the process for the patient, it meant one more page of documentation for the provider. The form was underutilized until providers began receiving feedback on performance and started to understand that those who used the one-page set had lower times.
“So even though there’s no incentive for decreased work, there is an incentive because of the buy-in and feedback on performance,” notes Quinn.
Recurrent feedback on times has proven to be an effective incentive for providers, says Quinn, noting that it also keeps them accountable and gives them ownership of the initiative.
“When people feel as if they have a seat at the table, then they are more likely to be interested in the project,” he says.
Quinn says some components of ED door-to-floor time have decreased. He notes that education and buy-in are critical for sustainable change.
“Once you take away incentives, you have to have some sort of internal drive that people believe in,” says Quinn.
Strategies for Nurse Managers provides content, news, and downloadable tools for new and seasoned nurse managers in a one-stop site that gets straight to the point-bringing you the nursing-specific management and leadership information, advice, and answers your need to save time in your job.
Strategies for Nurse Managers provides content, news, and downloadable tools for new and seasoned nurse managers in a one-stop site that gets straight to the point-bringing you the nursing-specific management and leadership information, advice, and answers your need to save time in your job.
Strategies for Nurse Managers provides content, news, and downloadable tools for new and seasoned nurse managers in a one-stop site that gets straight to the point-bringing you the nursing-specific management and leadership information, advice, and answers your need to save time in your job.
Strategies for Nurse Managers provides content, news, and downloadable tools for new and seasoned nurse managers in a one-stop site that gets straight to the point-bringing you the nursing-specific management and leadership information, advice, and answers your need to save time in your job.
Nurse managers spend a lot of time predicting and planning for the future, but when it comes to hiring and retaining employees, there are a lot more future problems than possible solutions.
This article first appeared in Strategies for Nurse Managers.
Nurse managers spend a lot of time predicting and planning for the future, but when it comes to hiring and retaining employees, there are a lot more future problems than possible solutions. In order to retain nurses, the hospitals they work at must be places that people are "dying to work at." But it is hard defining what those hospitals will look like.
Regardless of what the future holds for healthcare and hospitals, most experts agree that recruiting and retaining enough employees will take a lot of change—something that healthcare isn't always good at. So nurse managers need to change the way they look at staffing.
Making it a point to talk about people—and not just systems and processes—in meetings might be a good place to start. Many healthcare professionals have changed the way they talk about their staff and how they hire. Here are some things to keep in mind:
"We don't own them." Gone are the days when facilities could cage their nurses in one department because they feared another facility would "steal" their nurses. Today, smart facilities have learned that they don't own their nurses; so, if they don't offer experience and learning opportunities, other organizations will.
Some hospitals are offering their nurses travel and job-sharing opportunities. Cold-weather hospitals, for example, might allow nurses to travel to Florida for the winter months, then return to their jobs in the spring.
Or, if a good employee at a community hospital does leave to try a job at a larger tertiary system, the community hospital leaves the door open for that employee to one day return. Smart organizations already know that giving their employees exposure to the outside world will keep them on the inside in the future.
"They don't always have to be nurses." How many nurses does it take to run a hospital? It sounds like the start of a bad joke, but some organizations have discovered that they don't need as many nurses as they once thought. Forward-thinking hospitals are using nursing assistants, other staff, even family to take on roles that don't require a nursing degree.
"Newspaper want ads don't work." Your next good employee isn't sitting home with a newspaper and a highlighter. Today's candidates are online, in social networks like Facebook, and writing blogs, so that's where your want ads should be.
"Neither do sign-on bonuses." Often, when hiring gets tough, someone will say, "What about sign-on bonuses?" But, sign-on bonuses, in the long run, only temporarily fill a hole while ticking off other employees. If you want to attract good employees, pitch your facility's learning opportunities. Signing bonuses only attract people who are looking for sign-on bonuses. Once the bonus is spent, they'll be off to find another one.
"Turnover is good." Some CEOs don't want to retain just anybody-even when faced with shortages-so they're committed to hiring only good employees and weeding out bad ones. They'll even hire the right person who has no experience before they'll hire the wrong person who has an impressive resume.
