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Exemplary Professional Practice Quality Care Monitoring and Improvement EP35EO: Describe and demonstrate that patient satisfaction data aggregated at the organization or unit level outperform the mean, median or other benchmark statistic of the national database used. Provide analysis and evaluation of data and resultant action plans related to patient satisfaction with nursing The National Research Corporation (NRC Picker) has maintained a strong commitment to improving the quality of healthcare received by patients and consumers through a focus on continual improvement in patient experience and performance measurement within the healthcare industry. It has been the benchmark database chosen by YH to measure patient experience metrics. In 2001, NRC acquired the Picker Institute’s healthcare survey business, a highly regarded family of patient and employee surveys in healthcare quality assessment and improvement. Picker surveys use a technique of asking patients and families to objectively report on care experiences, rather than merely asking for subjective satisfaction ratings. The findings of the Picker research are classified into the Eight Dimensions of Patient-Centered Care. These dimensions are considered the authoritative definition of patient-centered care and the backbone of measurement techniques based upon the patient experience as opposed to just the common term of satisfaction. Most of the questions are on a 4-point Likert Scale. Results are reported as a “positive response” based on the percent of patients providing the highest score possible on the 4-point scale. For example, the highest score possible for most of the questions is “always”.

YH Nursing Staff has outperformed the NRC Picker benchmark mean in 2 out of the 4 questions asked for patient satisfaction at the organizational level as described below. Pain Nurses Helped with my Pain Purpose and Background Patient satisfaction with pain has been an integral component of YH focus of patient satisfaction and ultimately the overall patient experience. YH has been using the Healthcare Consumer Assessment of Healthcare Providers and Services (HCAHPS) survey as a means to submit data for the inpatient population for many years. All patient experience data submitted to HCAHPS has been retrieved from our relationship with vendor NRC Picker. There have been significant performance improvement plans aimed specifically at impacting patient perception of how well their pain is managed. Pharmacy, physicians and nursing have worked collaboratively in committees and groups to move these scores in a positive direction. At the nursing level, the staff has had “Pain” as an indicator that has been tracked not only from the quantitative perspective, but also qualitatively with patient experience metrics. Nurse’s assessment and interventions with pain help to drive the overall pain indicator and scores and therefore it remains a strategic priority for the organization as well as nursing itself. Methods and Approach

The following represents the significant initiatives that have been implemented to improve patient satisfaction related to pain management:

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Purposeful Rounding- one of the main components with nursing purposeful rounding is the assessment of Pain~ the first “P”. SDM Practice Council and the RBC Oversight Committee were asked to integrate Purposeful Rounding into their daily practice in the fall of 2011. The purposeful rounding metrics and interventions were discussed in SE5EO and the house-wide educational program that was completed. Nursing engaged their interdisciplinary partners in the initiative. All units were expected to develop unit based structure and process for hourly rounding. Over the last several months, this topic has been revisited, since many units had still not hard wired this hourly process into their workflow.

Pain Management Team- Dr. Larry Owens, the pharmacy doctoral students and the nursing staff developed a partnership to assist patients with pain medications. The pharmacy team rounds to assess and provide patient education and contracts regarding patient’s management of their pain medications. The Pain Team was the winner of the Innovative and Collaborative Practice Award in 2012 based on the work it had done on 4 Main (EP35EO.1). Some of that work that was accomplished can be seen on this poster.

· Data and Action Plans – As discussed in EP35, the primary means for the nursing staff to

address patient satisfaction metrics is by the review and discussion of results through data which is presented to the units by Chris Foore, Director of Customer Relations. A quarterly email is distributed to the nursing leadership, where they are expected to down load and review the results with their staff. In addition, the NRC Picker site is available on a constant basis to the NM, CD, and VPPCS who have the ability to review data on a daily, weekly, monthly basis for improvements prior to the availability of the final roll up scores for the quarter. This data is always changing, due to the rolling number of

EP35EO.1 Pain Patient Satisfaction Poster with 4Main NM

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responses loaded and collated by NRC Picker staff, however for those units that need to address improvements it provides a snapshot of their data at the point in time it is accessed and can prove useful for the staff.

