project: patient satisfaction with pain management … patient satisfaction with pain management...

Project: Patient Satisfaction with Pain Management

Name of Green Belt(s): Donna Grochow & Maurice

Espinoza

Name of Champion: Karen Grimley & Zeev Kain, MD

Date: March 18, 2013

Attachment EP13v, Lean Six Sigma Patient Satisfaction with Pain Management Project Summary.pdf

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Define Phase


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Problem Statement • What is the problem? Low patient satisfaction with pain management has been

identified as an organizational problem.

• How do we know it is a problem? The baseline patient satisfaction scores aggregated at the organizational level for satisfaction with overall pain management are at the 26th percentile when compared nationally. 4th Quarter 2011 baseline Top Box score =59.08 compared to Avatar Top Box 68.10.

• The baseline Top Box scores for “How often staff did everything they could to help with pain” aggregated at the organizational level for 4th Quarter 2011 baseline Top Box score =69.83 compared to Avatar Top Box 78.13.

• What data to we have on baseline performance? National comparative data from the HCAHPS Patient Satisfaction survey is available at the organizational and unit level. Additionally, nursing has been involved in a multi-center research problem sponsored by the National Database of Nursing Quality Indicators which has resulted in data regarding pain management.

• What “pain” does it cause? (impact to patient and/or bottom line): 74% of other benchmarked facilities receive better scores from the patient in regards to pain management, causing the patient to perceive less than optimal care was provided which can lead to poor satisfaction scores, poor publically reported data, decreased reimbursement, and a potential increase in length of stay.

DEFINE


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Why is this important?

• Include Voice of the Customer (VOC): Patients are not satisfied with the pain management that is provided.

• Why this, why now? (“Burning Platform”): Scores have been low for a long time, Publically reported, Reimbursement issues, Quality of care issues, Affects Magnet Status

• What will happen if we don’t fix this? Potential loss of patients to other providers, Probable decrease in revenue due to decreased reimbursement, Increase length of stay, loss of magnet designation, etc.

DEFINE


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Project Charter Project Name: Patient Satisfaction with Pain

Management Champion: Karen Grimley & Zeev Kain, MD

Belt: Donna Grochow & Maurice Espinoza Master Black Belt: Laura Winner/Henry Alvarez

Problem Statement:

The 4th quarter 2011 Top Box patient satisfaction scores aggregated at the organizational level for satisfaction with pain management are 64.91 (26th percentile) when compared nationally. Three units, DH32, Tower & Tower 5 have a Top Box score of 56.78 (<7th percentile). The baseline Top Box scores for “How often staff did everything they could to help with pain” aggregated at the organizational level for 4th Quarter 2011 baseline Top Box score =69.83 compared to Avatar Top Box 78.13. Three units, DH32, Tower 4 & 5 have a Top Box score of 68.43.

Project Goal:

To improve the Top Box score in overall pain management to 68.10 (50th percentile) on selected units. To increase Top Box scores for “How often staff did everything to help with pain” to 78.13 (50th percentile) on selected units To show improvement in the mean scores of the 3 Path Y statements.

Project Y / Path-Y:

Project Y: Patient satisfaction scores with pain management. Path-Y: Mean percent of patients with positive response to the statements: • “My Healthcare team involved me in the decisions about controlling my

pain”. • “My nurse suggested approaches to help manage my pain”. • “My nurse believed my reports about my pain”.

Scope:

Limited to these areas with current satisfaction scores <7th percentile: DH 32, Tower 4, & 5

Team Members:

Nursing: Physician:

Donna Grochow S. Liao, MD Maurice Espinoza I. De Alba MD Charlene Miranda-Wood Patient Relations:

Khaled Al Eid Carla Camarillo Van Le Pharmacy

Holly Wicklas Lan Zheng Dan Bernsein

Benefits:

Improved patient pain satisfaction scores Decreased length of stay Improved physiological and psychological healing Decreased rate of readmission Decreased rate of outpatient visits

Timeline:

