Nursing Executive Center

The Ideal Patient Experience Kaiser Permanente 9th Nursing Quality and Innovation Conference 2013

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Nursing Executive Center Practice Manager Jennifer Stewart Design Consultant Pascale Chehade Executive Director Steven Berkow

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The Ideal Patient Experience: Kaiser Permanente 9th Nursing Quality and Innovation Conference 2013

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A Groundswell of Interest Patient-Centred Care Gaining International Attention Ontario Hospital Association Redefining PatientCentred Care: What Does It Really Mean?

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NRC Picker International PatientCentred Care Symposium

Planetree Planetree Annual Conference: the Longest Running International Conference on Patient Centred Care

University Health Network Patient-Centred Care Symposium: From Patient to Person: Shaping a Uniquely Canadian Approach to Patient-Centred Care

Institute for Patient and Family Centered Care th 5 Annual International Patient and FamilyCentered Care Conference

In Need of a Change “Customising care to the individual takes health systems out of their comfort zones, forcing them to integrate people, technologies and organisations that are not part of their current routines. Consumers, government, health care providers and the health care industry will all need to pull together and partner to move Canada's healthcare agenda forward.” Pitts, B. PricewaterhouseCoopers Source: PricewaterhouseCoopers Health Research Institute, “Canadian consumers demand more patient-centred healthcare: HealthCast report,” HealthCast: the customization of prevention, diagnosis, care and cure, Canadian Compendium 2010; Global Centre for Nursing Executives interviews and analysis.

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“Patient Satisfaction Pays!”

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Select Headlines From the Press

The New York Times

The Washington Post

THE WALL STREET JOURNAL

Test for Hospital Budgets: Are the Patients Pleased?

Patient Ratings to Affect Medicare Payments to Hospitals

A Financial Incentive for Better Bedside Manner

Source: The New York Times, “Test for Hospital Budgets: Are Patients Pleased?” available at: http://www.nytimes.com/2011/11/08/health/patients-gradesto-affect-hospitals-medicareeimbursements.html?r=2&hpw, accessed November 10, 2011; The Wall Street Journal, “A Financial Incentive for Better Bedside Manner,” available at: http://online.wsj.com/article/SB10001424052970204190704577023882771323656.html, accessed November 10, 2011; The Washington Post, “Patient ratings to affect Medicare payments to hospitals,” available at: http://www.washingtonpost.com/national/patient-ratings-toaffect-medicare-payments-to-hospitals/2011/04/28/AFpecP9E_story.html, accessed November 10, 2011; Nursing Executive Center interviews and analysis.

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Incenting More Cost-Effective Care

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An Overview of Accountable Payment Methods

Pay-for-Performance

Bundled Payments

Shared Savings

Description: Financial bonuses, penalties, or withholds assessed based on outcome or process performance

Description: Payer disburses single payment to cover hospital, physician, or other services performed during an inpatient stay or episode of care

Description: Total expense (to payer) for a given patient population compared to risk-adjusted benchmark; portion of savings below benchmark returned to provider

Underlying Assumptions: Adherence to best demonstrated practice can improve outcomes and reduce long-term utilization

Underlying Assumptions: Better care coordination can reduce expenses associated with care episodes

Underlying Assumptions: Better care coordination can minimize inappropriate or duplicative utilization

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How Much Does HCAHPS Pay? Overview of Incentive Payment Based on Quality Performance

Payment Withhold

Performance Assessment

Redistribution of Payment

FY13 FY14 FY15 FY16 FY17

+ =

30%

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-1.00% -1.25%

-1.50% -1.75%

-2.00%

• Payment withhold applies to base operating DRG payment

• Assesses performance on 12 process of care measures, 8 patient experience of care measures

• Withhold applies only to roughly 3,100 hospitals meeting VBP inclusion criteria

• Scored on achievement relative to national benchmarks and improvement compared to historical baseline • Quality measure scores combined to form single figure Total Performance Score (TPS)

• Payment directly proportional to TPS score • Budget neutrality results in “winners vs. losers;” roughly half of hospitals earn back more than withhold, others earn back less

Source: Centers for Medicaid and Medicare Services; Advisory Board analysis.

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It’s All Relative Unbundling the TPS Score

Factors Determining Patient Experience Portion of Total Performance Score (TPS)

Achievement Score

Points gained for performing better than the national benchmarks in CMS final rule

Improvement Score

Points gained for performing better than institution’s own baseline performance

Consistency Score

Points lost if lowest scoring domain falls below 50th percentile

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30%

Source: Centers for Medicaid and Medicare Services; Advisory Board analysis.

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Clarifying Provider Risk Under Accountable Care Accountable Care Risk Outlook

Performance Risk

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Cost of Care

Utilization Risk

Quality of Care

Volume of Care

Bundled Pricing

Pay-for-Performance

Shared Savings

• Episodic Efficiency

• Process Reliability

• Readmission Reduction

• Clinical Quality

• Chronic Care Management

• Patient Experience

• Care Substitution

• Care Standardization

• Care Transitions

• Disease Prevention • Care Transitions

• Care Transitions

Source: Nursing Executive Center interviews and analysis.

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Imperative: The Patient Experience

Is This All We Aspire to Do?

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Summary of Eight HCAHPS Domains 1. Communication with nurses

5. Communication about medicines

2. Communication with doctors

6. Discharge information

3. Responsiveness of hospital staff

7. Hospital environment (quiet, noise)

4. Pain management

8. Overall hospital rating

Source: HCAHPS, available at: http://www.hcahpsonline.org/home.aspx, accessed November 11, 2011; Nursing Executive Center interviews and analysis.