Center for Nursing Excellence and Innovation (CNEI) - When Chris Foore sends the data to the nursing unit she also forwards it to the CNEI, who then takes the data and uploads it to the ongoing quarters of data graphs we prepare to track our outcomes to meet the performance benchmarks for Magnet Redesignation. Because some of the patient satisfaction metrics we are reviewing for the organization are not part of the sources of evidence for Magnet Redesignation such as cleanliness and quiet initiatives, those slides are not included in this document. The CNEI office prepares division based reports which provide easier roll ups for our clinical directors, who can download their own division report for purposes of having discussions and meetings with their respective NM regarding the results.

White Boards- A majority of our inpatient nursing units have easy erase white boards in the patient rooms where one of the components addressed is patient’s pain status. This provides a consistent mechanism for handoff communication and plan of care adherence relative to the patient’s pain status.

Chronic Pain CET- Since 2009 WSH has identified the need to have a clinical effectiveness team that addresses the needs of chronic pain patients across the system not necessarily just YH. System Coordination of this initiative includes:

o Plan of Care and Patient Handoffs o Environment/Accountabilities

§ Patient Education, Patient Incentives, Customer Service o Outcomes/Sanctions

In addition to the subgroups identified above, each CET has a work plan. While much of the work of the Chronic Pain CET involves out stakeholders outside YH, it remains a significant structure on our overall methods and approach to address patients “pain” beyond just patient satisfaction metrics.

Pain Management –The YH SDM Quality Council tracks the compliance for pain reassessment documentation (EP35EO.3) and has done so for the last several years. Patients will be more satisfied with their pain control if the medications that are given to them by the nurse are reassessed for effectiveness and pain relief. The graphs below demonstrate our successful outperformance of this metric from The Joint Commission related to pain reassessment for the last 18 months consecutively. This information is presented to the nursing staff on a monthly basis at the Quality Council meeting, and is also graphed on the nursing dashboard.

EP35EO.2 CET Chronic Pain work plan

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Who was involved All inpatient nursing staff that provides direct care to patient is involved in the management of the patient satisfaction metric for pain.

Chris Foore MS, CPHQ- Director Customer Relations Paula Coe MSN, RN, NEA-BC, Director, Center for Nursing Excellence and Innovation Stephanie Hess, Performance Improvement Specialist Christie Magsino BSN, RN- Pain Management Team Deborah Yommer BSN, RN Chair Quality Council 2011-2012 Jenna Kahler BSN, RN- Chair SDM Quality Council 2012-present Margaret Winemiller RN, CRN, CCRN- Co-Chair Quality Council 2012-present SDM Quality Council Members

Outcomes and Measurement The average response rate of return of NRC Picker Surveys is only 35-40% of patients who receive patient care across inpatient medical, surgical, step-down and critical care areas which represent this organizational data. YH outperformed the NRC Picker mean/ HCAHPS benchmark for the question YH Overall- Nurses helped Pain, in 3 out of 8 quarters of data. (EP35EO.4) The pie chart below represents the average percentage of patient responses to the question related to “nurses helped with pain”. The pie chart (EP35EO.5)clearly demonstrates that of the vast majority of patients who returned the survey, 73.68% responded that the nurses “always” helped with their pain. In addition 20.76% responded that the nurses “usually” addressed their pain. The chart demonstrates that only 5.56% of patients responded “never” or “sometimes” to the question. In each of the quarters that the nurses did not outperform the benchmark they were within 0.04 – 3.0 points away from achieving it.