Define/Measure July-September 2011 Analyze September-December 2011 Improve/Control January-March 2012

DEFINE


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Voice of Customer

Patients

Nursing

Physicians

Pharmacists

DEFINE


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Voice of Customer • What We Currently Have Available:

– Patient Satisfaction Data (HCAHPS)

– National Database of Nursing Quality Indicators (NDNQI): Patient Satisfaction with Pain Management Survey

• Participated in research study to identify issues with pain management

• All eligible medical-surgical patients were surveyed on 1 day in April 2011 and November 2011

• Baseline data available for review

• What We Need: – VOC from nursing, MD group, pharmacists

• Next Steps: – Focus groups with key stakeholders: MDs, nurses, pharmacist, etc

– Continue to conduct patient interviews & data collection as part of NDNQI study

– Continue HCAHPS data collection

DEFINE


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Voice of Customer (VOC): RN, MD, Pharmacist Focus Group Results

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Themes 1. Communication 2. Knowledge/Education 3. Process 3. Patient Condition 4. Influence of Supervisors 5. Equipment 6. Complementary Therapy

Focus groups were held in August 2011 with staff from DH32, 4T, 5T & MICU, MD groups and patient interviews. The focus group consisted of a written survey and verbal roundtable discussion

The following themes affecting pain management were identified from the focus groups:

MEASURE


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SIPOC

DEFINE


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Early Waste Identification DOMOWIT • Defects:

– Lack of communication between MD & RN regarding pain plan of care – Lack of communication between RN & aide regarding pain plan of care – Lack of communication between RN & patient regarding pain plan of care – Lack of communication between aide & patient regarding pain plan of care – Lack of communication between MD & patient regarding pain plan of care – All routine scheduled medications were due at 0900 and were required to be administered within 30

minutes of the scheduled dose. The med/surg RN’s had up to 5 patients with multiple medications. This created a barrier for them in getting to know their patients.

• Over-processing – RN often has to page and/or call MD multiple times for pain medication orders – Patient often unaware of when pain medication is available and has to repeatedly ask nurse

• Motion – RN or aide has to answer patient’s call light to answer question about when next pain medication is due

• Over-production: • Waiting

– Adequate/correct pain medication not given timely, patient has to request pain medication – HCAHPS Scores: Delayed time period for receiving results: Improved with switch from Avatar (Quarterly

results only available when final) to Press Ganey (Preliminary results immediately available)

• Inventory • Transportation

DEFINE


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Measure


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Baseline Data for Y

•Baseline data on patient satisfaction with pain management is based upon a sample size of 123 patient surveys collected from October 2011 through January 2012.

• The data is obtained from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey which is provided by a 3rd party vendor to 20% of discharged inpatients.

•Data is available aggregated at the organizational level and the unit level.

•The data for this project was includes the results of the following:

–HCAHPS Composite Score: “Overall Satisfaction with Pain Management”

–Individual questions that are combined for composite score:

•“How often staff did everything they could to help with pain?”

•“How often was pain well controlled?”

MEASURE

Describe how baseline data was obtained…


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Baseline Data for Y MEASURE

Measure Systems Analysis Performance Measure

Operational Definition Data Source and Location

Sample Size Who Will Collect the Data

When Will Data be Collected

How Will Data be Collected

Other Data that should be

Collected at the Same Time

Patient perception of pain management.

Discharged patients are sent a survey with questions about their pain management during recent hospital stay. The instrument asks patients to rate the frequency of events during their care (never, sometimes, usually, always): 1. How often staff did

everything they could to help with pain.

2. How often pain was well controlled.

HCAHPS survey of discharged patients

Survey sent to 20% of discharged inpatients. Sample size dependent on returned surveys

Third party vendor: Avatar and Press Ganey

Ongoing Survey Data collected via pre-set survey.

MSA validation consists of evaluation of incumbent from Press Ganey. Data is reproducable and repeatable,.