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Imperative: The Patient Experience

Returning to Our Mission

Representative Hospital Mission Statement

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We strive to heal, to comfort, to teach, to learn and to seek the knowledge to promote health and prevent disease. Our patients and their families are at the center of everything we do. We dedicate ourselves to furthering our rich tradition of health care innovation, leadership, charity and the highest standard of care and service to all in our community.

Source: Tufts Medical Center, available at: http://www.tuftsmedicalcenter.org, accessed November 9, 2011; Nursing Executive Center analysis.

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Imperative: The Patient Experience

Broadening Our Ambition

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Patient Experience • Ongoing Emotional Support • Family Involvement and Care Team Integration • Avoidable Disruptions Minimized • Compassionate, Empathetic Caregivers • Clear, Actionable Patient Education • Up-to-Date and Thorough Information • Physical and Emotional Needs Anticipated

HCAHPS • Communication • Quiet at Night • Information About Medications • Discharge Information • Cleanliness • Responsiveness • Pain Management

Source: HCAHPS, available at: http://www.hcahpsonline.org/home.aspx, accessed November 11, 2011; Nursing Executive Center interviews and analysis.

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Economics Aligning with Mission Evolving Market Demand

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Centering Hospital Care on the Patient

Managing Chronic Care for High-Risk Patients

Building Long-Term Patient Relationships for Ongoing, Coordinated Care

Improving Overall Health and Wellness of the Population

Source: Nursing Executive Center interviews and analysis.

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Imperative: the Patient Experience

Our Efforts Yielding Improvement Nationwide Trends in Overall Inpatient Satisfaction Scores1 85.5

85.0

84.5

84.0

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83.5

83.0 Jan 2005

July 2009 Average Press Ganey Top Box Score

1) Press Ganey data.

Trend Line

Source: Press Ganey, “2010 Hospital Pulse Report: Patient Perspectives on American Health Care,” available at http://www.pressganey.com/Documents_secure/Pulse%20Reports/HOSPPulseReport_12-28-2010.pdf?v iewFile, accessed November 10, 2011; Nursing Executive Center interviews and analysis.

Imperative: The Patient Experience

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Yet Still Ample Room for Growth Percentage of Physicians and Patients Agreeing With the Following Statements About Compassionate Care n=800 patients, 510 physicians

85% 78%

76%

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54%

Compassionate care is very important to successful medical treatment Physicians

Most health care professionals exhibit compassionate care Patients

Source: Health Affairs, “An Agenda For Improving Compassionate Care: A Survey Shows About Half Of Patients Say Such Care Is Missing,” available at: http://content.healthaffairs.org/content/30/9/1772.full, accessed November 10, 2011.

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Then and Now….

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Single-needs patient an endangered species Mr. Jones; 1973

Mr. Jones; 2013

AMI

AMI, chf, diabetes, obese

PCP

PCP, cardiologist, endocrinologist, hospitalist, geriatric NP

2 meds

15 meds

Lives at home

Lives in assisted living

Wife is caregiver

Multiple family members, no one designated

LOS: 10 days

LOS: 2.5 days

One admission in 1973

Third admission in 2013

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Advancing Multiple Aims

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Representative Studies About the Relationship Between Patient Experience and Outcomes

American Journal of Managed Care

Circulation: Cardiovascular Quality and Outcomes

Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days

Patient Satisfaction and Its Relationship With Clinical Quality and Inpatient Mortality in Acute Myocardial Infarction

Journal of the American Board of Family Medicine Patient-Centered Care is Associated With Decreased Health Care Utilization

Source: Boulding W, et al., “Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days,” American Journal of Managed Care, 2011, 17:41-48; Glickman S, et al., “Patient Satisfaction and Its Relationship With Clinical Quality and Inpatient Mortality in Acute Myocardial Infarction,” Circulation: Cardiovascular Quality and Outcomes, 2010; 3:188-195; Bertakis K, et al., “PatientCentered Care is Associated with Decreased Health Care Utilization,” Journal of the American Board of Family Medicine, 2011, 24:229-239; Nursing Executive Center interviews and analysis.

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Nursing at the Heart of Transformative Change

” Future of Nursing: Leading Change, Advancing Health

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Working on the front lines of patient care, nurses can play a vital role in helping realize the objectives set forth in the 2010 Affordable Care Act, legislation that represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs. Institute of Medicine

Source: Institute of Medicine, “The Future of Nursing: Leading Change, Advancing Health,” available at: http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-ChangeAdvancing-Health, accessed November 11, 2011; Nursing Executive Center analysis.

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Three Steps for a Holistic Patient Experience Strategy 3 Diagnosing Institution-Specific Process Barriers 2 Overcoming Universal Process Barriers to a Patient- and FamilyCentered Experience

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1 Cultivating Caregiver Empathy

Surfacing and addressing the process barriers that are endemic to each individual institution

Removing the primary process barriers that impede the creation of an exceptional patient experience

Ensuring bedside nurses consistently empathize with the patients for whom they care

Source: Nursing Executive Center analysis.

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Practice Priority

Struggling to See Through the Patient’s Eyes

Common Barriers to Bedside Nurses Understanding the Patient Experience Lack of direct personal experience as patient or family member of patient

Compassion fatigue or difficulty connecting back to inspiration for entering nursing

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Fear of emotional toll resulting from connecting with patients

Tradition of formality that separates patients from caregivers

Source: Nursing Executive Center interviews and analysis.