EP35EO.3 Pain Reassessment Monitoring per month

EP35EO.4 NRC Picker Organization Level Data

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Education Nurses provided information regarding symptoms to look for Purpose and Background Patient education has been an integral component of YH focus of patient satisfaction and ultimately the overall patient experience. YH has been using the HCAHPS survey as a means to submit data for the inpatient population for many years. All patient experience data submitted to HCAHPS has been retrieved from our relationship with vendor NRC Picker. The question above is an HCAHPS question that specifically addresses how well our nursing staff does at providing information to our patient related to symptom management. Patient education has been a focus of the Joint Commission Provision of Care Standards, Patient Safety Goals as well as Core Measures. Many of these chronic disease management populations our staff cares for, have a significant component of successful discharge teaching as a mean to prevent avoidable re-admissions. The ability to follow this metric assists our Clinical Effectiveness Teams with their metrics associated with appropriateness of care as well as readmission rates. Methods and Approach To meet the overall score for symptoms to look for, the primary strategy to meet this objective was the TEACH BACK strategy. Angie Robinson MS, RN, CCRN, CVRN, Clinical Educator on Tower 2 and the OHICU, had been utilizing this patient education strategy for quite some time in the cardiovascular patient population. Discharge instructions is a core measure for Heart Failure, in which teaching related to symptom management and when to call the physician is just one of several components which must achieve 100% compliance for the discharge instruction measure to be scored as 100%. When all nursing staff needed to improve this metric, Angie shared the following Teach Back education tips at the SDM Practice Council and disseminated this tool to all the nursing units.

EP35EO.5 NRC Picker Question by response; % always

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Teach-back is a way to confirm that you have explained to the patient what they need to know in a manner that the patient understands. Here are the core elements of the YH teach-back methodology.

· Explain tests, instructions and disease processes/symptoms as you have before, but instead of asking if they understand, ask them to “Teach–back”

· Ask learner to repeat back to you, in their own words what they need to know or do · NOT a test of the patient, but of how well you explained a concept. · It is a chance to check for understanding and, if necessary, re-teach the information. · Ask the patient to explain or demonstrate understanding in a way that is not demeaning.

For example: “What will you tell your spouse about your condition?” For example: “I want to make sure I explained everything clearly, please tell me in your own words what you heard me say so I can be sure I did” When asking patients to "teach-back" or "show me", the nursing staff should not blame the patient for poor understanding. For example, phrasing the request as—"Can you show me how you're going to do this when you get home? I want to make sure I did a

good job explaining this to you"—clearly places the onus of learning on the teacher, not just the learner. The teach-back method not only can uncover misunderstanding, but also can reveal the nature of the misunderstanding and thereby allow for corrective, tailored communication before the patient goes home so they can be aware of symptoms to look for in the event of complications post procedure, surgery and in exacerbations of chronic diseases such as heart failure (HF), diabetes (DM) and acute myocardial infarction (AMI) Some sample questions that our GI department developed are as follows:

· What are your activity restrictions? · Please explain to me what important signs or

symptoms should be reported to your physician. · What type of diet should you follow?

To help assist the staff with this important component of patient satisfaction the electronic medical

record was used to integrate the Teach Back methodology into the nurse’s workflow and practice (EP35EO.7) Who was involved All inpatient nursing staff that provides direct care to patient is involved in the management of the patient satisfaction metric related to patients who receive information on symptoms to look for.

Diagram developed by Dean Schillinger, MD Associate Professor of Clinical Medicine University of California, San Francisco ; San Francisco General Hospital

