Connecting Care and Quality in Nursing

Connecting Care and Quality

in Nursing

Lyn Ketelsen, RN, MBAJune 7, 2013

Copyright © Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization.

2010 2011 2012 2013 2014 2015 2016 2017 2018

REPORTING HOSPITAL QUALITY DATA FOR ANNUAL PAYMENT UPDATE

VALUE-BASED PURCHASING

READMISSIONS

2% of APU

2%

3%

CMS quality-based payment initiatives will put more than 11% of payment at risk

HOSPITAL-ACQUIRED CONDITIONS 1%

MEANINGFUL USE 5%

1% 1.25% 1.5% 1.75% 2%

1% 2% 3% 3% 3%

1% 2% 3% 4% 5%

Value-Based Purchasing Roadmap


Never Events: Financial ImpactCondition $ / Stay

Stage III & IV Pressure Ulcers $43,180

Falls & Trauma $33,894

Deep Vein Thrombosis/Pulmonary Embolism $50,937

Vascular Catheter-Associated Infection $103,027

Certain Manifestations of Poor Control of Blood Sugar Levels Range: $35k-45,989

Catheter-Associated Urinary Tract Infections $44,043

Foreign Object Retained After Surgery $63,631

Surgical Site Infections Following Certain Elective Procedures Range: $63k-180,142

Infection after Coronary Artery Bypass Graft $299,237

Air Embolism $71,636

Blood Incompatibility $50,455

Source: CMS Fact Sheet, “CMS PROPOSES ADDITIONS TO LIST OF HOSPITAL-ACQUIRED CONDITIONS FOR FISCAL YEAR 2009”


Patients’ Perception of Care = QualityPressure Ulcer Stages III and IV


Patients’ Perception of Care = QualityVascular Catheter-Association Infection


Patients’ Perception of Care = QualityManifestations of Poor Glycemic Control


High Patient Perception of Care Equals Lower Preventable Readmissions

1/5 of Medicare Beneficiaries are readmitted within 30 days with an

annual cost of $17.4 Billion

Source: The American Journal of Managed Care; Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days; 2011; Vol. 17(1)

2.3%Pneum-

onia

3.1%Heart

Failure

2.6%Acute

MI


Figure 11Percent of AMI Patients Surviving To One Year Post Discharge

Stratified by Level of Patient-Centered Care (PCC)

0.992

0.978

0.957

0.944

0.930

0.906 0.9030.895

0.8900.879

0.871

0.989 0.9870.981

0.9700.962 0.960

0.954 0.951 0.949 0.9460.938

0.997

0.997

0.8

0.82

0.84

0.86

0.88

0.9

0.92

0.94

0.96

0.98

1

1 2 3 4 5 6 7 8 9 10 11 12Months After Discharge

Perc

ent o

f Pat

ient

s Su

rviv

ing

Low PCC (n=372) High PCC (n=371)

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).

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.


Leader Rounding on Patients

Rounding for Outcomes

Performance Management

Aligned Behavior

Standardization Accelerators

Aligned ProcessAligned Goals

Objective Evaluation

System

Leader Development

Must Haves®

Aligning Leader Evaluations with Desired Outcomes

Rounding for Outcomes

Employee Thank You NotesEmployee Selection and the First 90 DaysPre and Post Phone Calls

Key Words at Key Times


Driving Performance


Rounding on PatientsWhy?

Foundational tactic that drives results

Reconnects leaders to patient care

Provides best opportunity for “eyes on the field” “boots on the ground” leadership

Builds leadership assessment skills just like we built nursing assessment skills


Leader Rounding on Patients“Did a Nurse Manager Visit You During Your Stay?”

Source: Arizona Hospital, Total beds = 355, Employees = 4,000, Admissions = 10,188; updated 2Q2010

n= 608

n= 106

n= 604n= 561

n= 601

n= 104

n= 96

n= 105

Tactic and Tool Implemented:• Leader Rounding on Patient


Four Goals

Create Empathetic Connection with PatientsService Recovery (if needed)Harvest Compliments and Manage UpAssess Quality of Care


Rounding with Patients and Families

Align Questions to Fit Desired Outcomes of the Organization

Set expectations/Validate Behavior

Identify patient and family needs

Document needs

Give instructions on what to do if they do not get the care they expect

Explain any post stay/visit calls or surveys

Recognize and Coach Staff


Two Key Questions

What have you learned about care being delivered?What MUST you do with that information?


