evidence-based leadership digging deeper rounding on employees rounding on patients hourly rounding
TRANSCRIPT
Evidence-Based Leadership
Digging Deeper
Rounding on Employees
Rounding on Patients
Hourly Rounding
Why Are We REALLY Here Today?
To create a place where employees and physicians want to work and patients choose to receive their healthcare
To deliver on the Institute of Medicine’s six Aims (safe, timely, effective, efficient, equitable, patient-centered care)
To implement strategies that get staff back to the bedside, increase effective communication, and provide harm-free patient/family centered care with good outcomes including a safe transition home
Execution FrameworkEvidence-Based LeadershipSM
Standardization AcceleratorsMust Haves®
Performance Gap
Objective Evaluation
System
Leader Development
Foundation Breakthrough
STUDER GROUP®:
Agreed upon tactics and behaviors to achieve goals
Re-recruit high and middle/solid performers
Move low performers up or out
Processes that are consistent and standardized
Process Improvement
PDCALeanSix Sigma Baldrige Framework
Software
Aligned Goals Aligned Behavior Aligned Process
Create process to assist leaders in developing skills and leadership competencies necessary to attain desired results
Implement an organization-wide staff/leadership evaluation system to hardwire objective accountability (Must Haves®)
Rev 4.8.11
Sustained Culture Change/StandardizationRequires Behavior Change
Performance
Insight and results
Instability
Reliability and Standardization
Technical Improvements
Behavioral effect
(can five front line users clearly articulate the process?)
Year 2Year 1 TimeYear 3
Performance
Insight and results
Instability
Reliability and Standardization
Technical Improvements
Behavioral effect
(can five front line users clearly articulate the process and do they know WHY?)
Year 2Year 1 TimeYear 3
HCAHPS – Hospital Consumer Assessment of Healthcare Providers and Systems
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 is publicly reported with other quality metrics on the Hospital Compare website. www.hospitalcompare.hhs.gov
The information will be used to provide meaningful data for improvement efforts, for comparisons between hospitals to help consumers choose a hospital and will be linked to reimbursement through the Value-Based Purchasing program.
What is What is HCAHPSHCAHPS
Why is it Why is it important?important?
How will it How will it be used?be used?
Articulation demands simplicity!
Patient Perspective of Clinical Quality
Communication with doctorsCommunication with nursesResponsiveness of hospital staffPain managementCommunication about medicinesDischarge informationCleanliness of hospital environmentQuietness of hospital environmentOverall rating of hospitalWillingness to recommend the hospital
Their perception of your
performance is a reportable and
tangible reflection
of yourreputation
Clear Connection between Patient-Centered Care and Clinical Quality Outcomes
HCAHPS Rating AMI CHF PNA Surgery
Lowest quartile 93.5 82.7 88.5 82.8
Second quartile 94.5 85.2 90.1 84.3
Third quartile 94.6 85.9 90.7 85.2
Highest quartile 95.3 86.0 90.8 85.7
P value for trend <0.001 <0.001 <0.001 <0.001
Compared Hospital Quality Alliance (HQA) scores for the Quality of Clinical Care to HCAHPS Global Rating for 2,429 hospitals
Source: Jha et al. New England Journal of Medicine 359, no. 18 (2008): 1921-1931.
Patients’ Perception of Care = QualityVascular Catheter-Association Infection
Engage Patient and Families in Reducing Infections
During bedside report, listen for reasons that catheter is still present
Ask your nurse about procedures to prevent central line infections
Tell nurse if bandage over central line is loose, soiled or wet or skin is red/inflamed
Watch that doctors/nurses wash hands
Make sure visitors do not touch catheter or tubing
Keep catheter ends clean and dry
If go home with catheter, teach-back appropriate care
High Patient Perception of Care Equals Lower Preventable Readmissions
1/5 of Medicare Beneficiaries are readmitted within 30 days with an
annual cost of $17.4 Billion
Source: The American Journal of Managed Care; Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days; 2011; Vol. 17(1)
2.3%Pneum-
onia
3.1%Heart
Failure
2.6%Acute
MI
Expanded HCAHPS Survey (Jan 1, 2013 Discharges)
3 Care Transition Items (4-point Agreement Scale)
(Strongly Disagree, Disagree, Agree, Strongly Agree)
During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose for taking each of my medications.