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Practice Priority

Distinguishing Stories From Comments

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Representative Patient Comment

Representative Patient Story

Hello,

Hello,

I’m writing to remark on the care I received at Shelton Health1 on Oct. 7-9. My nurses were absolutely fantastic– they were kind and courteous. I felt like I was always in great hands. Dr. Thompson was also fantastic. He did a great job explaining my condition. My only complaint is that my dinner arrived cold on the evening of the 8th, however this was quickly fixed when I informed the nurse.

I’m writing to remark on the care I received at Shelton Health1 on Oct. 7-9. I came into the hospital with acute respiratory distress, and felt like I could hardly breathe. Upon entering the ED, I was warmly greeted by the receptionist and immediately placed in a room. I waited only a few minutes before a nurse came to take my vital signs. She was reassuring, and immediately calmed my nerves and explained to my husband what to expect. Then, I was transferred to imaging to receive an MRI. At this point, I started feeling incredibly anxious as my husband was no longer with me […]

Thanks again for all you do! Best, Shirley McEverett

1) Pseudonym.

Source: Nursing Executive Center interviews and analysis.

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Practice Priority

Realizing the Full Potential of Patient Stories

Key Pitfalls to Overcome

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Story Capture

Story Dissemination

Few existing mechanisms in place for capturing patient stories after discharge

Stories not shared with appropriate hospital employees, or simply not shared with staff at all

Methods for story collection cumbersome, discourage patient submissions

Second-hand story recitation results in “telephone game” loss of detail, diminished impact

Stories collected generally reflect wholly positive or negative experiences

Stories not shared through compelling medium, fail to emotionally impact staff

Source: Nursing Executive Center interviews and analysis.

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Practice Example: Nurse-to-Nurse Experience Sharing

Leveraging Fellow Employees’ Hospital Experiences

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Key Steps for Toledo’s “Tales From the Other Side of the Bed” Speaker Selection

Experience Sharing

Employee Q&A

Hospital employee with prior experience as a patient or family member invited to tell their story

Speaker gives five- to fifteen-minute presentation on care received during unit staff meeting

Following presentation, nurse manager leads Q&A session with staff, debrief on lessons learned

Case in Brief: The Toledo Hospital • 794-bed hospital based in Toledo, Ohio • Oncology unit manager invited three hospital employees to provide feedback, insight on their care experience on the unit • Sessions approximately 45 minutes each, scheduled as mandatory staff meetings across all shifts

Source: The Toledo Hospital, Toledo, OH; Nursing Executive Center interviews and analysis.

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Practice Example: Nurse-to Nurse Experience Sharing

Patient Satisfaction on an Upward Trend

Percentage of Top Box1 Hospital Ratings2 Pilot Unit

76.0% Experience sharing implemented in March 2010

71.9%

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Q1 2010

Q2 2010

For additional information, see pages 34-36 of Instilling Frontline Accountability, available at www.advisory.com/nec.

1) Defined as rating the hospital a “9” or “10” out of 10. 2) Scores based on NRC Picker database.

Source: The Toledo Hospital, Toledo, OH; Nursing Executive Center interviews and analysis.

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Practice Example: Episode of Care Profile

Individual Experience Critiqued Key Elements of Care Profile Identifies Care Incident

Specifies Positive Care

Illustrates Care Shortfalls

Personalizes Patient Involved

x x

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Patient diagnosis, admit and discharge dates, responsibility of nursing care

All appropriate precautions taken for patient with given risk assessment score

Fallouts, lapses in care that could have contributed to, worsened patient condition

Long-term consequences for patient, family

Case in Brief: Ochsner Medical Center • 473-bed Magnet facility located in New Orleans, Louisiana • In 2009, manager of tele-stroke unit presents episode of care profile to decrease pressure ulcer rate on unit • Care profile poster placed in nurses’ lounge; emphasized permanent consequences of pressure ulcer for patient, nursing care actions that might have contributed to ulcer development Source: Ochsner Health System, New Orleans, LA; Nursing Executive Center interviews and analysis.

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Practice Example: Episode of Care

Episode of Care Poster at Ochsner We Caused a Pressure Ulcer! Mr. Ulcer, Now with a Left Heel Stage 2 Admit Date 7/10, Discharge Date 7/18 Dx: Dysphagia Aspiration Pneumonia Braden Score on Admit=13 (Moderate Risk)

What We Should Have Done

What We Didn’t Do

Braden Score 13= moderate risk: • Update Care Plan • Turn q2hr and document • Encourage proper nutrition • Place turn clock above head of bed • Order/apply AC/heel protector boots • Order/utilize body aligner when turning patient • Educate family, document

• • • • •

Care plan not up to date Q2hr turns/elevate heels not consistently charted 3 P’s not consistently charted No AC/heel protector boots ordered/used No education note

***If you did not chart it, you did not do it!***

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Lasting Impact When Mr. Ulcer was admitted, never would have he and his wife thought that he would be leaving with an ulcer. Since having a stroke and aspiration pneumonia secondary to dysphagia, he can’t move well or eat well, and now this. The Stage 2 can get worse because of his diabetes and may become infected. With his deteriorating condition, the wound, if infected, could lead to gangrene or amputation. All of this could have been prevented if we would have just done what we were supposed to do. Now Mrs. Ulcer will take on this responsibility because we didn’t. What if Mr. & Mrs. Ulcer were your family members?

Staff Assigned to Mr. Ulcer SJF100 JTW100

KES100 MFK100

SEA100 NAJ100

RPJ100 CEV100

Source: Ochsner Health System, New Orleans, LA; Nursing Executive Center interviews and analysis.

