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Discharge calls and key words help communicate ROI with passion.

MHS Spring 2009

Words matter B y Ly n n e C u n n i n g h a m

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aving lives. That’s the business we are in. We all know this, but sometimes it’s easy to get wrapped up in the day-to-day tactical activities that seem so important. Then we lose sight of why we got into healthcare in the first place—helping others, making a difference and saving lives. As communication and marketing professionals, we play a pivotal role in communicating the passion and purpose behind these tactics and activities. Let me focus on three evidence-based leadership tools that can help drive results and provide examples of how you can communicate organizational alignment between return on investment (ROI) and a passion for saving lives. Whether you call them goals, pillars or strategic initiatives, successful organizations take a balanced approach to organizational metrics. Often these pillars are labeled as service, quality, people, finance and growth. The key to success isn’t exactly what you label each goal but having a balance. Studer Group refers to these tools as evidence-based leadership tools because its work with more than 500 healthcare organizations nationally documents the results that organizations see when implementing these tactics.

Discharge Phone Calls Let’s start with discharge phone calls. Whether you’re simply reaching out to a patient with a care call or asking more prescriptive questions, discharge phone calls are a key tactic in the saving lives arsenal.

An ample body of research shows that post-visit phone calls to hospital inpatients deliver multiple benefits. Not only do they engage staff and offer an opportunity to harvest reward and recognition for highperforming physicians and employees, but they also tend to wow patients. It makes them feel cared about as a person—one of patients’ top three priorities when in the hospital. As a result, patient satisfaction climbs dramatically at hospitals that implement and consistently make discharge phone calls. Post-visit calls also 1. reconfirm discharge instructions, 2. reduce patient anxiety, 3. reduce complaints and claims, 4. reinforce patient perception that excellent care has been provided and 5. offer an opportunity for quick service recovery. “You have a 90 percent chance of keeping a patient if you call within 48 hours of discharge and do something—like apologize—to make the patient’s experience better. If you wait longer than a week, you have a 10 percent chance you’ll lose 10 other patients through word of mouth,” notes Jay Kaplan, Studer Group’s medical director. Another example in the persuasive case for making follow-up calls: In one study of 400 consecutively discharged patients, 19 percent of patients reported adverse events (drug events and procedure-related injuries) post-discharge. Of these, 48 percent were preventable. In an August 2005 follow-up study, researchers found that,

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of those patients who reported adverse events in the original study, 71 percent were significant, 13 percent were serious and 16 percent were life-threatening. James Brock remembers the early stages of Pikeville Medical Center’s discharge call process. Brock, who serves as director of telemetry at PMC in Pikeville, Ky., hit the ground running with the program. His unit engaged early, and 232-bed PMC bought into it. Debbie Puckett, CEO of rehab services at PMC, says, “We want our patients to know that our care extends far beyond their stay here.” “Our goal in this was twofold,” says Brock. “We wanted to know if we could do anything differently to make their stay more efficient and comfortable, and we wanted to know if they would like to recognize a member of our staff for their excellent care.” Typically, nurses, who provided care during a patient’s stay, will make the discharge calls. “That adds a personal touch,” Puckett said. “We want our patients to realize that we appreciate them and are proud that they chose us for their healthcare needs.” If a patient wishes to recognize a nurse or staff member, the director of the unit is notified immediately in an e-mail message. “We follow up on these compliments by placing them on bragging boards and recognizing these employees during regular staff meetings,” Brock explains. Puckett shares a story that brings the face of the patient into the discharge phone call tactic. “In a call to a patient recently discharged home after having a cardiac event, one of our callers was able to make a real difference in the patient’s life. A discharged patient was embarrassed to tell the nursing staff she could not afford her medication. When the nurse called postdischarge, she asked the patient if she was taking her medication as prescribed. The patient informed the nurse she did not have the money to buy her medication and had not filled her prescriptions. The nurse contacted our social worker, who enrolled the patient in a medication assistance program that provided her the needed medications to treat the cardiac ailment. The patient was extremely thankful for the help, and the nurse realized the purpose and importance of discharge phone calls as a result of this patient interaction. At times in healthcare we are overcome with tasks. Pikeville asks that post-visit calls never become a task and always are associated with providing excellent quality care.” Additional ROI from discharge phone calls has been documented at the 775-bed Hackensack Medical Center in Hackensack, N.J. Exhibit 1 shows consistent and sustained improvements in patient satisfaction for inpatients and emergency department patients when they receive discharge phone calls. This also contributes significantly to service quality goals. Discharge calls also affect financial results by identifying clinical issues and dealing with those immediately rather than waiting for the patient’s readmission to the hospital or ED. Exhibit 2 shows results from the 286-bed Regional Medical CenMHS Spring 2009

Exhibit 1 Impact of discharge phone calls Discharge phone calls are effective Patients who received Nurses section a discharge phone call 18th felt more prepared for “Extent felt discharge and were ready for discharge” 9th more satisfied with home care instructions “Instructions to and overall nursing care for yourself 30th at home” care. 0

Inpatient Satisfaction: 2Q07 National Percentile Ranking Source: Press Ganey Associates

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94th 98th 99th

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Patients who receive discharge phone calls are more likely to recommend As nurses and physicians saw what a difference discharge phone calls made to patients, it reinforced the value of the practice. Consistently, the patients that received calls are more likely to recommend HUMC.