(Health Literacy, Family Involvement and Teachback)
Source: http://www.caretransitions.org
New HCAHPS Questions (Jan 1, 2013 Discharges)
Demographic Items in the “About You” section
1. During this hospital stay, were you admitted to this hospital through the Emergency Room? (Yes/No)
2. In general, how would you rate your overall mental or emotional health?
(Excellent, Very Good, Good, Fair, Poor)
For additional details on these new HCAHPS items from CMS, please see Page 5 of the HCAHPS Quality Assurance Guidelines v7.0:
http://www.hcahpsonline.org/qaguidelines.aspx.
National Average Top Box Results have Improved Over Time for Each Composite
HCAHPS Answer Description
National Avg. 1Q07-4Q07
National Avg. 1Q08-4Q08
National Avg. 1Q09-4Q09
National Avg. 1Q10-4Q10
National Avg. 1Q11-4Q11
National Avg. Increase 2007-2011
Percent Increase 2007-2011
Overall rating of 9 or 10 (high) 63 64 66 68 69 6 9.5%
Quiet at night 54 56 57 58 59 5 9.3%
Responsiveness of Staff 60 62 63 64 65 5 8.3%
Communication about Medicines 58 59 60 61 62 4 6.9%
Room Clean 68 69 70 72 72 4 5.9%
Nurses Communication 73 74 75 76 77 4 5.5%
Discharge Information 79 80 81 82 83 4 5.1%
Pain Management 67 68 69 69 70 3 4.5%
Definitely Recommend 68 68 69 70 70 2 2.9%
Doctor Communication 79 80 80 80 81 2 2.5%
National Average Year to Year Change in Top Box Results has declined over time
Patient Experience, Safety, Effectiveness
The data presented display that patient experience is positively associated with clinical effectiveness and patient safety, and support the case for the inclusion of patient experience as one of the central pillars of quality in healthcare. It supports the argument that the three dimensions of quality should be looked at as a group and not in isolation. Clinicians should resist sidelining patient experience as too subjective or mood-oriented, divorced from the ‘real’ clinical work of measuring safety and effectiveness.
Source: Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 2013;3:e001570.doi:10.1136/bmjopen-2012
Value Based Purchasing FY 2014
Core Measures(45% Weight)
HCAHPS Composites(30% Weight)
1.25% Base operating
DRG payments
Performance attainment and improvement
willdetermine total
hospital reimbursement
Outcomes(25% Weight)Note: Implementation FY 2014
Source: OPPS VBP Final rule 11.1.11
2013 and 2014Process of Care Measures
Measure ID Measure2013 National
Threshold2014 National
Threshold2013 National Benchmark
2014 National Benchmark
AMI–7aFibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival 0.6548 0.8066 0.9191 0.9630
AMI–8aPrimary PCI Received Within 90 Minutes of Hospital Arrival 0.9186 0.9344 1.0000 1.0000
HF–1 Discharge Instructions 0.9077 0.9266 1.0000 1.0000
PN–3b
Blood Cultures Performed in the Emergency Department Prior to Initial Anti-biotic Received in Hospital 0.9643 0.9730 1.0000 1.0000
PN–6Initial Antibiotic Selection for CAP in Immunocompetent Patient 0.9277 0.9446 0.9958 1.0000
SCIP–Inf–1Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision 0.9735 0.9807 0.9998 1.0000
SCIP–Inf–2 Prophylactic Antibiotic Selection for Surgical Patients 0.9766 0.9813 1.0000 1.0000
SCIP–Inf–3Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time 0.9507 0.9663 0.9968 0.9996
SCIP–Inf–4Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose 0.9428 0.9634 0.9963 1.0000
SCIP–Inf–9Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2 N/A 0.9286 N/A 0.9989
SCIP–Card–2
Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period 0.9500 0.9565 1.0000 1.0000
SCIP–VTE–1
Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 0.9307 0.9462 0.9985 1.0000
SCIP–VTE–2
Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
0.9399 0.9492 1.0000 0.9983
Green = increased threshold from 2013Red = decreased threshold from 2013
NEW
Concurrent Interventions – High Performing HEN
Evidence-Based Leadership
Digging Deeper
Rounding on Employees
Rounding on Patients
Hourly Rounding
Warning Sounded on Demoralized WorkforceAmerican Medical News. March 25, 2013
Rounding on employees and asking questions about basic safety of the workplace demonstrates respect
Injury rate in healthcare is 5.6/100 FTE (33% higher than all private industry)
7/10 doctors see disruptive behavior once/mo and 11% said it happens daily
70% of doctors and others feel rushed in office setting
50% of doctors have symptoms of burnout
Evidence-based leadership trends themes and finds solutions
Source: Through the Eyes of the Workforce: Creating Joy, Meaning and Safety in Health Care. Lucian Leape Institute at the the National Patient Safety Foundation. March
Retained Staff is Correlated with Lower LOS and Lower Mortality Rates
Session Outcomes
Increased understanding of the Evidence-Based Leadership (EBL model) and expectations including:
RoundingSenior LeaderStaffPatientHourlyCustomer
“Leader rounding is not optional.