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Practice Example: Episode of Care

Helping to Make a Lasting Impression Pressure Ulcers Decline on Tele-Stroke Unit Total Number of Pressure Ulcers Developed

7

3 2

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Q3 2009

Q4 2009

Q1 2010

Poster placed in nurses’ lounge in July 2009 for two weeks Source: Ochsner Health System, New Orleans, LA; Nursing Executive Center interviews and analysis.

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Practice Example: Patient Personalization Posters

Getting to Know Patients Through Posters “Getting to Know You” Poster at UCLA

Designated fields personalize patient by capturing family, background, hobbies, preferences

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Prominent placement near patient bedside serves as conversation starter for caregivers

Poster travels with patient across inpatient stay, providing sense of continuity, comfort

Poster content informs plan of care by highlighting patient’s goals after hospitalization

Source: Ronald Reagan UCLA Medical Center, Los Angeles, CA; Nursing Executive Center interviews and analysis.

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Getting to Know Patients Through Posters (cont.)

Case in Brief: Ronald Reagan UCLA Medical Center • 520-bed academic medical center located in Los Angeles, California • Frontline nurse introduced “Getting to Know You” posters on ICU in October 2008 as part of Advisory Board Talent Development’s “Frontline Impact” program; currently in place on three units

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• Posters distributed to all patients, families at admission; completed posters kept in Plexiglas frames at patient bedside, travel with patient across inpatient stay

For full-sized version of UCLA’s “‘Getting to Know You’ Poster,” see NEC website

Source: Ronald Reagan UCLA Medical Center, Los Angeles, CA; Nursing Executive Center interviews and analysis.

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A Straightforward Process

Process for Utilizing “Getting to Know You” Posters at UCLA

Patient, families complete poster with patient’s personal information

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Caregiver introduces poster to patient, family at admission

1) Pseudonym.

Caregivers use information on poster to initiate conversation with patient

Poster displayed in location easily visible to caregivers entering patient room

Poster travels with patient through transfers across inpatient stay

Source: Ronald Reagan UCLA Medical Center, Los Angeles, CA; Nursing Executive Center interviews and analysis.

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Realizing Returns From Patient Posters at UCLA Percentage of Patients With Completed “Getting to Know You” Posters on ICU1

Percentile Ranking for Patient Confidence and Trust in ICU Nurses

95%

99 84

75%

19

29%

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Nov 2009

Mar 2010

Q4 2008

Oct 2011

Q3 2009

Q3 2011

A Recognized Leader in the Industry

93

M

Percentile for overall patient satisfaction scores

Magnet-Recognized Hospital

1) As measured by monthly audits conducted by Unit Practice Council. 2) Awarded by Advisory Board Talent Development.

Winner of “Future of Nursing Leadership” Award2

Source: Ronald Reagan UCLA Medical Center, Los Angeles, CA; Nursing Executive Center interviews and analysis.

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Practice Example:Inter-Assignment Rounding

Facilitating Just-in-Time Peer Follow-Up Nurses at Banner Good Samaritan Round on Peers’ Patients Inter-Assignment Rounding Steps 1 Select Five Patients

2 Speak With Patients

3 Follow Up with Peer

4 Balance Workload To Do

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One day each week, nurses select five patients to round on outside assignment; nurses select patients whose clinical situation falls into expertise

Nurses ask patients specific questions about their satisfaction; patients often more candid about their experience than with assigned nurse

Rounding nurse follows up with assigned nurse immediately afterward; discusses patient impressions of care, any identified needs

Nurses balance own priorities, perform inter-assignment rounding during 10 to 15 minute intervals across shift

Case in Brief: Banner Good Samaritan Medical Center • 662-bed teaching hospital located in Phoenix, Arizona; flagship facility of Banner Health, Magnetrecognized • Inter-assignment rounding began in 2008; nurses round on patients outside assignment to assess overall patient experience, follow up with assigned nurse • Rounds not limited to bedside nurses; auxiliary staff, charge nurses participate using same Source: Banner Good Samaritan Medical Center, Phoenix, AZ; Nursing Executive Center interviews framework and analysis.

Practice Example: Inter-assignment Rounding

Eliciting an Honest Patient Perspective Ensuring Efficiency With Three Targeted Questions Targeted Rounding Questions

1. Are we exceeding your expectations regarding your stay with us? 2. Do you know who to contact if you have questions, concerns, or compliments?

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3. Is there anything else I can do for you right now (to make you more comfortable)?

Source: Banner Good Samaritan Medical Center, Phoenix, AZ; Nursing Executive Center interviews and analysis.

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Practice Example: Inter-assignment Rounding

Equipping Staff With a Tool for Feedback

Three patient questions displayed at top for easy reference

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Space to capture details of patient feedback; serves as roadmap for follow-up with assigned nurse

Source: Banner Good Samaritan Medical Center, Phoenix, AZ; Nursing Executive Center interviews and analysis.

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Practice Example: Inter-assignment Rounding

Strong Results

Banner Good Samaritan Overall Positive Score1 Percentile

71st

74th

57th

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2008

1 Percentage 9’s and 10’s on patient satisfaction survey.

2009

2010

Source: Banner Good Samaritan Medical Center, Phoenix, AZ; Nursing Executive Center interviews and analysis.

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Practice Priority: Story Telling/Sharing

A Range of Story Dissemination Options

Four Primary Channels for Story Dissemination

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In-Person

Voice Recording

Book

Video

Source: Nursing Executive Center interviews and analysis.