MSA validation not feasible. Data is attribute data and a Kappa calculation is recommended. Rater repeatability is not applicable for this data because data is collected via anonymous patient survey sent via third party vendor and it is impossible to have rater evaluate measure twice to conduct calculation. Survey is a validated tool and measures patient perception. Patient’s perception would be expected to be the same on repeat samples.


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Baseline Data for Y MEASURE

Measure Systems Analysis Performance Measure

Operational Definition Data Source and Location





Collected at the Same Time

Patient perception of pain management.

Discharged patients are sent a survey with questions about their pain management during recent hospital stay. The instrument asks patients to rate the frequency of events during their care (never, sometimes, usually, always): 1. How often staff did

everything they could to help with pain.

2. How often pain was well controlled.

HCAHPS survey of discharged patients

Survey sent to 20% of discharged inpatients. Sample size dependent on returned surveys

Third party vendor: Avatar and Press Ganey

Ongoing Survey Data collected via pre-set survey.

MSA validation not feasible. Data is attribute data and a Kappa calculation is recommended. Rater repeatability is not applicable for this data because data is collected via anonymous patient survey sent via third party vendor and it is impossible to have rater evaluate measure twice to conduct calculation. Survey is a validated tool and measures patient perception. Patient’s perception would be expected to be the same on repeat samples.


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Baseline Data for Y-Template

•Baseline data from Patient Satisfaction Surveys—Selected Units: DH32, Tower 4 & 5

•HCAHPS Composite Score: “Overall Satisfaction with Pain Management”

• Data on scores based on sample size of 123 patients collected from October 2011 through January 2012

MEASURE


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2011-10 2011-11 2011-12 2012-01

Patient Satisfaction with Overall Pain Managment Tower 4, 5 & DH 32

Top Box % Goal


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•Baseline data from HCAHPS Patient Satisfaction Survey: DH32, Tower 4 & 5

–Question “How often staff did everything they could to help with pain?”

• Data on scores based on sample size of patients 109 collected from October 2011 through January 2012

MEASURE


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2011-10 2011-11 2011-12 2012-01

How Often Hospital Staff Did Everything They Could to Help with Pain

Top Box % Goal


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•Baseline data from HCAHPS Patient Satisfaction Survey: DH32, Tower 4 & 5

–Question “How often was pain well controlled?”

• Data on scores based on sample size of patients 109 collected from October 2011 through January 2012

MEASURE


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2011-10 2011-11 2011-12 2012-01

How Well Was Pain Well Controlled Tower 4, 5, & DH32

Top Box % Goal


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Baseline Data for Path Y MEASURE

•Baseline data collected during participation in a multi-center research study “Patient Satisfaction with Pain Management Survey” sponsored by the National Database of Nursing Quality Indicators (NDNQI)

•All eligible medical-surgical patients were surveyed on 1 day in April 2011 and November 2011

•Data on scores based on sample size of 53 patients on medical/surgical units

•Additional data on scores based on sample size of 23 patients on targeted medical/surgical units


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Baseline Data for Path Y

All Medical-Surgical Units

MEASURE

Interventions Implemented February 21,2012


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N=53 Patients

4.6

4.65

4.7

4.75

4.8

4.85

4.9

4.95

April/Nov 2011

NDNQI Survey My Healthcare Team Involved Me In The

Decisions About Controlling My Pain

UC Mean Benchmark Mean

MEASURE

Baseline Data for Path Y All Medical-Surgical Units


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N=53 Patients

MEASURE

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April/Nov 2011

NDNQI Survey My Nurse Suggested Approaches to Help

Manage My Pain





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N=53 Patients

MEASURE

5.3

5.35

5.4

5.45

5.5

5.55

5.6

5.65

April/Nov 2011

NDNQI Survey My Nurse Believed My Reports About My Pain





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Voice of Customer (VOC): Patient NDNQI Baseline Survey Results-Targeted Units

paste

Questions # of Yes Responses % 1. Did you expect you would have pain while in the hospital? 18 78% 2. When the staff came into your room, did they ask about your pain often enough? 20 87% 3. Do you understand the pain scale? 23 100% 4. Are you comfortable talking about our pain with the staff? 23 100% 5. Does the staff inform you of the plan to manage your pain so you understand? 18 78% 6. When you were in pain, did the staff act as fast as you expected? 19 83% 7. Do you believe the staff do everything they can to manage your pain? 18 78% 8. Do you notice any difference in your pain management day to day? 6 26%

→ 22% of the patients did not expect to have pain.