"Who cares about the hospital next door?" It's no longer enough just to emulate the hospital next door when it comes to finding and keeping good employees. Recruitment and retention—if you want them to be effective—must be based on the best practices out there, regardless of whether or not they're found in healthcare. That is where many work force changes are coming from.
Strategies for Nurse Managersprovides content, news, and downloadable tools for new and seasoned nurse managers in a one-stop site that gets straight to the point-bringing you the nursing-specific management and leadership information, advice, and answers your need to save time in your job.
Effective education is vital to the nursing department, but it can be hard to make the case for it in budget meetings. Here are some tips for evaluating and measuring education programs that reflect quality over quantity.
This article first appeared in Strategies for Nurse Managers.
Years ago, while working in nursing professional development and education, consultant Gen Guanci, MEd, RN-BC, CCRN, realized that she was doing herself and her department a great disservice by reporting out “productivity” of the nursing education department.
At the time, Guanci was working on reports based on quantitative data—the department conducted 20 classes, for example, serving 200 nurses. (She calls this concept “butts in the seat reporting.”)
What they were not doing, she explains, was demonstrating what outcomes those filled seats then led to. “In other words, what was different as a result of our educational activities?” says Guanci.
She undertook the task of identifying and explaining that qualitative aspect. These outcomes were then linked to the organizations’ goals and even pay-for-performance initiatives.
“Many of these are stretch goals or outcomes some educators have a hard time relating their work to,” explains Guanci.
For example, let’s say your department holds education classes on computerized physician order entry (CPOE). One of the main reasons organizations implement CPOE is to reduce transcription errors. After your classes, the order transcription error rate drops by 66%. This helps validate the critical importance of nursing professional development’s role in regards to patient safety and outcomes.
Beginnings
Guanci changed her views on how to demonstrate the effectiveness of nursing education based on her previous organization’s experiences on the ANCC Magnet Recognition Program® journey and its pursuit of the Baldrige Award.
“It’s not about how many people are in the seats—it’s about results,” says Guanci.
She advocates the use of Professor Donald Kirkpatrick’s Four Levels of Evaluation:
Reaction of student: What the student thought and felt about the training
Learning: The resulting increase in knowledge or capability
Behavior: Extent of behavior and capability improvement and implementation/application
Results: The effects on the business or environment resulting from the trainee’s performance
Guanci believes that pursuing recognition for the results of the department’s work is something every education department has to be aware of. “I went this way originally because in times of economic challenge, education departments are often the first to be slashed and burned,” she says. “Leadership often doesn’t perceive the value the department provides.”
At the time, Guanci was creating an outcomes report every six months—and having a terrible time getting credit for the work the department did. She knew she had to alter the way the department’s work was reported. Since then, the change has been notable.
“The process still occurs there,” says Guanci. “They’ve added positions instead of cut them—and [the education department has] really been able to create proof of worth for their department.”
Feedback
In her previous organization, the education department felt it had sufficient evidence to show that as a result of foundational education it provided, it was able to assist in a decrease in transcription error rates.
“Educators have a hard time trying to take credit for things that change in an organization that start with their education,” Guanci says. “We know education alone doesn’t invoke change. It’s a combination of many factors.”
There’s a partnership that needs to be formed—educators provide the education, and then managers make sure improved performance occurs after the learning.
“You’re not saying that it’s only because of your work, but it was the foundational behaviors leading to future behaviors,” says Guanci.
There is also the matter of making sure the education department chooses appropriate targets. The system in which this concept was implemented was set up so Guanci’s department could access all necessary outcomes data. This came to bear when they were targeting areas for education. For example, a nursing director called and reported an increase in errors whenever nurses used a pain pump. The director then asked that the entire department be educated on pain pumps.
Before making a decision, Guanci and her team drilled down to determine the cause of the errors. They discovered that there had indeed been a spike in pain pump errors. However, they were low in number (three), and each error had occurred on one particular nursing unit. Looking deeper, it turned out they occurred on the same shift, and finally they discovered the errors were the result of one nurse who needed additional training.
