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Karen Cook, RN, BSN Karen.cook@studergroup studergroup

Hardwiring A Culture of Excellence Impacting the Patient Perception of Quality Care. Karen Cook, RN, BSN Karen.cook@studergroup.com www.studergroup.com. Connect to purpose and doing work that makes a difference Integrate improvement efforts in systematic manner

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Karen Cook, RN, BSN Karen.cook@studergroup studergroup

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  1. Hardwiring A Culture of Excellence Impacting the Patient Perception of Quality Care Karen Cook, RN, BSNKaren.cook@studergroup.comwww.studergroup.com

  2. Connect to purpose and doing work that makes a difference Integrate improvement efforts in systematic manner Implement an OBJECTIVE, accountability system Train their leaders to be successful in a culture of top performance Focus on key behaviors that have measurable impact Re-recruit the high and middle performers and address low performers Standardize best practices across the organization Ensure leadership commitment is aligned to create a culture of execution Studer Group Studies What High-Performing Organizations Do Well • Organizational Change Process in High Performing Organizations: In-Depth Case Studies with Health Care Facilities - Alliance for Health Care Research, 2005 • Achieving an Exceptional Patient and Family-Centered Experience, IHI, 2011

  3. Execution FrameworkEvidence-Based LeadershipSM Breakthrough Foundation STUDER GROUP®: Objective Evaluation System Leader Development Must Haves® Performance Gap Standardization Accelerators Aligned Goals Aligned Behavior Aligned Process Re-recruit high and middle performers Move low performers up or out • Processes that are consistent and standardized • Process Improvement • PDCA • Lean • Six Sigma • Baldrige Framework Implement an organization-wide staff/leadership evaluation system to hardwire objective accountability (Must Haves®) Create process to assist leaders in developing skills and leadership competencies necessary to attain desired results Agreed upon tactics and behaviors to achieve goals Software

  4. Reliable Processes Require Standardization • Understand the evidence to support the process • Standardize the process infrastructure (the how, what, where, who and when) • Focus on the “why” • Involve the front-line staff in process development (habits and barriers) • Test frequently on a small scale • Reward reliability

  5. Key Strategic Aims to a Healthy SC • Establish highly-reliable systems of care that continuously provide evidence-based, patient-centered care in a safe and efficient environment. • Effectively improve the health status and outcomes of our state’s population while reducing the major areas of health disparity. • Ensure access for every patient to well coordinated care across all care settings and all stages of life, including compassionate care at the end of life. • Develop and implement reimbursement models and performance incentives that effectively align with and actively promote innovations and specific improvement efforts under other the strategic aims. Thornton Kirby, South Carolina Hospital Association, Jan, 2012

  6. http://www.studergroup.com/CCME2012 Carolinas Center for Medical Excellence

  7. Culture and Barriers Five Key Strategies Why Are We Here Today? What it is: An update on HCAHPS and overview of recommended strategies to improve the patient perception of care. HCAHPS and Value-Based Purchasing 60 min 30 min What it is NOT: Smile School 60 min

  8. What Is Important To CEO’s? Constant for years 2011 Moves up and down January 24, 2011; American College of Healthcare Executives Announces Top Issues Confronting Hospitals: 2010; 542 Hospital CEOs

  9. Patient Perspective of Clinical Quality Their perception of your performance is a reportable and tangible reflection of your reputation • Communication with doctors • Communication with nurses • Responsiveness of hospital staff • Pain management • Communication about medicines • Discharge information • Cleanliness of hospital environment • Quietness of hospital environment • Overall rating of hospital • Willingness to recommend the hospital

  10. Studer Group Partners Outperform the Nation across HCAHPS Composites 2Q10-1Q11 percentile points higher Source: The graph above shows a comparison of the average percentile rank for Studer Group Partners that have received EBL coaching since Oct 2008 and non-partners for each composite; updated 2.21.12 using 2Q10-1Q11 CMS data.

