Clean and Quiet Environment f

1. Clean and Quiet Environmentf August 14, 2013 Carrie Brady, JD, MA cbradyconsulting@gmail.com Ashka Dave adave@aha.org David Schulke dschulke@aha.org

2. AHRQ/HRET Patient Safety Learning Network (PSLN) Project • This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET). • HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education. • AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

3. The Patient Experience of Care is Fundamental to Clinical Improvement • Understanding the patient experience of care is not an add-on activity: it should be used as a fundamental element in your other improvement efforts. • For those working on the HRET Partnership for Patients Hospital Engagement Network (HEN) or another HEN, your work will benefit directly from your efforts to improve the patient experience of care (e.g., readmissions, ADEs). • Lessons you learn in this HCAHPS Learning Network will help you succeed in the HEN project because— • Patient-centered care is a driver of clinical outcomes • Employee and patient engagement are 2 sides of one coin • HCAHPS assesses key factors in ADEs and readmissions

4. New AHRQ Resource • Guide to Patient and Family Engagement in Hospital Quality and Safety • Provides detailed implementation guides and tools for four strategies: • Working with Patient and Family Advisors • Communicating to Improve Quality • Nurse Bedside Shift Report • IDEAL Discharge Planning http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html

5. HCAHPS Technical Assistance Faculty • Carrie Brady, MA, JD • HRET’s primary HCAHPS faculty • Former senior Connecticut Hospital Association staffer • Previously a vice president at Planetree • Exemplary hospital peers • Community Hospital of Monterey Peninsula, CA

6. HCAHPS Clean and Quiet During this hospital stay: • How often were your room and bathroom kept clean? • How often was the area around your room quiet at night? Source: CMS Summary of HCAHPS Survey Results and HCAHPS Percentiles July 2013 Public Report (October 2011 – September 2012 Discharges) www.hcahpsonline.org Clean • Natl Avg: 73% “Always” • Best performing hospitals in the country (95th percentile) get 86% or more “Always” Quiet • Natl Avg: 60% “Always” • Best performing hospitals in the country (95th percentile) get 78% or more “Always” • Lowest scoring topic

7. Think Broadly About Clean and Quiet • HCAHPS questions ask about: • Cleanliness “during this hospital stay” • Quiet “at night” • Patient perceptions are influenced by: • Cleanliness in outpatient areas • Noise level at other times of day • Consider expanded improvement strategies • Waiting area cleanliness rounding/concierge • Daytime quiet hours • Incorporate clean/quiet in facility design 7

8. Make the Connection Between Quiet and Healing 8

9. Hospital Noises Likely to Awaken Patients Source: Solet J et al., Evidence-Based Design Meets Evidence-Based Medicine: The Sound Sleep Study, The Center for Health Design, 2010. Remember noise has physiological effects on patients and on staff

10. Partner with Patients • Ask patients what noises are keeping them up • Offer to close the door if appropriate • Ask about and preserve patient sleep rituals • e.g., a cup of tea, reading material, snack • Pair patients by sleep habits in non-private rooms • Offer a sleep/relaxation kit • e.g., sleep mask, aromatherapy, door hanger • Consider soothing sounds/white noise • Provide TV headphones 10

11. Partner with Staff • Engage staff to identify and eliminate “noise”: • e.g. overhead paging, equipment “squeaks,” loud maintenance, unnecessary alarms • Use decibel meters creatively • e.g. put one in a bed and have staff members practice entering the patient’s room and performing tasks quietly • Raise awareness of “noise” • Have a staff member sleep on a unit and record what they hear 11

12. Restore Quiet Time • Implement quiet hours • Give patients respite from non-urgent medical interventions or bundle interruptions • Create quiet campaigns with tools to support staff in reducing noise generated by guests • Provide cues to staff, patients, and families • E.g. signs, brochures, dimmed lights, announcement 12

13. Cleanliness and Patient Safety • Environmental services staff are saving lives! • Patient reports of cleanliness are associated with lower rates of nosocomial infections • HCAHPS: Isaac T et al., The Relationship Between Patients’ Perception of Care and Measures of Hospital Quality and Safety, Health Services Research 45:4 (August 2010) • Patient reports (English National Health Service): Research Letter: Associations Between Web-Based Patient Ratings and Objective Measures of Hospital Quality, Arch Int Med 172:5, March 12, 2012.