“I made the decision that we were not going to educate the entire hospital on this matter,” says Guanci. “It wasn’t a hospitalwide problem.”
This is the department’s mind-set. Always look to the data and hunt for cause and effect.
“This is huge,” says Guanci. “It’s something [education departments] have often never been asked to do before.”
At national seminars Guanci has spoken at, she has found the topic to be “a bugaboo”—people are asking the wrong questions. “I’ll hear the question, ‘How are you measuring your hours per patient day?’ Education shouldn’t be measured in patient day!” she says.
Measurement gurus often try to slip education into measurement like any other measure of RN productivity. However, education is as much an art as it is a science in terms of measurability.
“Sometimes you’ll hear a department automatically jump to education—for example, let’s have a class for customer service,” says Guanci. “Educators will put together a customer service class. Then the original requester comes to you and says, ‘But they still are engaging in the same problematic behavior!’ It really is a matter of putting forward the mind-set of what do you want to see happen as a result of this education before you even plan the program.”
You have to define it before you can achieve it.
Another challenge: Quantifying evaluations
An evaluation might ask, “Did the program meet its objectives?” The answer might be yes, all of the objectives defined in the program were met. But were they put into practice after the program was over?
“The hardest part is educating the educators on how to write an outcome,” says Guanci. “I would ask for outcomes and I’d see four CPR classes with 22 attendees. That’s not an outcome! We have to step back.”
You can’t evoke these kinds of changes alone. It requires the entire department to understand what an outcome really is and hold fast to that belief.
The truth is, just because you told students something doesn’t mean you educated them—and just because you trained them doesn’t mean they’re doing it.
Don’t be afraid to let leadership see what the education department is doing. “You’re having an effect on outcomes in the organization, so claim it,” says Guanci.
Strategies for Nurse Managersprovides content, news, and downloadable tools for new and seasoned nurse managers in a one-stop site that gets straight to the point-bringing you the nursing-specific management and leadership information, advice, and answers your need to save time in your job.
Most patient satisfaction survey tools, including HCAHPS, are multidimensional. Thus, the physicians, nurses, other care providers, food service, and housekeeping staff must tackle patient satisfaction scores from multiple angles.
Healthcare providers understand that patients are customers, and customers can take their business elsewhere if they are unhappy about any aspect of their experience.
To keep patients, and thus reimbursement, coming in the door, hospitals must focus on achieving strong patient satisfaction scores. The Centers for Medicare & Medicaid Services’ (CMS) reinforces the idea. Its value-based purchasing program has incorporated Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) scores into its inpatient prospective payment system, so there is no better time to hop on the patient satisfaction wagon.
Most patient satisfaction survey tools, including HCAHPS, are multidimensional. Thus, the medical staff, nurses, other care providers, food service and housekeeping staff must tackle patient satisfaction scores from multiple angles, according to Peter Short, MD, senior vice president of medical affairs at Beverly Hospital, (MA).
The HCAHPS survey contains 18 patient perspectives on care that encompass eight key topics:
Communication with doctors
Communication with nurses
Responsiveness of hospital staff
Pain management
Communication about medicines
Discharge information
Cleanliness of the hospital environment
Quietness of the hospital environment
“When you talk about HCAHPS, you are talking about the whole patient experience. To demonstrate to patients that we have their best interests at heart, we have to be a team. It takes a team approach to improve HCAHPS,” says Short. Medical staff leaders can help heighten the team spirit by creating a patient-centered medical staff culture using the following hospitalwide tips.
Implement multidisciplinary rounds
Jonathan Lovins, MD, SFHM, assistant clinical professor of medicine at Duke University Health System and hospitalist at Durham Regional Hospital (DRH) in Durham, NC, says that multidisciplinary rounds have helped improve the organization’s HCAHPS scores by 5% during the past three years because patients perceive a more coordinated approach to their care. “I think one of the things that disheartens patients the most is when they hear different stories from different providers,” says Lovins.