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Practice Example: Off-unit Shadowing

Limited Caregiver Visibility Into Off-Unit Occurrences Nurse Perception of Patient Care and Overall Patient Experience on Goulet Hospital1 Oncology Unit

Nurse Actions

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Patient Experience

1) Pseudonym.

Nurse sends patient to radiology for MRI

Patient waits in hallway for MRI, feels cold, anxious

Nurse receives patient back on unit

Noise and darkness of MRI frightens patient

Laying still on MRI table makes patient feel stiff, sore

Nurse doesn’t acknowledge patient’s discomfort

Patient in pain, in need of emotional reassurance

Source: Nursing Executive Center interviews and analysis.

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Practice Example: Off-Unit Experience Shadowing

Shadowing Patients to Enhance Nurse Line of Sight Five Oncology Shadowing Experiences at Bethesda North

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Capsule Description

Key Benefits

Potential Variations

Radiation Tour: Nurse tours radiation oncology department, meets staff, lays on radiation table

Allows nurses to personally experience discomfort of radiation process; opens up interdepartmental communication

Tour cath lab, EP lab, nuclear medicine suite

Chemo Administration: Nurse administers chemotherapy in outpatient oncology clinic

Solidifies importance of accurate discharge teaching; reinforces concept that patient experience extends beyond inpatient stay

Observe procedure at primary care, other outpatient clinic

Same-Day Surgery Shift: Nurse spends shift starting IVs and helping with admission paperwork in Same-Day Surgery

Ensures nurses can start, place lines; allows nurses to observe how patients are prepared for surgery, what different procedures entail

Nurse shadows anesthesiology team

Skin and Wound Rounds: Nurse shadows wound/ostomy/ incontinence nurse on rounds

Demonstrates human impact of poor wound care; allows nurses to see long-term impact of marking intended ostomy site

Nurse shadows colleague in ICU

Off-Unit Test Shadowing: Nurse shadows patient during off-unit test or procedure

Informs nurses about what to expect when patients return to unit; ensures caregivers can recognize signs of deterioration

N/A

Source: Bethesda North Hospital, Cincinnati, OH; Nursing Executive Center interviews and analysis.

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Shadowing Patients to Enhance Nurse Line of Sight (cont.)

Case in Brief: Bethesda North Hospital • 333-bed hospital located in Cincinnati, Ohio

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• In 1996, began requiring all new oncology nurses to complete oncology orientation within first 18 months on the unit • Oncology orientation includes several off-unit shadowing activities to help nurses understand what patients experience physically and emotionally across stay; goal to better enable nurses to anticipate and address patient needs • Each shadowing session followed by structured debriefing session to discuss the nurse’s clinical performance during the exercise, observations, implications for inpatient nursing

Source: Bethesda North Hospital, Cincinnati, OH; Nursing Executive Center interviews and analysis.

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Structured Debrief Solidifies Lessons Learned Off-Unit Shadowing Debriefing Guide

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Clinical Feedback: 1. How do you think you performed on procedure X? What would you have done differently? 2. Clinically, what did you observe that surprised you? Why? 3. What was the most valuable information you learned about the clinical care/procedures provided outside of the unit? Experience Debrief: 4. What did you learn about the patient’s physical experience of care that surprised you? How will that impact your future practice? 5. What did you learn about the patient’s emotional experience of care that surprised you? How will that impact your future practice? 6. Based on the patient’s physical and emotional experiences of care that you observed, will you do anything differently to better prepare the patient prior to the procedure? Will you do anything differently to meet the patient’s needs after returning to the unit?

For complete version of “Off-Unit Shadowing Debriefing Guide,” see NEC website

Source: Bethesda North Hospital, Cincinnati, OH; Nursing Executive Center interviews and analysis.

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Practice Example: Patient Experience Blueprinting

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Using Experience Blueprinting to Target Improvements

Patient-Centered Care Methodology and Practice Process at UPMC

Simplified Blueprinting Process

1.

Select a care experience to evaluate, defining beginning and end points

1

Select Care Experience

2.

Establish a care experience guiding council

3.

Evaluate the current state of the care experience using shadowing, care flow mapping, patient storytelling, patient surveys

2

Identify Problem Areas

3

Deploy Targeted Improvement Teams

4.

Develop a care experience working group

5.

Create a shared vision of the ideal patient and family care experience

6.

Identify experience improvement projects and project teams

Source: UPMC, Pittsburgh, PA; Nursing Executive Center interviews and analysis.

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Using Experience Blueprinting to Target Improvements (cont.)

Case in Brief: University of Pittsburgh Medical Center (UPMC) • 20+ hospital, 4,500+ bed health system headquartered in Pittsburgh, Pennsylvania; two UPMC hospitals are Magnet-recognized • Patient and Family Centered Care Methodology and Practice, more commonly known as patient experience mapping or blueprinting, introduced in orthopedics department in 2006

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• As of 2011, more than 35 clinical and non-clinical working groups in place across ten hospitals within system

Source: UPMC, Pittsburgh, PA; Nursing Executive Center interviews and analysis.

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Select Care Experience

Breaking Patient Experience Into a Manageable Load

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Options for Mapping the Ambulatory Surgery Patient Experience

Patient Arrival and Parking

Registration

Preparation for Surgery

Procedure

Recovery

Discharge

Post-Surgery Office Visit

Patient Arrival and Parking

Registration

Preparation for Surgery

Procedure

Recovery

Discharge

Post-Surgery Office Visit

Patient Arrival and Parking

Registration

Preparation for Surgery

Procedure

Recovery

Discharge

Post-Surgery Office Visit

Source: UPMC, Pittsburgh, PA; Nursing Executive Center interviews and analysis.