14. Perceptions of Cleanliness • Routinely change your point of view to match the patient perspective • e.g. ride on gurney, in wheelchair, sit in bed • Sights • e.g. dirt, clutter, areas needing maintenance • observing things being cleaned • Smells, Sounds, Touch (e.g. hand sanitizer) • A Reality Check: the toddler/cell phone test

15. Make Environmental Services Visible • Recognize EVS as key team members • Encourage communication with patients • Consider assignment by unit • Provide patients with ability to directly contact environmental services team • Let patients know service was provided, even if they aren’t there • e.g., white board note, washcloth animals on admission, mints, newspaper, quote of the day, sanitized strips/stickers 15

16. Engage Your Team • Revise job descriptions and related materials • e.g., role is to prevent nosocomial infections • Provide business cards • Professionalize training • Emphasize that cleanliness is the responsibility of all staff • e.g., overflowing trash cans, clutter 16

17. Terril Lowe, RN, Vice President, NursingRaul Lopez, Director, Environmental ServicesPhillip Williams, RN, Director, Comprehensive Cancer Center

18. HCAHPS Run Chart Overall Rating for the Hospital(Q1 2012 – q1 2013)

19. HCAHPS Run Chart Cleanliness of Hospital Environment(Q1 2011 – q1 2013)

20. Room kept clean during stay • Our Strategy: • Reliable Means of Assessing Cleanliness • A Focus on Customer Service • A Process to Ensure Compliance & Accountability

21. Room kept clean during stay Ensuring the patient experiences a clean environment by: A reliable means of assessing cleanliness. Microbial contamination contains ATP (adenosine tri-phosphate), which should be significantly reduced after cleaning. Handheld monitor measures ATP bioluminescence as an indicator of surface cleanliness. We sample 4 rooms/week, 20 high-contact surfaces are sampled.

22. The use of scripting to facilitate use of desired patient-centered behaviors and eliminate variation. Room kept clean during stay Ensuring the patient experiences a clean environment by:

23. Instilling a sense of pride & accountability with the use of business cards. Room kept clean during stay Ensuring the desired behaviors are happening reliably by: Compliance monitoring via director rounding with EVS staff & patients.

24. Monitoring Plan: Daily: EVS Supervisor/Charge person observes sample of 4 Housekeepers interactions with patients. Weekly: Management Team (Director, Supervisor) round on patients. Ask about interactions with Housekeepers, actual cleanliness of room, solicit comments/suggestions.

25. Factors that Contribute to Higher HCAHPS Scores • Access to Care • Wait Times: • ER, seen by MD • For Inpatient Bed • Patient Registration Experience • Parking • Wayfinding • Communication of Services • Outreach • Marketing • Public Education • Cost of Care • Coverage • Pt. Billing Experience • Physician Communication • Courtesy & Respect • Care Coordination • Listening • Explanations Understood • Availability • Trust • Safety Overall Rating of Hospital GeneralCommunication • Nursing Communication • Courtesy & Respect • Listening • Explanations Understood • Response time • Pain Management • Medication Teaching • Trust • Safety • Care Coordination • Patient Discharge • Continuity • Transition • Hospital Environment • Cleanliness • Noise • Safe Environment • Food Quality • Equipment in working order • Comfort (furniture, temp.)

26. Studer, NRC/Picker, Press Ganey & the IHI all agree with our observation that communication as a whole & NURSING COMMUNICATION specifically has the highest correlation with the patient’s overall rating of the hospital.

27. But as Studer research indicates, patients categorize caregivers as either doctors or nurses so essentially all staff members affect the patient experience and ultimate satisfaction.

28. Words that Work • A key factor in improving the patients’ care experience is CONSISTENCY in how we communicate with our patients & we have adopted Baptist Health’s Words-that-Work scripting. • Words that Work are patient-centered communication scripts that are aligned with specific HCAHPS indicators and allows staff to connect with patients on both an emotional and clinical level. • The scripting helps ensure patients receive a consistent message throughout the organization. • It allows us to “narrate our care” to reinforce to our patients that we are providing the care we set as an expectation.

29. Mining the Data When initiating your improvement strategy, it helps to illustrate your target audience (the Usually Respondents). Typically, there aren’t enough of the Sometimes & Never Respondents to make the effort to improve their perception worthwhile. Focus on the Usually Respondents is a far better use of time & resources.

30. Mining the Data Catalyst Background Data by Responses(Age Group)

31. Mining the Data Catalyst Background Data by Responses(Gender)

32. Don’t forget the ER! Remember, HCAHPS are based on the patient’s entire hospital experience.

33. Questions and Discussion

34. HCAHPS Curriculum 2012-13All Web conferences are archived at: http://www.psl-network.org/ • December 7, 2012: Fundamentals of HCAHPS • December 18/19, 2012: Using HCAHPS Data Effectively • January 16, 2013: Nurse Communication • February 13, 2013: Responsiveness • March 13, 2013: Medication Communication • April 24, 2013: Discharge Information • June 5, 2013: Physician Communication and Engagement • July 17, 2013: Pain Management • August 14, 2013: Clean and Quiet