EP35EO.6 Teachback Diagram

EP35EO.7 EMR integrates TEACHBACK

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Chris Foore MS, CPHQ- Director Customer Relations Paula Coe MSN, RN, NEA-BC, Director, Center for Nursing Excellence and Innovation Stephanie Hess, Performance Improvement Specialist Angie Robinson MS, RN, CCRN, CVRN, Clinical Educator Tower 2, OHICU Chris Hess, Patient and Family Education Coordinator SDM Practice Council Members Outcomes and Measurement YH outperformed the NRC Picker mean/ HCAHPS benchmark for the question YH Overall-received information on symptoms to look for in 7 out of 8 quarters of data (EP35EO.8). The pie chart below represents the average percentage of patients responses to the question related to “received information” in a yes or no format. The pie chart (EP35EO.9) clearly demonstrates that of the vast majority of patients who returned the survey, 87.74% responded that nurses provided this education. In addition only 12.26% responded that the nurses did not meet their needs regarding providing education related to symptoms to look for. These were “Yes” and “No” questions, unlike the others which used a Likert scale. In the quarter that the nurses did not outperform the mean, they were only 0.4 points away from achieving the benchmark in all 8 quarters of data. The nursing staff continues to use Teach-back in many areas of patient education. Members of the patient family education advisory team (PFEAT) discuss this strategy often. In fact one of the nurses from Tower 2, was honored by one of her peers and received an education award for using Teach-back so well, she is frequently recognized by patient’s comments on the NRC Picker and RBC Discharge surveys.

EP35EO.8 NRC Picker Outcomes

EP35EO.9 NRC Picker Question by response; % Y or N

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Courtesy and Respect from Nurses RN’s Treated Me with Respect Purpose and Background

Both the American Nurses Association in 1985, and the American Association of Colleges of Nursing in 1986, included respect in their codes for nurses. These efforts indicated that respect is a vital concept for nursing. Nursing researchers in the mid 1990’s provided the first conceptual definition and empirical clarification of respect in nursing. The qualitative studies that were performed reported that there were three components of respect in nursing; 1) respect for the human dignity and uniqueness of a patient, 2) respect for a patient’s autonomy or self determination, and 3) acceptance of a patient’s values even when the nursing and healthcare team disagree in terms of the patient’s lifestyle or treatment choices. As a guiding principle for actions toward others, respect is conveyed through the unconditional acceptance, recognition and acknowledgment of human dignity, worthiness, uniqueness of persons and self-determination and values in all persons. As a primary ethic of nursing, treating patients with respect is one of the core values that YH Nurses have embedded into their professional practice. Methods and Approach One of the main focus areas to address courtesy and respect by the nursing staff is the YH care delivery model in which the nurse functions as the primary coordinator of the patients care. As described in EP35, the SDM Practice Council is primarily responsible for vetting patient satisfaction/ experience results to the direct care staff with the Global Action Plan template. (EP35EO.10) Many of the best practice initiatives that the staff have employed to raise this metric include: hand off communication, bedside shift report, as well as scripting how nurses talk to patients and their families using the GLATS model. Sitting at the bedside for 5 minutes at eye level helps the patient see that nurse is caring and respects the patient’s situation; that s/he is empathetic in making clinical care decisions; and that s/he fosters a relationship with the patient and families which lead to them feel that the staff is courteous.

The following template helps to address the guidelines the nursing staff was provided.

4. Transfer the Trust: Hand-off Rounds and/or Bedside Shift Report

Hand-Off Rounds: At shift change, the departing and on-coming RNs round together to introduce the oncoming nurse, including a statement that “transfers the trust” (for example, “Molly has worked with surgical patients for 20 years; you are in good hands.”) Also include a brief statement explaining that you have provided an update to the oncoming nurse and that she understands that “x” needs to be accomplished and/or is important to you this shift. This would include things like, walking up and down the hall 3 times or getting a shower. Bedside Shift Report is the next level of hand-off rounds. Report occurs at the bedside which gives patients/families the opportunity to ask questions and learn about their plan of care which allows for communication between oncoming and off-going staff. More importantly, it enhances patient safety because the patient/family can sometimes identify

Can be monitored through:

· Leadership interviews;

· RBC discharge surveys;

· NRC Picker, and · Observation by

leadership · Listening/ · Observing

reports by unit based Council

EP35EO.10 RBC Global Action Plan

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incorrect medications, allergies, etc. 5. Improve Patient Safety: Purposeful Rounding

Purposeful Rounding provides a safer environment for patients and decreases patient falls and call bells. It also enhances staff and patient satisfaction. Rounds are focused on the “3 P’s”. Pain, Positioning, Personal needs (Toileting, tissues, fresh water, beside table, phone room tidy, nurse call bell within reach, tray emptied, TV remote) Many hospitals choose to have RNs and LPN/NA alternate rounding responsibility throughout the day.

