Connecting Care and Quality In Nursing

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Connecting Care
and Quality
in Nursing
Lyn Ketelsen, RN, MBA
June 7, 2013
Value-Based Purchasing Roadmap
CMS quality-based payment initiatives will put more than 11% of payment at risk
2010
2011
2012
2013
2014
2015
2016
2017
REPORTING HOSPITAL QUALITY DATA FOR ANNUAL PAYMENT UPDATE
2% of APU
2%
VALUE-BASED PURCHASING
1%
1.25%
1.5%
1.75%
2%
READMISSIONS
1%
2%
3%
1%
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2018
3%
3%
3%
HOSPITAL-ACQUIRED CONDITIONS
1%
MEANINGFUL USE
5%
2%
3%
4%
5%
Never Events: Financial Impact
Condition
$ / 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
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Source: CMS Fact Sheet, “CMS PROPOSES ADDITIONS TO LIST OF HOSPITALACQUIRED CONDITIONS FOR FISCAL YEAR 2009”
Patients’ Perception of Care = Quality
Pressure Ulcer Stages III and IV
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Patients’ Perception of Care = Quality
Vascular Catheter-Association Infection
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Patients’ Perception of Care = Quality
Manifestations of Poor Glycemic Control
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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%
Pneumonia
Source: The American Journal of Managed Care; Relationship Between Patient Satisfaction
With Inpatient Care and Hospital Readmission Within 30 Days; 2011; Vol. 17(1)
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Patient-Centered Care and Mortality
Figure 11
Percent of AMI Patients Surviving To One Year Post Discharge
Stratified by Level of Patient-Centered Care (PCC)
1
0.997
0.989
0.997
0.98
0.987
0.981
0.992
0.970
0.962
0.978
0.960
Percent of Patients Surviving
0.96
0.954
0.951
0.949
0.946
0.957
0.94
0.938
0.944
0.930
0.92
0.9
Low PCC (n=372)
High PCC (n=371)
0.906
0.903
0.895
0.88
0.890
0.879
0.871
0.86
0.84
0.82
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).
0.8
1
2
3
4
5
6
7
Months After Discharge
8
9
10
11
12
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.
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Rounding for Outcomes
Leader Rounding
on Patients
Aligning Leader Evaluations
with Desired Outcomes
Rounding for Outcomes
Employee Thank You Notes
Employee Selection and the
First 90 Days
Pre and Post Phone Calls
Key Words at Key Times
Objective
Evaluation
System
Leader
Development
Aligned Goals
Must
Haves®
Performance
Management
Aligned Behavior
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Standardization Accelerators
Aligned Process
Driving Performance
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Rounding on Patients
Why?
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
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Leader Rounding on Patients
“Did a Nurse Manager Visit You During Your Stay?”
n= 561
n= 604
n= 601
n= 608
Tactic and Tool Implemented:
• Leader Rounding on Patient
n= 106
n= 104
n= 105
n= 96
Source: Arizona Hospital, Total beds = 355, Employees = 4,000, Admissions = 10,188; updated 2Q2010
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Four Goals
Create Empathetic Connection with Patients
Service Recovery (if needed)
Harvest Compliments and Manage Up
Assess Quality of Care
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Rounding with Patients and Families
Set expectations/Validate Behavior
Identify patient and family needs
Align Questions Document needs
to Fit Desired
Outcomes of the Give instructions on what to do if
they do not get the care they expect
Organization
Explain any post stay/visit calls or
surveys
Recognize and Coach Staff
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Two Key Questions
What have you learned about care being delivered?
What MUST you do with that information?
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Verification:
Patient Rounding
Log
Priorities
Staff and Physicians
to Recognize
Issues for follow-up
Notes and
comments
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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…
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Validation
A robust system of
validation must be in
place to ensure
frequency, quality
and outcomes are
achieved
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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
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Hourly Rounding®
Lyn Ketelsen, RN, MBA
Studer Group Coach
Hardwire the full scope of the Patient Care
Model
Hourly Rounding®
1.
2.
3.
4.
5.
6.
7.
8.
Use opening Key words: Round
Perform scheduled tasks
Perform 3P’s
Additional Comfort measures
Environmental assessment of room
Closing Key words
Tell when you will return
Log the round
Nursing and
Patient Care
Excellence
Individualized Patient
Care
1.
2.
3.
4.
Ask what 2-3 things will ensure excellent care
Write on board
Used by all members of the care team
Ask each shift to reinforce listening
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Bedside Shift Report
1. AIDET® introduction
2. Communication of current state and plan of
care
3. Teach back reinforcement of important
patient care information such as drug side
effects
Post visit calls
1. Questions designed to assess patients
progress at home
2. Listening with more than your ears
Reference: Studer Group Patient Care Model
Hourly Rounding℠
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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
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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)
4
Address additional comfort needs
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
Document the round
Quality and accountability
8
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Quality indicators – falls, decubitis,
pain management
Improved patient satisfaction on pain,
concern and caring, efficiency
Ancillary and Support Departments
Everyone can be trained to do the environmental
assessment of the room
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THE LOGS…The Promise
Rounding Log
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
22:0020:00 21:00 23:00
MM/DD/YY
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Eight Key Behaviors:
1) Use opening key words
2) Perform scheduled tasks
3) Address the 5 P's-Pain, Potty, Position, Possesion, Plan of Care
4) Assess additional comfort needs
5) Conduct environmental assessment
6) Use closing key words and/or actions
7) Explain when you or others will return
8) Document the round on the log
Initials:
Signature:
Initials:
Signature:
Key:
S= Patient Sleeping
R = Patient in Radiology
E = Room Empty
OR = Patient in Surgery
P = Procedure in Process
CT = Patient in C.T. Department
PT = Phyisical Therapy
Initials:
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Signature:
Initials:
Signature:
1:002:00
3:004:00
5:006:00
Use of Communication Boards…the promise
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Cost Avoidances – Falls
Estimated Cost
Avoidance =
Actual Falls Incidents
99
$367,064
100
70
50
Tactic and Tool Implemented:
Hourly Rounding
0
1
1st-3rd qtr average
4th qtr
Source: Tennessee Organization, Admissions: 15,598, Bed size: 304, >1400 employees, Employees=1441
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Cost Avoidances – Decubitus
Estimated Cost
Avoidance =
Actual Decubitus Incidents
120
130
$330,658
108
97
110
90
70
Tactic and Tool Implemented:
Hourly Rounding
50
2005
1
2006
2007
Source: Tennessee Organization, Admissions: 15,598, Bed size: 304, >1400 employees, Employees=1441
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Tips
Must have a buddy system formalized
Can’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 Listening
Eye contact
Tone of voice
Appropriate speed of speech
Appropriate use of touch
Not multi-tasking
Appropriate use of humor/emotion
Physical positioning – sitting, kneeling, etc.
Energy mirrors the needs of the patient
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Robots?!?
Being Robotic is a
function of the messenger
– Not the message!
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Jazzercise vs. Rockettes
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Phases of Competency and Change
Even with positive change, there is resistance . . .
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Rounding Queen
This is hard
Takes longer than you think
Try to make it fun
http://www.youtube.com/watch?v=ovNWV1D4X0c
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Thank You!
Lyn Ketelsen RN, MBA
[email protected]
www.studergroup.com
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