→ 22% of the patients were not informed about plan to manage pain

N=23 English speaking patients interviewed on the target units The following lists the questions that the patients were asked to answer along with the responses.

→ 26% of the patients noticed differences in the management of pain from day to day

MEASURE


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paste

Questions UC Mean Benchmark 50th Percentile 1. My nurse believed my report of pain 5.24 5.68 2. I had pain medication available when I needed it. 5.04 5.56 3. My nurse suggested approaches to manage my pain. 3.36 3.67 4. My nurse discussed side effects of pain meds with me 3.85 3.63 5. The pain medications worked well to control my pain 4.48 5 6. My healthcare team involved me in decisions about pain control 4.46 4.94

→ Our scores were < 50th percentile in almost all categories

N=23 English speaking patients interviewed on the target units

The following lists the questions that the patients were asked to answer along with the responses.

MEASURE

Baseline Data for Path Y Voice of Customer (VOC): Patient

NDNQI Baseline Survey Results-Targeted Units


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Normality

MEASURE

Overall Satisfaction with Pain Management-October 2011-January 2012….

The P-value is 0.795.

Because the P-value is .05 or more, the distribution is considered normal


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Stability

MEASURE

Is the process stable (Predictable)? Insert control chart to demonstrate stability…

Overall Satisfaction with Pain Management-October 2011-January 2012

The process is stable.


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Capability MEASURE

What is our baseline performance? How well are we meeting expectations (How good is our process)?

Percent Defective: 39.45


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Baseline Process Map

MEASURE


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Filter X’s FMEA Filtering of X’s to vital few…

MEASURE


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Pilot Data Collection for X’s

Performance Measure

Operational Definition

Data Source and Location





Collected at the same time

Specialist Seen Time, # of

Specialists, PFT, Pts wait

time.

Shadow pts. And measure how many minutes each specialist

takes. Doc. How many specialists

are seen including PFT

CF Clinic 50 Chad Smith

During the first week of the

month, 8/29/2007 to 10/5/2007

Data will be collected using digital watch,

data collection sheet

Day of Wk, any pertinent

comments or issues noted

during observation.

MEASURE

Revise and pilot data collection to include data

on the vital X’s identified in C&E


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Voice of Customer (VOC): RN Focus Group Results

paste

Themes 1. Communication 2. Knowledge/Education 3. Process 3. Patient Condition 4. Influence of Supervisors 5. Equipment 6. Complementary Therapy

Focus groups were held in August 2011 with staff from DH32, 4T, 5T & MICU. The focus group consisted of a written survey and verbal roundtable discussion


MEASURE


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Voice of Customer (VOC): RN Pareto Chart August 2011

paste

Focus groups were held August 2011 with staff from DH32, 4T, 5T & MICU. The focus group consisted of a written survey and verbal roundtable discussion


C3 47 29 28 8 4 3 2

Percent 38.8 24.0 23.1 6.6 3.3 2.5 1.7

Cum % 38.8 62.8 86.0 92.6 95.9 98.3 100.0

C2

Complim

entary The

rapy

Equipm

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Influ

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of S

uper

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Patie

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Pareto Chart of C2

MEASURE


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Analyze

Which X’s are key?

5 Whys

Cause & Effect Analysis

ANALYZE


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Analyze


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Fishbone Results from Brainstorming on ALL potential X’s …

ANALYZE


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Cause & Effect Summary

• Multiple Inputs were originally identified in the SIPOC

• Common themes were identified via surveys and focus groups

• These were then rated within categories – Patient Satisfaction with Pain Management

– RN Role in Pain Management

– MD Role in Pain Management

• The C & E methodology identified the top Inputs/themes with scores as seen in the next slide

• The top ranked Inputs/themes guided the work for the Improve phase

paste

ANALYZE


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Cause & Effect

paste

ANALYZE


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Cause & Effect

paste

ANALYZE

Top Five 1. Patient Knowledge-Expecations of Pain Control 2. Caregiver Knowledge-Inconsisent Pain Management 3. 4. 5.