Every time rounding is completed as well as the purposeful acts that were accomplished are being monitored by RBC Discharge Surveys (Revised October 2011, January 2012) During leadership rounds- leadership assesses that the form is filled in- Leadership rounds can be OOP safety rounds/service rounds and unit/service line rounds. Purposeful Rounding Cards should be used as prompts and reminders to staff of what to include with hourly rounds for patients

In addition to the global action plan template for the staff, nursing leadership made sure that this

metric was outlined in the nursing strategic plan (EP35EO.11) IInniittiiaattiivveess TTaaccttiiccss MMeeaassuurree

((11 yyrr)) MMeeaassuurree ((33 yyrrss))

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YH Professional Nursing Practice Model integrated with RBC (Nursing Care Delivery Model)

Define and measure outcomes of the PPM integrated with nursing care delivery model (RBC)

50% of the units will outperform the mean NRC Picker indicators: Patients Treated with Respect and Courtesy by Nurses

All of the units will outperform the mean in the NRC/Picker and NDNQI RN satisfaction indicators listed in Year 1

All of the units will outperform the mean and 25% will have a star performer in the NRC/Picker and NDNQI RN satisfaction indicators listed in Year 1

SDM PI Council Results Council Practice Council Leadership Council Education Council EBP/Research Consultant

Who was involved All YH nursing staff Relationship Based Care Oversight Committee

EP35EO.11 Patient Sat outlined in YH NSP

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RBC Steering Committee Chris Foore MS, CPHQ- Director Customer Relations Paula Coe MSN, RN, NEA-BC, Director, Center for Nursing Excellence and Innovation Stephanie Hess, Performance Improvement Specialist SDM Practice Council Members Outcomes and Measurement YH outperformed the NRC Picker mean/ HCAHPS benchmark for the question YH Overall- RNs treated me with respect in 3 out of 8 quarters of data. (EP35EO.12) The pie chart below represents the average percentage of patients responses to the question related to “RN’s treated me with respect”. The pie chart (EP35EO.13) clearly demonstrates that for the vast majority of patients who returned the survey, 80.66% responded that the nurses “always” treated them with respect. In addition 16.44% responded that the nurses “usually” treated them with respect. The chart demonstrates that only 2.64% of patients responded “sometimes” and 0.24% responded that the nurses “never” treated them in this manner. In the 4 out of the 5 quarters that the nurses did not outperform the mean, they were within 0.3-1.0 points of achieving the mean.

EP35EO.12 NRC Picker Outcomes

EP35EO.13 NRC Picker Question by response; % always

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The following story (EP35EO.14) was written by one of our Tower 2 Managers Roxie Breighner (Cooley) BSN, RN, CEN, CVRN and clearly depicts the length the nursing staff will go to show our patients and their families courtesy and respect, in their time of need. The story was published in the July 2010 edition of our Nursing Newsletter and Roxie received many positive comments regarding her thoughtful initiative and lasting memory she provided to this patients family. The picture included within the story is the actual picture that was taken that was provided to the patient’s daughter.

Other nurse related survey question HCAHPS- YH Overall Confirmed Identity of Medications Purpose and Background In this litigious society, harm from serious medical events caused by medication errors which are the result of system and process failures, makes this metric an important one for us to track. Medication errors is also a metric that is monitored on our monthly nursing dashboard report. Also a national