  11. 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. HCAHPS – Hospital Consumer Assessment of Healthcare Providers and Systems What is HCAHPS Why is it important? How will it be used? Articulation demands simplicity!

  12. http://www.medicare.gov/quality-care-finder

  13. Family – Respected Part of Care TeamNever Visitors (Leape, et al, 2009) • “The memo clarifies that hospitalized patients have the right to determine who can visit them, participate in their care plan, and make decisions for them in medical emergencies.” (Obama, April, 2010 memo to Sec Health) • As well as changing the language typically used in “visiting” polices, it is equally important to revise the rules and practices that limit the times and places families and other “partners in care” are able to provide support. For a number of years, The Joint Commission recommended that patients bring a family member or trusted friend with them to the hospital as a safety strategy (McGreevey, 2006).

  14. Retained Staff is Correlated with Lower LOS and Lower Mortality Rates

  15. Figure 11 Percent of AMI Patients Surviving To One Year Post Discharge Stratified by Level of Patient-Centered Care (PCC) 0.997 1 0.989 0.987 0.981 0.997 0.992 0.98 0.970 0.962 0.978 0.960 0.954 0.951 0.96 0.949 0.946 0.957 0.938 0.94 0.944 0.930 0.92 Percent of Patients Surviving 0.9 0.906 0.903 Low PCC (n=372) High PCC (n=371) 0.895 0.890 0.88 0.879 0.871 0.86 0.84 Level of PCC was defined using the composite average of Picker dimension scale scores (see Fig. 8.1). Low PCC = bottom fifth of the distribution (scores <=56.85); high PCC = top fifth of the distribution (scores >=97.14). 0.82 0.8 1 2 3 4 5 6 7 8 9 10 11 12 Months After Discharge Patient-Centered Care and Mortality A different source: Glickman SW et al, Patient Satisfaction and Its Relationship with Clinical Quality and Inpatient Mortality in Acute Myocardial Infarction, Circa Cardiovasc Qual Outcomes 2010;3:188-195.

  16. Clear Connection between Patient-Centered Care and Clinical Quality Outcomes 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.

  17. 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 2.6% Acute MI 3.1% Heart Failure 2.3% Pneum-onia Source: The American Journal of Managed Care; Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days; 2011; Vol. 17(1)

  18. New HCAHPS Questions (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. Source: 2013 IPPS Proposed Rule, exp finalization 8/12 http://www.caretransitions.org

  19. New HCAHPS Questions (Jan 1, 2013 Discharges) • Demographic Items in the “About You” section • During this hospital stay, were you admitted to this hospital through the Emergency Room? (Yes/No) • 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. Source: 2013 IPPS Proposed Rule, exp finalization 8/12 http://www.caretransitions.org

  20. Patient Experience of Care Domain (HCAHPS) Note: Implementation FY 2014 Source: OPPS VBP Final rule 11.1.11

  21. 2013 and 2014Process of Care Measures Green= increasedthreshold from 2013 Red= decreased threshold from 2013 NEW

  22. Patients’ Perception of Care = QualityVascular Catheter-Association Infection

  23. Another word for Pay-for-Performance, this is a program intended to transform healthcare by fostering a joint clinical and financial accountability system. This new payment system will change CMS from a “passive payer” of services into an “active purchaser” of high quality, affordable, safe healthcare. Hospitals will be reimbursed based on their performance, not just reporting of quality metrics, including the patient perception of quality. If you perform “better” – you’ll be paid more Better = patient-centered, efficient, quality care Overview - Value-Based Purchasing (VBP) What is VBP? Why is it important? How will it be used? • Source: “Report to Congress: Plan to Implement a Medicare Hospital Value-Based Purchasing Program” ,CMS, Nov. 27, 2007

  24. Value Based Purchasing FY 2014 Core Measures(45% Weight) Performance attainment and improvement will determine total hospital reimbursement 1.25% Base operating DRG payments HCAHPS Composites(30% Weight) Outcomes(25% Weight) Note: Implementation FY 2014 Source: OPPS VBP Final rule 11.1.11