Every morning, nurse managers, case managers, nurses, physicians, and pharmacists meet for 10–20 minutes to discuss each patient.
“As a hospitalist, I don’t feel like it saves me time, but at the very least, it seems to make patients more comfortable,” says Lovins.
Not only do multidisciplinary rounds help get all care providers on the same page, but they also help reduce mistakes that result from miscommunication (or noncommunication). In addition, they help all members of the healthcare team feel included in care decisions.
To implement multidisciplinary rounds, the medical staff appointed a physician to serve as the medical director for each of DRH’s two floors. Patients were then distributed geographically, meaning Dr. Jones’ patients are clustered on the first floor, while Dr. Smith’s patients are clustered on the second floor.
“That was the hardest part. When we distribute the patients in the morning, we try to make sure that each physician gets patients only on that floor, which was hard because we have to sacrifice things like continuity of care to a degree,” explains Lovins.
For example, although hospitalists, who generally work seven days on and seven days off, were previously not assigned new patients on their last day of work, they sometimes now receive new patients so that patients are located on the correct floor for the hospitalist who starts work the next day.
According to Short, Beverly Hospital also performs multidisciplinary rounds. One of the major benefits, he explains, is that the same group of nurses works with the same handful of physicians, creating a team environment.
“We go in the patient’s room together to see the patient. That way, if anyone has a question, they can get the same answer from the nurse or the doctor, and the patients know it is a team approach. Patient satisfaction is about communication to their family and the rest of the caregiver team,” says Short.
Use electronic discharge instructions and medication reconciliation
DRH recently switched to electronic discharge instructions and medication reconciliation, and it saw an increase in patient satisfaction. “We know patients are more satisfied with an electronic discharge document and electronic medication reconciliation because it is legible and clear,” says Lovins.
Rather than a physician writing out discharge instructions and a list of medications by hand and risking the patient or the pharmacist misunderstanding or misreading instructions, physicians now fill out an electronic form and print it for the patient.
The electronic discharge instructions and medication reconciliation documents also work to reduce errors by helping physicians make decisions. For example, if a physician selects an antacid drug, the computer program automatically eliminates the option for selecting other antacid drugs.
Get an outside opinion
An outside opinion may be just what physicians need to improve their communication scores on the HCAHPS survey, says Gerda Maissel, MD, chief medical officer at Baystate Franklin Medical Center, a 90-bed community hospital in Greenfield, MA.
Physicians at Baystate Franklin consistently scored low on the HCAHPS survey. “As physicians, we were in a little bit of denial, which is classic for physicians. We assumed the scores were wrong,” says Maissel.
But after tracking the scores over a period of months, it became clear that the problem didn’t rest with the data.
“We researched the literature and implemented best practices, and we saw a little bit of an improvement, but we were still baffled. We started color coding the data, and if you were below the line, you were red. We wanted to be green,” Maissel explains.
To address the problem, the medical staff brought in an individual with marketing experience and a kind, calming demeanor. She watched physicians interact with patients and gave them concrete, useful tips on how they could improve. Her demeanor was instrumental in relaying information to the physicians without sounding harsh or critical.
Although an evaluator does not need a background in marketing, Maissel notes that this evaluator’s experience helped her articulate to physicians what patients (i.e., consumers) want. It is important for the evaluator to be a nonphysician who can see the patient-physician interaction from the patient’s point of view. “I tried to evaluate physicians when I was in a different role, and I didn’t come close to what [our evaluator] came up with,” says Maissel.
As it turned out, the little things were what made all the difference. One physician wasn’t listening to patients long enough, and the evaluator suggested that the physician wait three to five seconds before responding to the patient to make sure the patient was done speaking. Another physician was overloading patients with information, making them feel overwhelmed. A third physician rushed when she explained things.
“It is not that anyone was being rude to patients or behaving outrageously where we had to discipline them, but there were subtleties that, when addressed, helped us cross the line from red to green,” explains Maissel.