It has to be looked at as seriously as
correct medication.”
Quint Studer
Define the Term “Hardwired” Rounding
90% of leaders rounding with the prescribed frequency, utilizing good skills, to elicit actionable reward/recognition and process improvements that are documented and followed up on.
These are trended and reported to give a more global organizational perspective.
1. Personal Connection2. What is working well? 3. Anyone I can recognize? Why?4. What systems or processes are not working well?5. What can we do to improve them?6. Do you have the tools you need to do your job?7. What’s one way we can improve…8. Is there anything you need from me?9. Thank you for making a difference!
Rounding on Staff: Leader WIIFM Rounding questions
Foster team development, take a pulse of the Department & provide insight into
staff skills & behaviors
Rounding for Outcomes – Direct Reports
Who Rounds? Leader With Hire/ Fire responsibility
How Often? (minimum)
With <40 Direct reports Monthly
With 40-80 Direct Reports Every other month
With over 80 direct reports Quarterly
Rounding on Employee Worksheet
Focused Huddle
Daily Safety
Daily core measure patients
Weekly HCAHPS actions
Evidence-Based Leadership
Digging Deeper
Rounding on Employees
Rounding on Patients
Hourly Rounding
Source: The graph above shows a comparison of average percentile rank improvement using the Studer Group partner database compared to CMS data based on 3Q09-2Q10. N = 12 hospitals that implemented in 2008.
Nurse Leader Rounding Improves Patients’ Perception of Nursing Quality
Leader Rounding on Patients“Did a Leader Visit You During Your Stay?”
90 98 99
55
44
9990
0
10
20
30
40
50
60
70
80
90
100
Overall OB Card Neuro 7th floor 8th floor 9th floor
Yes
No
Per
cen
tile
Source: Sacred Heart Press Ganey Data, Jan 1, 2012 – Dec 31, 2012
Leader Rounding on Patients“Did a Staff Member Visit You Hourly?”
83
99 96 90 92 90 9995
0
10
20
30
40
50
60
70
80
90
100
Overall OB Card Neuro 7th floor 8th floor 9th floor ICU
Yes
No
Per
cen
tile
Source: Sacred Heart Press Ganey Data, Jan 1, 2012 – Dec 31, 2012
HCAHPS Data“Answered Yes to Both Questions
9897 97
99
90
91
92
93
94
95
96
97
98
99
100
Yes
Yes 99 98 97 97
Overall WTR Staff took pref into acct Listen carefully
Per
cen
tile
Source: Sacred Heart Press Ganey Data, Jan 1, 2012 – Dec 31, 2012
Leader Rounding on Patients
What is it?
Why is it important?
How will it be used?
Structured process to ensure we create a quality, safe and compassionate environment and resolve issues by obtaining “just in time” feedback from patients and families.