98th

3Q06

75th 98th

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76th 99th

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Inpatient “Likelihood of Recommending” National Percentile Ranking Source: Press Ganey Associates

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ter of Orangeburg and Calhoun Counties in South Carolina. It shows the impact of discharge phone calls on patients returning to the inpatient setting within 72 hours of discharge or to the ED within 24 hours of discharge. Insurance companies as well as government payors are becoming more and more reluctant to reimburse hospitals for care of patients who return to the hospital within these limits.

Hourly Rounding In the September 2006 issue of American Journal of Nursing, Studer Group’s Alliance for Health Care Research published its national study of hourly rounding on patients. The results follow: • • • •

Call lights down 38 percent Falls down 50 percent Decubiti (bedsores) down 14 percent Patient satisfaction up 10 percent

Since then, hundreds of hospitals have adopted hourly rounding on inpatients and patients in the emergency department with impressive benefits to the bottom line, too. Covenant Health System, a six-hospital system with 6,000 employees serving West Texas and Eastern New Mexico, initiated hourly rounding in August 2006. Six months later, leaders credited those tools with saving $132,000 in patient falls (estimated at six fewer falls since baseline measurement before implementing hourly rounding

at $22,000 cost per fall), capturing lost charges of $81,600 per year and overtime savings of 220 hours or $1,764. (Overtime savings were based on an hourly rate of $8 for three nurses multiplied by 1.5 hours less overtime per week for 49 weeks.) How does hourly rounding link to capturing lost charges? “The reduction in call lights was so dramatic that it created a calmer work environment for nurses,” explains Studer Group coach Dan Collard. “As a result, nurses had more time to be proactive about capturing charges, documenting and coding.” Karen Baggerly, chief nursing officer for Covenant Health System in Lubbock, Texas, has seen the results of hourly rounding first hand. “We chose a handful of units to pilot hourly rounding, and the results have been remarkable,” Baggerly explains. “What I enjoy most is hearing from the nurse leaders and nurses themselves about the real wins: reduced call lights, fewer falls and reduced incidences of pressure ulcers. This tactic supports our desire to do the right thing for all the right reasons.” What do nurses at Covenant like best about hourly rounding? “It creates an environment where our nurses have more time to do what they came here to do: provide the very best care to our patients,” Baggerly adds. A recent story from Catholic Healthcare West’s 250-bed St. Bernardine Medical Center in San Bernardino, Calif., demonstrates how hourly rounding saves lives, the importance of this nursing tactic and how it can be communicated with passion to the entire hospital team. “On our ortho/neuro/surgical unit, one of our fairly new nurses went in to do her hourly rounding,” notes Cindy Bean, senior director of med/ surg and maternal child health inpatient services at SBMC. “On the previous rounding the patient appeared to be fine with no complaints. In the old days we probably would not have looked in on this patient until two hours had lapsed. However, when the nurse went in after one hour she noticed that the patient was in distress. In checking oxygen saturation, the nurse found it was in the 70s. She immediately alerted the charge nurse and respiratory who were both on the unit. Our safety net team was also called. When safety net arrived in just a few minutes time, we were already bagging the patient and were able to transfer the patient down to the ICU. This patient was in his 30s!” Driving home the message that hourly rounding can save lives, Studer Group coach Faye Sullivan adds that the patient ultimately had a full recovery.

Key Words Key words at key times can reduce the patient’s anxiety by providing an explanation of who will be providing care and service and what will be done. Reducing the patient’s anxiety, in turn, leads to greater compliance in the prescribed treatment plan and better clinical outcomes. The premier set of key words is known as AIDET: • Acknowledge. Greet the patient, ideally by name.

Exhibit 2 Likelihood of patient return Improved clinical quality Inpatient: Volume adjusted 72 hour inpatient returns 8% 7% 6% 5% 4% 3% 2% 1% 0%

6.7%

6.6% 5.3%

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5.3%

Tactic and tool implemented: Post visit calls

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Improved clinical quality Emergency department: Volume adjusted 24 hour emergency department returns 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% .5% .0%

2.9% 2.5%

2.1%

1.9%

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Tactic and tool implemented: Post visit calls

