presentation 1211
TRANSCRIPT
Before I start I would like to thank my preceptors for coming to this event.
Hello everyone! My name is Diana Katsereles. My case study was on
improvements for HCAHPs at Greater Baltimore Medical Center
(GBMC).
Does everyone know what GBMC is?........ For those of you who do not
know, GBMC is a 245 bed medical center located in Towson, MD. It is
about less than five minutes from here. GBMC is a private, not for
profit community medical center. Their vision phrase is to every patient
every time; we will provide care that we would want for our own loved
ones At GBMC all staff are encouraged to not only know what the
phrase but also to emphasize how work should be done it was for our
loved one.
I accepted an internship at Greater Baltimore Medical Center.
My internship was in the Nursing Administration Department of
GBMC. My preceptors were Dr. Porter and Ms. O’Connor Devlin. Dr.
Porter is the Chief Nursing Officer and Sr. VP of Patient Care Services.
Ms. O’Connor Devlin is the Administrative Director of Patient Flow and
Nursing Quality. Dr. Porter directs and facilitates the development of
hospital-wide patient care programs, implementing plans for nursing
care, and participates in quality improvement programs. Ms. O’Connor-
Devlin is a nursing leader who is responsible for the oversight of
HCAHPS initiatives for the inpatient units and for Partnership for
Patients (PFPs) initiatives measuring quality outcomes through evidence
based practices hospital-wide. She also manages patient flow. Ms.
O’Connor-Devlin also participates in multiple committees related to
patient safety and quality (Better Health/Better Care Committee, Patient
Safety, Quality and Safety, and Board Quality Committees).
HCAHPS stands for Hospital Consumer Assessment of Healthcare
Providers and Systems. It is the first national, standardized, publicly
reported survey of patient’s perception of hospital care. It was
developed by the Centers for Medicare and Medicaid (CMS) partnered
with the Agency for Healthcare Research and Quality (AHRQ) and the
Department of Health and Human Services. The first public report was
in 2008. The results were reported on the Hospital Compare website at
www.hospitalcompare.hhs.gov. According to CMS, the survey was
shaped by 3 goals:
Goal number one is to produce comparable data on patients’
perspectives of care so that consumers can make an informed decision
among hospitals.
Goal two is to create incentives for hospitals to improve their
quality of care.
Goal three is to enhance public accountability in healthcare by
increasing the transparency of the quality of hospital.
The HCAHPS surveys have a standard set of questions. The report
is randomly sent to a defined number of patients per month. The
surveys are available in English, Spanish, Chinese, Russian, and
Vietnamese and are sent via US mail. Surveys are also done by phone
or online. The patients who receive the survey are of all payer types.
They are required to be over the age of 18 at the time of admission; have
at least one overnight stay in the hospital as an inpatient; have a non-
psychiatric MS-DRG/principal diagnosis at the time of discharge; and be
alive at the time of discharge. There are twenty one questions that are
categorized into eight domain scores. The eight domains are the
considered significant aspects of the hospital experience. The domains
are Nurse Communication, Responsiveness of Staff, Medication
Communication, Cleanliness, Pain Management, Physician
Communication, Quietness, and Overall Hospital Experience. Of the
eight domains, three domains were chosen as a focus by nursing. These
were Nurse Communication, Responsiveness of Staff, and Medication
Communication.
The organizational strategy chart of GBMC shows the significance
of HCAHPS and who is involved (Appendix B). The Chief Operating
Officer leads the Better Health/Better Care Committee. Each Vice
President is responsible for a strategy and has an administrative director
who manages the processes with a performance improvement colleague.
They provide updates/reports to the senior executives. The HCAHPS
aspect is separated into the eight domains by domain leaders that are
specializing in that area. The domain leaders are usually nurse
managers. The domain leaders involve the physicians, ancillary
departments, and the front line staff when a new process is being
implemented. Front line staff would include the registered nurses (RNs)
and the nursing support technicians (NSTs).
The Nurse Communication domain is analyzed by plotting the
current HCAHPS score on a P chart over time. The responses to the
questions are measured using a scale of never, sometimes, usually, or
always. The graph shows the percentage of always responses. This is an
internal measurement tool and is publically reported on the GBMC
website. The percent always scores are also reported on the
hospitalcompare.gov website. The questions from the survey as listed in
the Studer reference are:
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 the nurses explain things in a way you could understand? (43)
For the month of September 2014 the score for the overall Nursing
Communication was 79.04% (Appendix B). No special cause at this
time. P chart special causes are categorized by seven rules. Juan Negrin
personally communicated the seven rules:
1) 1 or more data points above/below the control limits.
2) 2 of 3 consecutive data points above/below the 2 sigma line.
3) 4 of 5 consecutive data points above/below the 1 sigma line.
4) 8 or more data points in a row above/below the mean (known as a shift)
5) 6 data points or more all consecutively higher/lower than the preceding one, known as a trend.
6) 15 data points or more hugging the mean.
7) 14 data points or more alternating up and down (2014).