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Identify Problem Areas

Observing the Actual Patient Experience

Sample Process for Shadowing Patients and Families

Shadower Selection

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Individual selected to shadow patient can be hospital employee or volunteer—but should be unfamiliar with care process he/she will shadow to minimize bias

Patient/Family Introduction Shadower introduces himself/herself to patient and family, explains shadowing process, obtains permission to shadow

Observation of Care Experience Shadower observes all aspects of care process, records detailed notes using shadowing template; does not interact with caregivers in the moment to ensure observation of representative experience

Post-Shadowing Debrief Shadower debriefs with rest of care experience team to discuss observations, findings, potential room for improvement

Source: UPMC, Pittsburgh, PA; Nursing Executive Center interviews and analysis.

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Capturing Observations With a Template UPMC Patient and Family Shadowing Template Identifying Information • Date • Project Name/Scenario • Location • Start Time • Finish Time First Impressions: How would you feel as a patient or family member experiencing what you are observing for the very first time?

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Flow Observations: The overall flow of patients, families, and staff. For example, record the time for all events, record who enters and leaves and where they go, how long they are gone, when they come back, what they do, etc. First-hand Observations: Comments made by patients, family members and/or staff that have any relevance to the overall patient experience. Paint the Ideal Experience: What would you do to change this experience and how would you change it to create the ideal patient experience? Conclusion: Summarize your overall impression of what you observed.

Source: UPMC, Pittsburgh, PA; Nursing Executive Center interviews and analysis.

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Surfacing Shortfalls in the Patient Experience Completed Day Surgery Shadowing Template From Riley Children’s

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Laura, RN

For a full-sized example of a completed “Shadowing Template,” see NEC website Source: Riley Hospital for Children at IU Health, Indianapolis, IN; Nursing Executive Center interviews and analysis.

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Using Experience Blueprinting to Target Improvements (cont.)

Case in Brief: University of Pittsburgh Medical Center (UPMC) • 20+ hospital, 4,500+ bed health system headquartered in Pittsburgh, Pennsylvania; two UPMC hospitals are Magnet-recognized • Patient and Family Centered Care Methodology and Practice, more commonly known as patient experience mapping or blueprinting, introduced in orthopedics department in 2006

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• As of 2011, more than 35 clinical and non-clinical working groups in place across ten hospitals within system

Source: UPMC, Pittsburgh, PA; Nursing Executive Center interviews and analysis.

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Practice Priority: Staff involvement in Change

Behavioural Expectations Lacking Clarity Organisation-Wide Ambition Not Made Meaningful for Staff Representative Patient Experience Strategy Statement

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Articulations of mission fail to connect to wardlevel behaviours.

This comprehensive, robust and measureable Patient and Family Experience Strategy will ensure that we achieve our core purpose which is to provide the highest quality patient and family experience with care delivered by competent and compassionate staff, putting the patient at the heart of everything we do.

Vague terms leave room for interpretation.

Source: NHS England Trust Patient Experience Strategy Statement; Global Centre for Nursing Executives interviews and analysis.

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Stretching the Boundaries of Acceptable Behaviour Pressure, Lack of Clarity Allow Standards to Slowly Slip Nurse Views of Acceptable vs. Unacceptable Behaviour

Nurse Executive

Nurse A

Acceptable

Acceptable

Unacceptable

Unacceptable

Pressurised Work Environment

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Nurse B

Acceptable

Unacceptable Behaviour Warranting Disciplinary Action

Optimally PersonCentred Behaviour Nurse perception of acceptable behaviour shifts

Source: Global Centre for Nursing Executives interviews and analysis.

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Practice Example: Staff-Driven Code of Conduct

Drawing a Line in the Sand Guidelines for Supporting Staff in Setting Standards of Behaviour

Ensure Facilitator Credibility

• Facilitator who has existing, or has gained, credibility on ward • Objective, positive individual dedicated to understanding staff perspective

”

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Open Dialogue to Reflect on Practice

Lead Staff in Articulating Commitment

• Structured questions to promote reflection, ask staff what care looks like at best, worst

• Staff agrees upon discrete list of clear behavioural expectations

• “Safe,” “no-blame” environment for staff to share thoughts Reinforcing the Organisational Mission

• Charter signed by all ward staff to solidify commitment

“I think, in some respects, there was some skepticism about what the charter was going to really mean. But it was really part of the process of identifying the behaviours that helped us to reflect. Reflecting on what’s good, what are our ‘always’ behaviours and ‘never’ behaviours; it helps to reinforce what we should be doing.” Service Improvement Project Lead Northumbria Healthcare NHS Foundation Trust Source: Northumbria Healthcare NHS Foundation Trust, Northumberland, UK; Global Centre for Nursing Executives interviews and analysis.

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Drawing a Line in the Sand (cont.)

Case in Brief: Northumbria Healthcare NHS Foundation Trust • 1375-bed acute trust located in Northumberland and North Tyneside, UK • Real-time patient experience measurement revealed suboptimal patient experience scores on rehabilitation ward within community hospital in November 2010

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• Chief Executive identified high-potential leader to direct intervention to transform patient experience on ward in January 2011 • Team agreed upon actionable list of “always” and “never” events for their ward; committing to patient-centred behaviours, April 2011 • Finalist for Patient Experience Network Award in 2011

Source: Northumbria NHS Healthcare Foundation Trust, North Tyneside, UK; Global Centre for Nursing Executives interviews and analysis.