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Analyze: 5 Whys of Pain ANALYZE


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Analyze: 5 Whys ANALYZE


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Analyze: 5 Whys ANALYZE


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Analyze: VOC-Nursing

ANALYZE

C3 47 29 28 8 4 3 2

Percent 38.8 24.0 23.1 6.6 3.3 2.5 1.7

Cum % 38.8 62.8 86.0 92.6 95.9 98.3 100.0

C2

Complim

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rapy

Equipm

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Influ

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Patie

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Commun

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Pareto Chart of C2


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Improve


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Ease of Implementation

Pain Scale Poster

Pain Goal & Medication Poster

Huddle Education

Quick Education Sheet Campaign

Pain Score Dashboards

Pain Score Reports to MD

MD Pain Management Education

Communication Reminders to MD

Require Pain Consult for Chronic Pain Patients

Pain Free Campaign-Lounges, Workroom & Intranet

Improve Pain Resource Website Visibility

IMPROVE

Ease v. Impact Based on key X’s identified, what improvements were identified?


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Interventions What X’s were selected for modification? Communication Education What are the Interventions and the key X’s they address? Improved Communication: Pain Scale Poster Pain Goal & Medication Poster Poster Campaign-Lounges & Workroom (Potentially) Improve Pain Resource Website Visibility (Potentially) Nursing Education Huddle Education Quick Education Sheet Developed Pain Score Dashboards MD Education Pain Score Reports to MD Communication Reminders to MD Pilot interventions and collect data…

IMPROVE


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Visual Pain Tools in Every Patient Room

IMPROVE


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Ongoing Education-Example

IMPROVE


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Control


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Control Plan CONTROL

→ Control Plan to keep Improvements in place

→ Reaction plan/feedback mechanism


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Control Plan CONTROL

→ Control Plan to keep Improvements in place

→ Reaction plan/feedback mechanism


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5.4

4.12

4.7

5.76

3.06

4.98

5.6

4.12

4.89

My Nurse Believed My Reports About My Pain My Nurse Suggested Approaches to Help Manage MyPain

My Healthcare Team Involved Me in the Decisions AboutControlling My Pain

NDNQI Pain Management Study

Pre-November 2011 & April 2012 Post-April 2012 NDNQI Benchmark

NDNQI Pain Management Study Pre & Post Results

Interventions Implemented February 21,2012

CONTROL

Evaluation: 1. The questions, “My Nurse Believed My Repots About My Pain” and “My Healthcare Team involved Me in the Decisions About Controlling My Pain” improved and out-performed the mean post intervention. The focus of the project was centered on the patient perception of the teams involvement/interest in pain management. These questions reflect that focus. 2. The question, “My Nurse Suggested Approaches to Help Manage My Pain” scored lower in the post measurement. The focus of the project did not work on this topic, therefore the results are not surprising.


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CONTROL → After key interventions implemented, Audit Results: March 2012

→ Visual Pain Tool is present in room

→ Visual Pain Tool Present in 99% of Pilot Unit Rooms

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Yes No No Answer

Is the pain tool in the room?


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CONTROL

→ Visual Pain Tool is being used by 68% of RNs

→ Education regarding tool was provided

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Yes No No Answer

Is the staff RN utilizing the tool?

→ After key interventions implemented, Audit Results: March 2012


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CONTROL → Right after key interventions implemented, Audit Results

→ Visual Pain Tool is visible to 96% of patients

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Can the patient see the tool?


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→ 82% of patients understand the tool


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Does the patient understand the tool?


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→ 78% of patients like the tool

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Yes No No Answer

Does the patient like the tool?