  25. New 2014 update 2014 Outcome Measures Note: Implementation FY 2014 Source: OPPS VBP Final rule 11.1.11

  26. VBP Linear Exchange Function - Example • Higher total performance scores = higher incentive • Slope adjusted to achieve goal of budget neutrality

  27. http://healthreform.kff.org/timeline.aspx Example: Roper St. Francis Healthcare 2013 Preventable Readmission $$ at risk = $972,000 1.25% 2% 3% 1. 75% 1% 1% 1. 5% 3% 2% 3%

  28. Culture and Barriers Five Key Strategies Why Are We Here Today? What it is: An update on HCAHPS and overview of recommended strategies to improve the patient perception of care. HCAHPS and Value-Based Purchasing 60 min 30 min What it is NOT: Smile School 60 min

  29. Typical Verbatim Comments . . . Why did it take 2 maintenance guys 2 hours to fix the light in the other bed. There was dust flying in a surgical patient room. Doctors and nurses ignore each other. I asked for fresh linens and the housekeeper acted angry. I was afraid to ask to her to clean off the sticky bedside table. They asked me for money while I was sick in ICU and treated me like I was asking for free care. I have insurance. I had to have my husband call from home to tell 9th floor I had been waiting on potty chair for 25 min and the person that answered the phone was rude about it. Very poor attitude – radiology tech kicked door closed and I heard her complaining that I wasn’t scheduled for today.

  30. What Is A Moment of Truth? • Moments of Truth are events, observations, and interactions that create impressions. • Moments of Truth create impressions in five areas. MOT MOT MOT MOT MOT MOT

  31. High Impact Suggestion for Improvement # 1 – Elevate Accountability at ALL Levels WHY? We must engage the hearts and minds of all staff to promote effective communication and coordination of care. With a scale of Always, every interaction impacts the patient perception of quality care. • Train all staff to: • Make a connection • Instill confidence • Deliver a consistent experience

  32. Barrier #1: Failure to Deal With Low Performers “Our industry is loaded with compassionate people. This may prevent us from dealing with performance issues. What makes us good at the work of healing holds us back in weeding out problem employees.” “Straight A Leadership”, Quint Studer Advocate Good Samaritan N=113

  33. Coaching Tips: • Determine if the issue is skill or will. Coach for skill. • Show what “right” looks like • Address performance through direct coaching conversations on a consistent and regular basis • Consistently reward and recognize positive behaviors and actions • Low performer = technically sound but lousy team player AND great attitude but inconsistent job functions • Use Behavior Standards as foundation for desired behaviors • Track Employees disciplined for Standards non-compliance • Ensure consistent consequences across all disciplines • Train all staff on their role in a culture of always

  34. Barrier #2: Misaligned Goals and Evaluations

  35. Coaching Tips: • All leaders have accountability for patient experience • Ensure goals are cascaded to all leaders • Weighting is appropriate to drive results • 30% creates sense of urgency • 20% creates focus • 10% keeps on the radar • Do you have a culture of accountability – ALWAYS • How clearly have I communicated my goals to my direct reports? • Can I define the skills, tools my employees need to achieve this? • Is it possible to get a good evaluation and not get good results?

  36. Coaching Tips: • Ensure a process is in place for continual validation and ensuring a consistent level of performance • Real time process for sharing feedback on performance • Track improvement after feedback • Senior leaders must follow the Monthly Meeting model with standardized agenda items to ensure consistency across the organization • Themes from rounding • R/R • Monthly evaluation results and progress on goals • Safety concerns

  37. High Impact Suggestion for Improvement# 2 – Coaching is Caring in A Culture of Safety • You can talk with almost anyone about almost anything when you drive out fear • People feel safe when they think: • You respect them • You care about them • The more you value them, the more they live your values

  38. “Coach Ryan” and “Good Catch” Tanner • Describe the Behavior • When I see you sitting on your sister… • Explain the Impact (why) • She is small and you are big - you might squish her • State the change needed • I need you to sit beside her but not on top of her so she is safe

  39. Barrier #4: We Don’t Speak Up in Healthcare • 62% of nurses see coworkers taking shortcuts that may endanger care • 48% of providers believe coworkers show poor clinical judgment at times • 10% of nurses, physicians, and other clinicians directly confront colleagues about performance concerns. Silence Kills: The Seven Crucial Conversations for Healthcare, 2005, AACN and VitalSmarts. A national study of 1700 healthcare workers.