Institute hourly nursing rounds
Medical staff leaders can encourage their respective nursing departments to institute hourly rounds. At DRH, hourly nursing rounds have improved patient satisfaction scores because they ensure patients don’t feel forgotten. DRH nurses check each patient for the four P’s:
Pain
Position
Potty
Partner (nurses work with nursing assistants)
“Potty (toileting) is really important. By far the most common cause of falls is patients getting up to go to the bathroom. It has been shown many places that if you ask patients every hour if they need to potty, you can get your fall rate down to almost zero,” says Lovins.
Beverly Hospital’s nurses also round hourly. In addition, the hospital has a rule that a nurse should never ignore a call bell; even if the patient is not assigned to the nurse who notices the call bell, that nurse should still respond. The initiative forces nurses to think outside of their own workloads and focus on the needs of all patients on the unit.
Make each patient feel like the only patient
Physicians can have a profound effect on the patient experience by simply focusing on the patient in front of them and not succumbing to the buzz of distractions. When Short, a pediatrician, enters a patient’s room, the first thing he does is introduce himself. The second thing he does is say, “Let me wash my hands before I examine your child.”
He then washes his hands in front of the parents. After examining the patient, he washes his hands again and makes a point of sitting down with the parents to talk. “Sitting down sends the message that you are not rushed, even if you are,” says Short.
“All of us need to understand that we are not just taking care of the medical problems of the person who is admitted; we are taking care of the person and the family. As long as you keep that in mind, you are going to have great patient satisfaction scores,” he says.
Take time to talk to nurses
When dealing with sicker patients, physicians should take the time to explain their thought processes to nurses. “I explain what I am doing and ask the nurse if he or she is comfortable with that. In the end, they are in the front lines. The benefit [physicians] get on the other end is if you communicate up front, you don’t get all these calls on the back end,” Short explains.
Be a team player
Caregivers often operate with blinders on. Nurses focus on their nursing responsibilities, and physicians focus on medical decision-making. In the process, they may both overlook the dirty towel on the floor or the empty juice cup on the bedside table.
“Patient satisfaction is everyone’s job in every area, which means if there is stuff on the floor, you don’t call housekeeping—you pick it up. If there is a spill on the floor, I clean it up because if I don’t, someone is going to slip,” says Short.
Remind caregivers of their commitment
At Beverly Hospital, each floor receives its own patient satisfaction scores. “Sometimes, just knowing your scores and having a little competition is healthy,” says Short. The hospital also reviews Press Ganey and HCAHPS scores weekly. If a physician, nurse, or other caregiver receives a compliment from a patient, the hospital recognizes that individual. If a physician goes the extra mile, Short writes him or her a personal thank-you note.
At DRH, physicians see a group patient satisfaction score, but they don’t see their colleagues’ individual scores. “We don’t compare with other departments, but the interesting thing is that our incentive is based on the hospital’s score and our individual scores, not the hospitalist group’s score,” explains Lovins.
Consider giving patients health-related gifts at discharge
Giving patients a gift at discharge, such as a pedometer, calorie counter, or pillbox, has two benefits: Patients may perceive their experience more positively, and the gift may help motivate them to follow their discharge plan, says Bradley Flansbaum, MD, a hospitalist engaged in a patient satisfaction improvement experiment at Lenox Hill Hospital in New York City.
Flansbaum notes that hospitals are constantly trying to improve the patient experience by offering Wi-Fi or installing bigger television sets. “If you are giving patients something that is useful for health, I would argue that you are doing more for the patient experience than putting a fountain in the lobby,” he says.
Patients should be given gifts that will help them stick with their discharge plans. For example, if a physician talks to a patient about cutting out soda to reduce insulin spikes, a calorie counter would help the patient keep track of his or her intake. If a physician prescribes more exercise, a pedometer will help the patient reach that goal. “As long as the item itself has a health-related meaning, I think it is legitimate,” says Flansbaum.
Hospitals may question whether the return in healthy habits is worth the investment in purchasing the gifts. “If one person changed their lifestyle for every 50 or 100 pedometers you give out, it may be worth it,” Flansbaum says.