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Opportunity for Spread

• Could other areas of the organization benefit from a similar improvement effort?

Plan is to disseminate interventions to entire organization once pilot is completed and any needed changes are finalized.


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→ 64% of patients think pain tool is helping team to effectively manage pain


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Yes No No Answer

Is the pain tool helping you and your nurse manage your pain effectively?


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2011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08 2012-09 2012-10 2012-11 2012-12

Overall Pain Management Patient Satisfaction

Pilot Units

Top Box % Goal

Final Data for Y-Template •HCAHPS Composite.

•Overall Satisfaction with Pain Management on DH32, Tower 4 & 5 (Pilot Units)

•Data on scores based on sample size of 619 patients discharged from September 2011 through December 2012

CONTROL

?

Essence of Nursing-Oct-Dec classes-Focus on patient-centered care/pain management

Improve Phase Begun January 2012: 1. Education 2. Pilot Pain Poster and Pain Thermometer 3. Flexibility added to medication administration policy 4. Patient Education: Pain Management Video

Baseline: Sept 2011-January 2012

Installation of revised White Boards & New Pain Tools in medical/surgical units


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2011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08 2012-09 2012-10 2012-11 2012-12

How Often Hospital Staff did Everything They could to Help with Pain

Top Box % Goal

Baseline: Sept 2011-January 2012

Improve Phase Begun January 2012: 1. Education 2. Pilot Pain Poster and Pain Thermometer 3. Flexibility added to medication administration policy 4. Patient Education: Pain Management Video

Final Data for Y-Template •Baseline data from HCAHPS Patient Satisfaction Survey: DH32, Tower 4 & 5

–Question “How often staff did everything they could to help with pain?”


MEASURE



Data collection/focus groups: August 2011-January 2012


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2011-09 2011-10 2011-11 2011-12 2012-01 2012-02 2012-03 2012-04 2012-05 2012-06 2012-07 2012-08 2012-09 2012-10 2012-11 2012-12

How Often Pain Was Well Controlled Patient Satisfaction

Top Box % Goal

Final Data for Y-Template •Baseline data from HCAHPS Patient Satisfaction Survey: DH32, Tower 4 & 5

–Question “How often staff pain was well controlled?”


MEASURE



Data collection/focus groups: August 2011-January 2012


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paste

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Overall Pain Management Patient Satisfaction

Top Box % Goal


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Normality

MEASURE

Overall Satisfaction with Pain Management-October 2011-January 2012….

The P-value is <0.005.

Because the P-value is not .05 or more, the distribution is considered normal

6050403020100-10-20

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Always1

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Mean 21.27

StDev 16.11

N 11

AD 1.074

P-Value <0.005

Probability Plot of Always1Normal


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Stability

MEASURE

Is the process stable (Predictable)? Insert control chart to demonstrate stability…

Overall Satisfaction with Pain Management-October 2011-January 2012

The process is stable.

1110987654321

1.0

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Sample

Pro

po

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_P=0.659

UCL=1

LCL=0.249

P Chart of Always1

Tests performed with unequal sample sizes


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Capability MEASURE

What is our baseline performance? How well are we meeting expectations (How good is our process)?

Percent Defective: 39.45

4321

0.6

0.4

0.2

Sample

Pro

po

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_P=0.3945

UC L=0.5778

LC L=0.2112

4.03.53.02.52.01.51.0

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Sample

%D

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Upper C I: 0.4422

%Defectiv e: 39.45

Lower C I: 32.92

Upper C I: 46.27

Target: 0.00

PPM Def: 394495

Lower C I: 329159

Upper C I: 462742

Process Z: 0.2676

Lower C I: 0.0935

(95.0% confidence)

Summary Stats

806040

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%D

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45.0

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%Defective

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Binomial Process Capability Analysis Pain Post Intervention

P Chart

Tests performed w ith unequal sample sizes

Cumulative %Defective

Rate of Defectives

Histogram


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project: patient satisfaction with pain management … patient satisfaction with pain management...

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