Month 1

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Month 5

Source: Regional Medical Center

• I ntroduce. Introduce yourself and tell the patient about your skill set and experience. • Duration. How long will the procedure or process take? • Explanation. What are you going to do? • Thank you. Thank the patient for choosing your healthcare facility. In the medical office setting, key words used by physicians, medical assistants and front office staff produce dramatic improvements in patient satisfaction as demonstrated at the 347bed University Medical Center in Tucson, Ariz., after physicians and staff consistently used AIDET. (See Exhibit 3.) Key words can also be used in other areas to improve financial performance. Sometimes it’s as simple as asking, “How are you going to pay your co-pay today?” instead of asking, “Are you going to pay your co-pay today?” This dramatic improvement from month one to month two was seen at 356-bed Southwest Washington Medical Center in Vancouver, Wash. Key words also work in the hospice environment as demonstrated at Sharp HospiceCare in San Diego, which boosted family satisfaction from the fifth to the 74th percentile and pain control from the 11th to the 88th percentile in less than one year. Sharp HospiceCare has an average daily census of 270 patients, annual admissions of 1,600 patients and an average MHS Spring 2009

Exhibit 3 Key words improve patient satisfaction UMC medical practices patient satisfaction

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100% 90% 87% 79% 80% 75% 70% Physician and staff 71% 66% AIDET training 60% 63% 64% 53% 51% 50% 40% 38% 29% 38% 38% 30% 27% 20% 12% 10% 0%

length of stay of 58 days. Employee turnover is just 2 percent. “Key words at key times are a must-have for service excellence,” says Suzi Johnson, RN, MPH and vice president of Sharp HospiceCare. “Even though staff at Sharp Hospice was initially resistant to using ‘scripted’ words, they have come to see the impact these words have on patient and family satisfaction. Key words also imprint a greater consciousness of service excellence by hardwiring consistency into each and every patient/family interaction. In a similar way, using AIDET also raises patient and family satisfaction by communicating respect, communication, appreciation, and confidence.” Key words take many forms. The following story is illustrative of the impact special words can have and is told by Marianne Hatfield, from 427-bed Children’s Healthcare of Atlanta. “A few years ago, I came in to help supplement a nursing shortage on a particularly busy winter night in the ED. We received word that we were getting a very sick six-year-old girl from an outlying county. She had suspected bacterial meningococcemia and was being flown in by a helicopter. When she arrived, we rushed her into the trauma room and began to treat her. Purpura was blossoming all over her body as we worked. She had lost IV access during the flight, and it was critical that we get antibiotics administered as soon as possible. She was going to need to be intubated and rushed to the ICU. In our haste to try and stabilize her, we didn’t think about the fact that she was still awake and aware of what was going on.” “As I was cutting off her clothes, I looked up and our eyes met and she asked, ‘Am I going to die?’ My heart ached. We had been practicing using key words for years. If anyone ever needed an explanation of what was happening to her, it was this little girl, right now. I said, ‘I’m one of your nurses and my name is Marianne. This is your doctor, Dr. Sharna, and P.K. is your respiratory therapist who is going to make sure you can MHS Spring 2009

breathe. You are very sick right now, but we are going to do everything we can to try to help you get better.’ A good deal of the terror left her eyes and she actually said, ‘Okay.’” “Both Dr. Sharna and P.K. then explained everything they were going to do to this child. We had to sedate and intubate her; then we moved her to the ICU. That precious six-year-old survived and is now a healthy, happy eight-year-old. It’s one of those patient stories that I’ll never forget and I’ll always remember the importance of key words.”

Communicating with Passion Communicating the passion of the work we do in healthcare is as easy as being alert for the stories that are all around us. Your colleagues in the finance department can help quantify the ROI of results seen when implementing a new tool or best practice. Staff and leaders who interact with patients and families have stories to tell every day. Connecting the dots between the financial ROI and the passion of the actual experiences will reconnect staff and physicians with why they got into healthcare in the first place. Once you have the ROI and the stories, they can be shared in publications, during employee forums or town hall meetings and at department meetings. Some organizations are collecting their own stories into books to share with staff and physicians. Knowing you are doing worthwhile work and looking forward to each new day as an opportunity to make a difference is what brings renewal and meaning to the work. MHS About the Author Lynne Cunningham is a 30+ year veteran of healthcare marketing and today is a coach with Studer Group. She may be reached at [email protected]. Additional Reading Forster, A., H. Murff, J. Peterson, T. Gandhi and D. Bates (2003), “The Incidence and Severity of Adverse Events Affecting Patients After Discharge from the Hospital,” Annals of Internal Medicine, 138 (3), 161-67. Forster, A., H. Murff, J. Peterson, T. Gandhi and D. Bates (2005), “Adverse drug events occurring following hospital discharge,” Journal of General Internal Medicine Apr; 20 (4): 327-23. Studer Group (2007), What’s Right in Health Care: 365 Stories of Purpose, Worthwhile Work, and Making a Difference. Gulf Breeze, Fla.: Fire Starter Publishing. Helldorfer, Martin, and Terri Moss (2007), Healing with Heart: Inspirations for HealthcareProfessionals. Re-ignite Your Passion for Your Work. Orinda, Calif.: Moss Communications. Dasgupta, Sayantani, and Marsha Hurst (2007), Stories of Illness and Healing. Kent, Ohio: Kent State University Press.