• Furthers mission to deliver patient-centered care• Builds relationships and provides emotional support• Improves clinical outcomes and quality of care• Promotes patient safety and a culture of safety• Increases efficiency and discovers opportunity to reduce “waste”• Raises patient engagement and perception of quality • Proactively addresses service recovery opportunities • Sets expectations of quality care in that area• Validates behaviors and raises the performance bar of all staff• Allows opportunity for reward and recognition• Builds leader skills
Nurse leader rounds on 100% patients daily to obtain feedback on quality, care and validation of staff expected behaviors. Staff then coached/recognized and actions taken to address improvement opportunities. Support Departments round as appropriate.
1. Prep with Nurse2. Personal Connection3. AIDET®4. Focus on key drivers of satisfaction5. Validate staff behaviors – AIDET®, Hourly Rounding®, etc.6. Identify staff to be recognized7. Check Bathroom8. Is there anything you need from me?9. Thank you 10.What did I learn about the QUALITY of care for that patient?11.Log findings12.Review finding with Nurse – Coach & Reward & Recognize
Nurse Leader Rounding on PatientsRounding questions
are focused on ensuring quality care , solving for gaps and validating staff
performance
Key Points on First RoundExpectations
Person of authority
Manage up and reduce anxiety
Goals of unit/department – what they can expect and what processes are in place like bedside report, hourly rounding, checking arm bands, etc.
Ensure family is comfortable and involved as the patient requests
Provide contact information
Validate behaviors are apparent
“How WELL are we doing….”Keeping you informed?
Keeping your room clean?
Explaining test and treatments?
Explaining what will occur after discharge?
Managing your pain?
Responding to your requests for assistance?
Addressing your questions and concerns?
Washing our hands?
Plan for the Day, Plan for the Stay
Plan for the DayPatient goal for the shiftPatient and family included in care and decisionsReinforces learning
Plan for the StayAnticipated discharge date and what needs to happen before patient can go homeEngages primary caregiver at home as well as patientContributes to reduced LOS
http://www.mc.vanderbilt.edu/reporter/index.html?ID=11199
Discharge Readiness ToolIntroduced by admission nurseUpdated daily until discharge
Suggested questionsMedicationsActivity/Home NeedsDietWorsening symptomsFollow-up
Start Discharge Planning at Admission
M in the Box: Step 1
If a new med ordered during the shift, the nurse will explain the medication and possible side effects to the patient.
Then, puts the letter “M” in the box drawn on the board.
“Mrs. Smith, I’m writing the M in the box to remind both of us that you had a new medication and I have communicated to you the reason for the medication and any possible side effects.”
M in the Box: Step 2
Later, during bedside shift report, the off- going nurse points out the “M in the Box”
“Dr. Jones ordered Mrs. Smith a new medication”. “Mrs. Smith, do you remember the name of the new medication? Can you tell me why Dr. Jones ordered it for you?Can you also tell me one of the side effects of the medication?”
M in the Box: Step 3
The off-going nurse checks back with the on-coming nurse
The process continues each shift until the patient is released. If no new medication is ordered the box should be empty.
“As you heard, Mrs. Smith is aware of her new medication and possible side effects.” “I will erase the “M in the box”, so that you can fill it in if another new medication is ordered for Mrs. Smith during your shift.”
Simple Tactic, Profound Results
Safety: Engage patient in monitoring for side effects/reactions; Opportunity for “teach-back”
Patient engagement: verbal and visual, two-way communication with patient about all new medications and any possible side effects
HCAHPS: Hardwire explanation of medication and side effects
Challenge – multiple medications
%tile ranking increased 30 - 60 when d/c call made!
Important Discharge Phone Call
Start Discharge Planning at Admission
Sets expectation for follow-up call including appropriate phone number
“Is there anything that makes it hard for you to care for yourself at home?”
Customized to high-risk for readmission diagnosis or specialty units (CHF, AMI, PN, Mother/Baby, etc.)