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Codifiying Shared Definition of Appropriate Behaviour Ward-Based Charter Ensures Clear Understanding of Expectations Blyth Community Hospital - Ward 1 Charter

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As an individual working here, I will ALWAYS: • Treat every patient and their families with the same dignity and respect that I would want for myself and my family • When someone is in pain, always express empathy before I ask questions and try to help • When I am using a computer or doing essential paperwork – I will always look at the patient when the patient is talking to me or I am talking to the patient • When a patient complains, I will always express sincere regret that the person is some-how suffering e.g. “I’m really sorry this isn’t what you were expecting” As a team, we will provide best care when we ALWAYS: • Ensure that all staff are informed of the needs of each individual patient on the ward • Ensure that all team members are up to date and involved in issues on the ward

Prominent display in public ward area for staff, patient visibility Identification of specific, actionable behaviours

Encourages individual, collective responsibility

For full-sized copy of Northumbria’s “Ward 1 Charter,” see NEC website

Source: Northumbria Healthcare NHS Foundation Trust, Northumberland, UK; Global Centre for Nursing Executives interviews and analysis.

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Setting Clear Standards Triggers Culture Change Patients Reporting Increase in Satisfaction1 100% of patients reported always being treated with dignity and respect

Average Score Out of 10 on Real-Time Patient Experience Surveys Conducted at Northumbria 10.0

10.0

8.13

9.63 7.24

Respect & Dignity

”

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9.87

Baseline 2010

Good Nurses 11-May

11-Oct

Proud of the Team “All I wanted was to be proud of the team and the care we provide, and now I really am.” Staff Nurse Northumbria Healthcare NHS Foundation Trust

1) Composites of National Inpatient Survey questions.

Source: Northumbria Healthcare NHS Foundation Trust, Northumberland, UK; Global Centre for Nursing Executives interviews and analysis.

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Practice Priority: Involving Patients in the Change Process

Struggling to Optimise Consumer Participation

Progress Towards Optimal Consumer Engagement

Minimum Compliance with Mandate

Operating in True Partnership with Consumers

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Variability in Performance “Stakeholders are increasingly expecting to see more consumer participation with consumer representatives having input into the way problems are discussed and solved. And there’s a continuum…there are some organisations that have only just started that journey, and there are others who have been doing it for 20 years.” Executive Director of Nursing and Midwifery Australian Public Hospital

Source: Global Centre for Nursing Executives interviews and analysis.

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Practice Example: Embedded Patient and Family Advisors

Securing the Right Pool of Patient Advisors University of Washington Medical Center’s Ward-Based Patient Advisory Council Recruitment and Selection Process

Staff member, such as bedside nurse, nominates patient/ family member for ward-based council membership

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Council facilitator sends nominee letter, e-mail outlining program, extending invitation to apply

For University of Washington Medical Center’s recruitment flier, outreach letter, and application forms, see NEC website

If interested in council membership, nominee completes, submits application; coordinator meets with nominee, refers nominee to best-fit council

Two co-leaders of recommended Patient Advisory Council interview applicant over telephone to assess fit and explain time commitment

For additional tools and templates to assist with advisor recruitment and training, access The Patient Experience Toolkit on www.advisory.com

Source: University of Washington Medical Center, Seattle, Washington, US; Global Centre for Nursing Executives interviews and analysis.

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Securing the Right Pool of Advisors (cont.)

Case in Brief: University of Washington Medical Center • 450-bed academic medical centre located in Seattle, Washington • Implemented Patient and Family Advisory Council on three wards in 2003; have subsequently expanded to seven wards • Patients, families may be nominated to serve on ward-based council by staff members, self-select based on recruiting fliers posted around hospital

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• Advisors are asked to make one-year commitment and are expected to attend seven of nine annual meetings • Hospital-wide patient and family steering committee helps to elevate efforts of ward-based councils; patients, families interested in steering committee participation attend information session with three to four other applicants, share hospital experiences; Patient and Family Advisory Council coordinator evaluates candidates on communication, interpersonal skills Source: University of Washington Medical Center, Seattle, Washington, US; Global Centre for Nursing Executives interviews and analysis.

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Preparing Advisors With Formal Orientation Memorial Regional’s Advisory Council Orientation Outline Memorial Healthcare System Orientation for Patients and Families When patients or their family members join an MHS Advisory Council, they receive a thorough orientation not only to the work of the Council, but also to the “culture” of the organisation and the “dos” and “don’ts” of their new role.

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Topics Covered in the General Advisory Council Orientation 1. The vision and goals of Memorial Healthcare System. 2. An overview of the Patient and Family-Centred Care approach to healthcare. 3. The role of the Advisory Councils, and how they assist the organization in achieving Patient and Family Centred Care. 4. How to be an effective Council member. 5. Serving on organisational committees: • Communicating effectively — techniques for getting your message across: o Telling your story so people listen. o How to ask tough questions. o What to do when you don’t agree. o Listening to and learning from others’ viewpoints. o Thinking beyond your own experiences. 6. Advisor Self-Study Guide & Test – required of all volunteers 7. Required documents: HIPAA1 & IT Security Forms, Consent to Photograph

1) US Department of Health “Health Insurance Portability and Accountability Act,” privacy rule.

Orient advisors to overall hospital mission, culture, key elements of new role

Educate advisors on importance of effective communication skills to further council goals

Provide study guide, administer test to ensure comprehension of confidentiality, safety policies

Source: Memorial Regional Hospital, Hollywood, FL; Global Centre for Nursing Executives interviews and analysis.

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Preparing Advisors With Formal Orientation (cont.)