  40. Coaching = Teamwork • Dr. Jones - When I see that you didn’t wash your hands when you came out of that patient’s room • The result is that it is unsafe for you, for our other patients and can lead to higher infection rates • I need for you to be sure to wash your hands when you go in and come out of the patient’s room

  41. What Are Barriers to Effective Communication? • Don’t send the mail to the right address • Letting too much time go by • Ignoring problems, and hoping they will go away • Giving a softened form of correction • Giving general vs. specific feedback • Not getting the facts before deciding action • Not indicating the consequences • Not acting on stated consequences

  42. Barrier #5: We Don’t Deal With Disruptive Behaviors • Staff who have witnessed disruptive behavior:  80% • As a result of disruptive incident, they were stressed or intimidated or lost ability to concentrate leading to gaps in communication:  90% • Staff who saw a direct linkage between disruptive behavior and a compromise in quality and patient safety:  70% • Sentinel events caused by communication: 70%

  43. Coaching = Teamwork • Dr. Cook - When I hear that you yelled at the night nurse that called you about the patient’s blood pressure last night • The result is the nurses are afraid to call you in the night and this could be unsafe for our patients • I need for you to help me understand what happened as this doesn’t seem consistent who I know you to be…

  44. Hospital Profile: 400-bed hospital 18% RN Turnover 6-12% leave due to DB 1.8 = average number of nurses who leave as a result of disruptive incident Impact: Cost to recruit one nurse = $60,0000 - $100,000 Average cost per year associated with recruitment of 1.8 nurses = $153,000 50% of Staff THINK About Leaving6-12% Actually Do Amer Jour Nursing. 2002; 102 (6) 26-34. Jt Comm J Qual Pat Safety. 2008; 34 (8) 464-471

  45. In Summary: Build a Culture of Excellence and Safety • Elevate accountability at all levels • Educate on “why” and deal with low performers • Align goals and evaluations • Develop process to validate and standardize • Coaching is caring in a culture of safety • Focus on the “why” to encourage people to speak up • Be fair and consistent with disruptive behaviors

  46. Culture and Barriers Five Key Strategies Why Are We Here Today? What it is: An update on HCAHPS and overview of recommended strategies to improve the patient perception of care. HCAHPS and Value-Based Purchasing 60 min 30 min What it is NOT: Smile School 60 min

  47. Five Key Strategies # 1– Use Key Words at Key Times WHY? Key words reflect a communication style that improves the quality of information provided by every person in every interaction. This makes care safer, patients less anxious and informed about their care. • Identify key times (defining moments that occur during times of vulnerability that create memorable experiences (positive or negative) • Train and validate all employees on “why” it is critical to build trust, make a connection and instill confidence

  48. Communicating with Empathy The researchers identified 384 "empathic opportunities," but found physicians responded with empathy to only 39 of them. Archives of Internal Medicine, Sept, 2008.

  49. Make A Connection – Keep Informed “…patients and doctors are more likely to base their choice of hospital on non-clinical aspects of a visit – like communication.” “Being Kept Informed” was the MOST important characteristic when “returning to a hospital for future visits.” 2007 McKinsey Survey of >2,000 patients with commercial insurance or Medicaid

  50. Make The Connection - AIDET Focus on the “A & I” to show courtesy and respect and reduce anxiety A Acknowledge I Introduce D Duration Focus on the “ D & E” to educate on treatment/process and to increase compliance E Explanation T Thank You

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