After observing the scores for HCAHPS for each of the units, the
current processes were observed this was the 5 Phase Team
Communication process. The findings were from the team huddles, RN
to RN and NST to NST handoffs, and the RN to NST handoff. The
observation was to see how each unit performed the process and what
improved throughout the observations and the areas that need
improvement. The areas of improvement for team huddles included the
reduction of the duration of the huddle and to increase the attendance of
off going and oncoming staff. RN and NST handoffs were with five
minutes or less the majority of the time and always done in the patient
room. The RN to NST handoff was apparent on units that had been part
of the test project where the process was trialed. The opportunity for
improvement for the team huddles was the content of the information. It
was different on each unit. RN and NST handoffs lacked a standard
process and the handoff tools varied with the NSTs. RN to NST handoff
was not completed on some units. The units that had the handoff lacked
standardization.
The Responsiveness of Staff domain is analyzed by plotting the
current HCAHPS score on a P chart over time. The responses are
measured in the same fashion for each of the HCAHPS domains. The
percentage of always is publicly reported on the hospitalcompare.gov
website. From the Studer Group the questions from the survey are:
How often did you receive help getting to the bathroom or using the bed pan as soon as you wanted?
During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted? (131)
For the month September 2014, the score for the overall Responsiveness
of Staff was 66.50% (Appendix D). No special cause at this time.
The current initiative for this domain is purposeful rounding by
using the four P’s (Pain, Possessions, Potty, and Pain). The leader
rounding tool is used to interview patients on the unit. A clinical care
coordinator or the nurse manager usually does this to measure if the staff
is being responsive to the patient needs. There were improvements with
unit observations. Staff is always courteous and purposeful rounding
was done every hour. The four P’s were asked when the RN did rounds.
Patient interviews improved (Appendix E) over a period of time. The
area of improvement observed is the variable response time to actually
respond to the patient’s needs. Units that had quicker response times
had the unit secretary call the RN or NST by phone. There is an
opportunity for improvement with this metric where the manager can
observe staff rounding to see if they are consistently reinforcing the 4
P’s with the patient on each interaction...
The Medication Communication domain is analyzed by plotting
the current HCAHPS score on a P chart over time. The responses are
measured in the same fashion for each of the HCAHPS domains. The
percentage of always responses is publicly reported on the
hospitalcompare.gov website. From the Studer Group the questions
from the survey are:
1. Before giving any new medicine, how often did hospital staff describe possible side effects in a way you could understand?
2. Before giving you any new medicine, how often did staff tell you what the medicine was for? (183)
For the month September 2014, the score for the overall Medication
Communication was 61.74% (Appendix F). This is a trend which is a
type of special cause.
The current initiative for the domain is the Welcome Folder. On
all of the units the Welcome Folder has the same basic contents.
Information specific to specialty units is also included. When a new
medication is ordered the RN explains to the patient that this is
something new, what the medication is for, and what the most frequent
side effects might be. A medication education sheet is printed by the
staff and placed in the folder for the patient and family’s reference. The
sheet has more information about the medications the patient is taking.
A survey tool was developed for patient interviews (Appendix G).
Observations were also conducted on units to observe staff providing
this information. There is an area for improvement with the nursing
education and for follow-up during the patient interviews regarding
understanding the Welcome Folder (Appendix H). Over time there was
an increase with the Welcome Folder being present in the patient room.
Patients also could verbalize medications because the nurse
communicated the medications frequently as seen during observations.
The opportunities for improvements are the explanation of the new
medications and side effects, the process to explain the folder, and
engaging staff to print medication education sheets.
Overall findings from the three domains are: inconsistent practice,
lack of standard tools/practice, and lack of follow through. Inconsistent
practice was found with mixed reviews from patients about response
time and RN to NST handoffs. Lack of standard practice was found
with the NST handoff tools, content of huddles, and with the explanation
of the Welcome folder. Lack of follow through was found with
rounding on patients every day for feedback about response time and
medication education sheets.
From the findings, the following recommendations were made.
The solutions should be done all for current and future initiatives for
HCAHPS. This would include better leadership roles, accountability,
follow through, and standard work. Leadership should be from the
CUC. The CUC should be coaching, mentoring, and educating staff
about what the expectations are for the unit. If the CUC provides a good
leadership presence, the staff will be more involved with future
processes. There needs to be accountability for what those expectations
are of the staff. The nurse manager and the CUC should have the same
expectations and follow through with consistent counseling. Standard
work is important for better communication of information and to
decrease errors.
By using these recommendations, future initiatives could be better
organized and also achieve the opportunities for improvement. Projects
in progress for HCAHPS include introduction of a “No Pass Zone” as
outlined in the HCAHPS Handbook. When this is fully implemented no
staff member can pass a patient room where a call light is on without
answering it. This is used to improve the response time for patient needs
and should increase the domain of the Responsiveness of Staff score and
the Quietness domain score. In order for this to be effective all staff
must be accountable for answering the lights and either providing the
necessary care or by obtaining assistance from someone who can
address the patient’s needs. This would also be evaluated during
consistent leader rounding. The Medication Communication domain
would be addressing New Medications is being addressed by having the
resident physician educate the patient about new medications. This will
also help improve the Physician Communication domain. The outcomes
will be evaluated in the HCAHPS scores from both of the domains.
Finally the last new initiative is restructuring units by zones. This would
increase the Responsiveness of Staff since the team assigned to the area
can respond more quickly to patients needs.