Case in Brief: Memorial Regional Hospital • 684-bed hospital located in Hollywood, Florida; part of Memorial Healthcare System • Hospital-wide Patient and Family Advisory Council implemented in 2005; has 30 active members in addition to six nurse managers who regularly attend • Each hospital committee includes seats for one to two patient advisors, including: performance committee, quality care committee, discharge planning task force, falls team, smoke-free campus task force, bereavement committee

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• HCAHPS1 top-box2score for September 2011 is 92 percent

For a full-sized copy of Memorial Regional’s “Advisory Council Orientation Outline,” see NEC website.

1) Hospital Consumer Assessment of Health Providers and Systems, a government survey for measuring patient satisfaction at hospitals across the United States. 2)Based on rating of “9” or “10” on willingness to recommend domain of HCAHPS survey,

Source: Memorial Regional Hospital, Hollywood, FL; Global Centre for Nursing Executives interviews and analysis.

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Practice Example: Patients select Staff….

Kingston Advisors Making Far-Reaching Contributions

”

Small Sample of Projects Incorporating Patient Experience Advisor Input

Recognising the Value of Patient Input “At least three times a week, somebody’s phoning me saying, we have an educational piece we want to put before the council; we’re starting a new committee and we want an advisor on it. The organisation is really beginning to see that this is the way things are done and they’re a great resource to have on these committees.”

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• Patient and Family-Centred Care definition • Patient and Family-Centred Care language in job postings and description • Discharge summary • Critical incident reporting and disclosure • Support for family in the ED • Patient relations process • Visitor designation • New hire orientations

Patient and Family-Centred Care Lead Kingston General Hospital

Impressive Commitment by Patient Experience Advisors

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> 500

325

Total Patient Experience Advisors active in organisation

Hours worked by patient experience advisors, June 2012

Current opportunities for Advisor involvement

Source: Kingston General Hospital, Kingston, Ontario, Canada; Global Centre for Nursing Executives interviews and analysis.

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Kingston Advisors Making Far-Reaching Contributions (cont.)

Case in Brief: Kingston General Hospital • 430-bed regional hospital located in Kingston, Ontario • Facility serves 500,000 residents in rural Canada. Local hospital to Kingston community, tertiary/referral hospital for complex and specialty inpatient care for the region

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• Leaders sought to incorporate patient experience advisors into organisational decisionmaking, solicited guidance from Medical College of Georgia, US • In February 2010, leaders developed a body of patient experience advisors to inform decision-making at strategic level as part of broader Patient and Family-Centred care initiative • Patient Experience advisory council began with three advisors, grew to 12 from 2010 to date

Source: Kingston General Hospital, Kingston, Ontario, Canada; Global Centre for Nursing Executives interviews and analysis.

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Patient Interviewers Looking for Caring Behaviours Representation Embeds Prioritisation of Person-Centredness in Hiring Valued Role on Interview Panel

Active Involvement in Debrief

Patient/family interviewers share in the questions to ensure active participation

Patient/family interviewers invited to share their impressions of candidates during hiring decisionmaking process

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A Unique Perspective “Health care professionals can become task-focused and lose sight of the human side, the dignity side, and the vulnerability side. That however is foremost in the former patient or family member’s mind. That’s the perspective they’re looking for. Involving the patients and families in their plan of care and recognising that hospitalisation is just one short span in their life continuum.” Nurse Recruitment Advisor Kingston General Hospital Source: Kingston General Hospital, Kingston, Ontario, Canada; Global Centre for Nursing Executives interviews and analysis.

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Structuring the Role of the Patient Interviewer Representative Patient Interviewer Guide

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Patient/family interviewer allocated discrete list of questions to ensure active participation

Scenario aimed at assessing propensity to consider patient and family perspective

Question

Ideal Response

Evaluation

What does Patient & Family Centred Care mean to you? How do you integrate PFCC into your practice?

• • • • •

Patient Advocacy Effective Communication Patient at centre of all we do Patient/family wishes are respected Patient/family involved in decisions

Describe the characteristics a professional nurse should demonstrate.

• • • • •

Values Positive attitude Organisation/person fit Professional/courteous Patience

Tell us about a time when you had a conflict with a patient/family over the plan of care. How did you resolve the conflict?

• Ask about patient’s point of view • Respect patient’s preferences • Respectfully describes different points of view • Recognises the dynamics that factor into different perspectives

Questions directed at understanding nurse values related to patient-centred care

For full-sized versions of Kingston’s patient interviewer guide, see NEC website Source: Kingston General Hospital, Kingston, Ontario, Canada; Global Centre for Nursing Executives interviews and analysis.

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Key Success Factors for Consumer Involvement Lessons from Exemplars

Executive Support

Ward-level Visibility

• Consumer participation driven at the highest levels of leadership

• Consumer presence on wards builds relationships across organisation, reminds staff of the importance of the consumer’s role

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• Ensures meaningful incorporation in decision-making, advocates for consumer representation at executive table

Defined Responsibility

Consumer-driven Agenda

• Representatives given meaningful roles in important hospital processes

• Advisor ideas highly valued, considered before organisation priorities in meetings

• Integration into quality, safety initiatives expands advisor reach into key strategic priorities

• Committee members empowered to lead, determine, and act on their own priorities

Source: Mack, Linda. “Community Advisory Committees: Drivers of Consumer, Carer, and Community Participation in Victoria’s Public Health Services,” J. Ambulatory Care Manage, 2010 Vol. 33, No. 3, pp 1-7. Global Centre for Nursing Executives interviews and analysis.

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” The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.

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George Bernard Shaw

Source: The Quotations Page, available at: http://www. quotationspage.com/quote/2097.html, accessed December 2, 2010.

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