EP35EO.14 Tower 2 Grandma’s Hands Story

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Patient Safety Goal, the labeling of medications on sterile fields and prior to giving them to patients, is a key component of YH nurses workflow. There have been many interventions to reduce medication errors over the past 10+ years at YH (two patient identifiers, forcing functions, smart pumps, etc.). To further strengthen this goal and outcomes at YH, one of the strategic priorities for YH nursing staff in 2012-2013, is the go-live of bar coded medication administration (BCMA). As a significant patient safety initiative, this is also a huge time saver for nursing and also reduces the significance of medication errors that reach the patient. Methods and Approach Each month the SDM Quality Council reviews the medication error rate for medications given at YH. One of the resources that is available to provide best practice information in confirming the identity of patients medications is the use of the Institute of Safe Medication Practices (ISMP) Medication Safety publications (EP35EO.15). These are distributed from the Patient Safety Office to our colleagues in Pharmacy who then circulate them to all appropriate stakeholders throughout the YH. The strategies that assist the YH nursing staff in meeting this patient satisfaction metrics are starred below

The Nursing Dashboard Results for Nursing Medication Errors for FY 11 and 12 are found below.

EP35EO.15 ISMP Publication provides support for teaching

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During FY11, the medication error rate decreased from 0.25 errors/1000 doses administered to 0.20 errors/1000 doses. (EP35EO.16) FY 12 results as of the writing of this document reflect a decrease as well. Using our information systems, as well as clinical focus on patient safety and clinical quality, has allowed YH nursing to be purposeful with reviewing and confirming the identification of medications prior to giving them to patients. In doing so, our patients feel cared for in a safe environment which contributes to patient satisfaction and experience scores. When implemented, the BCMA system will require clinicians to use a hand-held scanner or other electronic device connected to a portable computer. Before giving medication to a patient, the clinician will scan the bar-code on the container and match it to the patient identification bar code. If there is a mistake, the computer sends a warning signal to the clinician to stop the procedure. The bar-coding also will provide a "real time" electronic record of when medications were administered. Physicians and other clinicians currently use a paper file to document medication. Despite providing significant declines in medication errors, the BCMA system has been slow to be integrated through health care because of expense. There is extensive work required to repackage and apply barcodes to medications. The repackaging and bar-coding process also will likely require additional pharmacy technician positions, and scanners will need to be purchased for each patient care area. York Hospital is making a large investment in this technology. "Doing what it takes to provide the best patient care possible. Who was involved All YH nursing staff that dispense and give medications to patients Chris Foore MS, CPHQ, Director, Guest Relations Paula Coe MSN, RN, NEA-BC, Director, Center of Nursing Excellence and Innovation Stephanie Hess, Performance Improvement Specialist YH Nursing Informatics SueAnn McKniff MBA, RN-BC- Medication Process Specialist Members of YH SDM Quality Council Jenna Kahler BSN, RN Chair SDM Council 2012 Margaret Winemiller RN, CRN, CCRN, Co Chair SDM Quality Council 2012-present Deb Yommer BSN, RN Chair SDM Quality Council 2011-2012

EP35EO.16 YH Nursing Medication Errors 1000 doses administered

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Outcomes and Measurement YH outperformed the NRC Picker mean/ HCAHPS benchmark for the question YH Overall Medications- Confirmed Identity in 6 out of 8 quarters of data (EP35EO.17). The first two quarters have no data as NRC Picker re-scripted the question and a new benchmark mean needed to be set beginning with the data seen in the third quarter of data display on the graph. The pie chart below represents the average percentage of patient’s responses to the question related to “Medications- Confirmed Identity” The pie chart (EP35EO.18) clearly demonstrates that of the vast majority of patients who returned the survey 90.84% responded that the nurses “always” confirmed the identity of the medications. In addition 6.84% responded that the nurses “usually” confirmed the identity of medications. The chart demonstrates that only 1.70 % of patients responded “sometimes” and 0.64% responded that the nurses “never” tried to confirm the identity of medication prior to administering them to patients.

EP35EO.17 NRC Picker Outcomes

EP35EO.18 NRC Picker Question by response; % always

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The YH SDM Quality Council and YH Nursing Informatics Council will be working in tandem

over the next several months to prepare the staff for medication administration using bar coding. It is even more important at that time for the patients to feel confident in the hand held technology which will be deployed to ensure the right medication is given to the right patient at the right time.