Rounding by Assignment
Care giver focused which enables focused validation of staff behaviors & coaching for improved outcomes
SafetyHourly RoundingWhite BoardsPain educationCore measure patients/bundleDischarge planningPatient/Family educationEmpathy
Aligns staff very quickly when round by assignment
Sample Patient Rounding Log
Complete dailyStore in binderReview for trendsShare “trends from rounding” monthly with direct report during supervisory meetingUse to write thank you notes and R/R
Sample Patient Rounding Summary - Weekly
Complete weeklyUsed to track organization wide compliance with % of patients rounded onShare “trends from rounding” monthly with direct report during supervisory meetingUse to write thank you notes and R/R
Coaching Tips – Organizational Compliance and Correlation With Other Quality Metrics
Lessons Learned About Rounding on Patients
Schedule rounding as if it is a standing meetingNo meeting zone – TBD with staff inputThis is not a TASK – this is evidence-based leadershipDon’t underestimate the value of proactively offering service recoveryPost rounding questions in the lounge so staff are aware of priority focus Documentation on rounding tool/log is critical – not optional Census sheets may be used – keep a summary log of key informationThis is for the patients comfort, not ours
Coaching Tip: Role of the Leader
Train in skills lab and validate in real-timeReward top performance and coach opportunitiesReinforce the WHY, connect to safe patient careTrack impact and communicate results• Patient satisfaction by unit and HCAHPS
– Nurse communication, pain, responsiveness• Falls, pressure ulcers, and other core measures• Call lights
Audit the rounding logsRound on patients to confirm behaviorsPost results from rounding – thank you notesCommunicate results in Supervisory Monthly Meeting
Hourly Rounding
A process to proactively interact with patients every hour during the day using focused key words to assess needs (pain, position, personal needs and patient education). A care model to help return care to the bedside and a process to help achieve our goal to “always” deliver exceptional clinical quality care in a safe and compassionate environment.
•Evidence supports a decrease in patient anxiety, falls, skin breakdown, and nursing steps as well increased patient satisfaction•It allows nurses to provide more care at the bedside•It is just good patient care•There is no other initiative that impacts the patient perception of quality care as this ONE does.
While in the patient room performing regularly scheduled tasks, include 6 additional behaviors to proactively address the patient needs and promote safety. Support areas address patient environment and see what patient may need.
What is it?
Why is it important?
How will it be used?
8 Behaviors of Hourly Rounding
Hourly Rounding Behavior Expected Results
Use Opening Key words Demonstrates respect and reduces anxiety
Perform scheduled tasks Contributes to efficiency
Address 3 P’s (pain, personal needs, position)
Impacts quality indicators – falls, HAPU, pain control and responsiveness
Address additional comfort needs Improved patient perception of pain control, responsiveness and caring
Conduct environmental assessment Focuses on culture of safety and clean, healing environment
Ask “Is there anything else I can do for you before I go, I have time?”
Builds a proactive, efficient care model and improves patient perception of care
Tell patients when a team member will be back
Contributes to efficiency and builds teamwork
Document the round on log in patient room
Shows visible commitment to excellent quality care
Hourly Rounding Logs
Non- negotiable if you want to achieve desirable results
Is a visible representation to patient/family of excellent, safe, quality care
During rounds, nurse leaders ensure logs represent hourly rounding behaviors are completed (R/R top performers)
Sustained results – can consider taking logs down but remember this if for the patients
Hardwired: 100% of Key Support Departments Round on Inpatient Units
If not directly serving patients, we are serving someone who is…
How can my department help improve the patient perception of care?
Reward and recognition
Link to quality
Track and trend issues
Posted monthly
Rounding on Internal Customer Process
Schedule Rounding
Appointment*
Schedule Rounding
Appointment*
Complete Preference
Card
Complete Preference
Card
Round on CustomerRound on Customer
Schedule next Rounding
Schedule next Rounding
Copy Preference Card & leave with
leader
Copy Preference Card & leave with
leader
Review preferences with staff
Post Cards in department
Review preferences with staff
Post Cards in department
Follow up on identified actions
Follow up on identified actions
Next Rounding Next Rounding
• Customize service to meet customer priorities
• Align customer priorities with reality of resources
• Educate staff
• Prioritize
• Organize work flow
Preference Card
Verification
• Synthesize Rounding information
• Trend process issues
• Review at MM“If you have accountability
with no consequences,
you have no accountability.”
Identify areas you support that are high impact
Round in these areas weekly
Schedule the time
Rotate the others so you connect with all departments served on a regular basis
Define which leaders will be rounding on which areas
Validate areas of focus
Determine how progress will be communicated
Follow up and follow through
Capture the WINS
Don’t be defensive
Coaching Tips