With CMS incorporating HCAHPS and other patient satisfaction measures into the inpatient prospective payment system in the near future, hospitals must begin thinking creatively about ways to improve patient satisfaction. These tips can get you started without much monetary investment and serve as a jumping-off point for bigger initiatives.
Hospitals have been seeing a steady increase in the number of behavioral health patients over the last 20 years or so.
To meet the needs of behavioral health patients while making sure their facilities remain safe, new hospitals are being designed with features aimed at the comfort of these patients.
Older hospitals that can't afford drastic overhauls are finding wasy to safely accommodate the influx of behavioral health patients by changing their triage protocols and making treatment rooms more flexible. One goal is to speed up the process of getting patients to a provider so patients are not subjected to long waits.
A few modifications to current environment and protocols,can enhance quality of care while also improving security.
5 Success Keys
1. Decrease wait times. This is the kind of advice that can benefit any facility, but is particularly apt to facilities serving a population with behavioral health needs. Experts say one of the biggest factors behind violent incidents involving behavioral health patients is a long wait that increases anxiety. Something as simple as installing a digital clock listing wait times, can calm nerves.
Take a look at what is causing the backup in the first place. Chances are it starts in the triage area of the ER. Are triage nurses and front-end staff overwhelmed? Maybe it's time to hire some extra help.
Even better, perhaps it's time to get triage staff out into the waiting room to see patients before they are called.
2. Design flexible spaces. The key to being flexible with patients is to be flexible with treatment spaces. To avoid the risk of putting patients in spaces where they may be able to harm themselves, redesign treatment rooms so that they can accommodate everyone, safely.
3. Make the environment friendly. Many hospitals are creating behavioral health units that boast high ceilings, open areas, and large windows that allow more natural light to come in. The result is friendly, therapeutic places that can have a calming effect on patients.
Behavioral health units are being designed with "wander space," to provide visitors, such as elderly patients with dementia or other behavioral health patients, a group area to walk off their energy as opposed to sitting around.
Some hospital waiting rooms are being designed with a living room feel, with comfortable furniture and fireplaces in some cases, as well as shower and video game areas to create a less-threatening environment for those who may be subjected to longer stays.
4. Train staff to respond to the right things. In the event there is a violent incident, staff will be instrumental in keeping it from escalating. Preparedness is key.
The problem is, most workers in hospitals are not trained in de-escalation techniques and other self-defense strategies that could stop a small issue from becoming a major incident.
Instead, experts say, they often let such issues develop into larger problems that can result in violent attacks and a response from security, giving the illusion of a police state and raising the likelihood of injuries.
5. Eliminate potential dangers. Certain aspects of patient treatment rooms can be dangerous.
Items such as plastic trash bags can be used as ways to suffocate oneself; high door hinges can used as a means of hanging. Other dangers include glass in picture frames that can be broken and used as weapons, or needles, or anything else that can be used by patients to hit or hang themselves.
While no one likes to think of these scenarios, removing such items from the environment reduces the chance that they can be used in a violent incident, and at the same time, increases the number of rooms that can be used for all patients.
Hospitals have complained that the star ranking system is too simplified to show true quality. The release of the star system has been postponed until July.
Some of the changes include the elimination of 14 voluntary measures falling under the “effectiveness of care” and “timeliness of care” categories. Measures for 20-day mortality and readmission coronary bypass grafting were added in April, with two colonoscopy measures to be added in July.
One of the webinar’s speakers was Arjun Venkatesh, MD, director of quality and safety research and strategy at the Yale University School of Medicine. He said that the five guiding principles behind the hospital star ratings simplicity/accessibility, inclusivity, scientific rigor, stakeholder engagement and consistency. The ratings methodology itself comprises of five steps:
1. CMS select measures
2. Measures are grouped into respective categories, such as safety, mortality or patient experience
3. Group scores are calculated based on latent variable models
4. A weighted summary score is generated for each hospital
5. A final star rating is awarded
In addition to the Hospital Compare data, CMS will also start providing hospital-specific reports with additional details, such as individual standardized measure scores. The release of the star system has been postponed until July. Click here to see the CMS webinar slides.