Verification:

Patient Rounding LogPriorities

Staff and Physicians to Recognize

Issues for follow-up

Notes and comments


This is a test

The ability of nurse leaders to hardwire nurse leader rounding on patients directly correlates with their ability to lead the hardwiring of practices they

will be asking of their staff…


Validation

A robust system of validation must be in place to ensure frequency, quality and outcomes are achieved


If you are not getting value or results

Are you asking the right questions during rounds? Are you using what you learned from rounding to make improvements?Are you doing enough of it?Round on one nurses assignments and then give him/her feedback, then repeat. The learning based on this ability to compare will be very beneficial

Every Patient, Every day…Always

Hourly Rounding®

Lyn Ketelsen, RN, MBAStuder Group Coach

Copyright © Studer Group. Please do not quote, cite, or disseminate without Studer Group authorization. Reference: Studer Group Patient Care Model

Bedside Shift Report1. AIDET® introduction2. Communication of current state and plan of

care3. Teach back reinforcement of important

patient care information such as drug side effects

Individualized Patient Care

1. Ask what 2-3 things will ensure excellent care2. Write on board3. Used by all members of the care team4. Ask each shift to reinforce listening

Post visit calls1. Questions designed to assess patients progress at home2. Listening with more than your ears

Hourly Rounding® 1. Use opening Key words: Round2. Perform scheduled tasks3. Perform 3P’s4. Additional Comfort measures5. Environmental assessment of room6. Closing Key words7. Tell when you will return8. Log the round

Nursing and Patient Care Excellence

Hardwire the full scope of the Patient Care Model


Hourly Rounding ℠


The Why

Hourly Rounding on patients is one of ten (10) new ways hospitals can ‘see’ differently. “Hourly Rounding, developed by Studer Group, the largest study ever focused on the impact of rounding. Hourly Rounding ‘restores sanity and joy to our workforce.’”

» Maureen Bisognano, COO of IHI, 2007


Behaviors of Hourly Rounds: The P’s Aren’t Enough

HOURLY ROUNDING BEHAVIOR EXPECTED RESULTS

1 Use Opening Key words Creates efficiency“checkin’ on ya” won’t suffice

2 Accomplish scheduled tasks Contributes to efficiency

3 Address 3 P’s (pain, potty, position) Quality indicators – falls, decubitis, pain management

4 Address additional comfort needs Improved patient satisfaction on pain, concern and caring, efficiency

5 Conduct environmental assessment and ensure bed technology is correctly utilized Contributes to efficiency, teamwork

6 Ask “Is there anything else I can do for you before I go? I have time.”

“Call me if you need me” decreases efficiency and improves patient satisfaction on teamwork and communication

7 Tell each patient when you will be back Contributes to efficiency

8 Document the round Quality and accountability

8


Ancillary and Support Departments

Everyone can be trained to do the environmental assessment of the room


THE LOGS…The Promise

Please place your initials in the corresponding time box after round has been complete. **Round is only complete if all 8 Key Behaviors have been done.**

6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:0022:00-23:00

1:00-2:00

3:00-4:00

5:00-6:00

MM/DD/YY

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Eight Key Behaviors: Key:1) Use opening key words S= Patient Sleeping

2) Perform scheduled tasks R = Patient in Radiology

3) Address the 5 P's-Pain, Potty, Position, Possesion, Plan of Care E = Room Empty4) Assess additional comfort needs OR = Patient in Surgery5) Conduct environmental assessment P = Procedure in Process

6) Use closing key words and/or actions CT = Patient in C.T. Department

7) Explain when you or others will return PT = Phyisical Therapy

8) Document the round on the log

Initials: Signature: Initials: Signature: Initials: Signature: Initials: Signature:

Rounding Log


Use of Communication Boards…the promise


Cost Avoidances – Falls

99

70

0

50

100

1

Actual Falls Incidents

1st-3rd qtr average 4th qtr

Estimated Cost Avoidance =

$367,064

Source: Tennessee Organization, Admissions: 15,598, Bed size: 304, >1400 employees, Employees=1441

Tactic and Tool Implemented:

Hourly Rounding


Cost Avoidances – Decubitus

120

10897

50

70

90

110

130

1

Actual Decubitus Incidents

2005 2006 2007

Tactic and Tool Implemented:

Hourly Rounding

Estimated Cost Avoidance =

$330,658

Source: Tennessee Organization, Admissions: 15,598, Bed size: 304, >1400 employees, Employees=1441


TipsMust have a buddy system formalizedCan’t be delegated outside of the staff within the matrix but needs to include all staff in the matrix.Let’s talk about pain, communication, medication, clean and quiet.Behaviors matter

Active ListeningEye contactTone of voiceAppropriate speed of speechAppropriate use of touchNot multi-taskingAppropriate use of humor/emotionPhysical positioning – sitting, kneeling, etc.Energy mirrors the needs of the patient


Robots?!?

Being Robotic is a function of the messenger – Not the message!


Jazzercise vs. Rockettes


Phases of Competency and Change

Even with positive change, there is resistance . . .


Rounding Queen

This is hardTakes longer than you thinkTry to make it fun

http://www.youtube.com/watch?v=ovNWV1D4X0c

http://www.youtube.com/watch?v=ovNWV1D4X0c

Thank You!

Lyn Ketelsen RN, [email protected] www.studergroup.com

mailto:[email protected]

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Connecting Care and Quality in Nursing