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“What Can Florence Teach Us About Patient-Centered Care

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1 “What Can Florence Teach Us About Patient-Centered Care
Rounding for Outcomes “What Can Florence Teach Us About Patient-Centered Care Welcome to our call everyone. The Georgia Hospital Association members are some of my favorite to work with and I am happy to be back with you all again as we strive to achieve the Hospital Engagement Network goals and make care better in the state of Georgia. Karen Cook, RN © 2012 Studer Group

2 Objectives Articulate what is purposeful hourly rounding
Describe the behaviors needed to accomplish an effective and purposeful hourly round and bedside handover List strategies to overcome the common barriers to successful hourly rounding and bedside handover We will focus our time together today on the evidence-based results proven to impact the true delivery of patient centered care. Our objectives today are to describe the evidence based results proven to occur when hourly rounds are truly hardwired. Effective hourly rounds is dependent on staff behavior so we will discuss the behaviors needed to truly hardwire it. Almost all of you are doing it to some degree so this is definitely not a tutorial on how to do it. We will spend about 60 minutes on hourly rounding and about 30 minutes on Individualized Patient care and bedside report. © 2012 Studer Group

3 Driving Performance Using a physician evidence based practice model, this is the format that the Studer Group follows with all initiatives. First assess and diagnose the problem you are trying to treat. Then research the actions proven to impact that area. Next look at the processes that can be implemented and who needs to learn about it. After staff have learned the process, let them practice. You must validate to ensure reliability and consistency. Ongoing validation is as important as “signing off as competent.” This is where ongoing coaching comes into play. The most important step is to reward those that are doing it well and achieving results. © 2012 Studer Group

4 Patient-Centered Care Delivery Model
Meeting Title Here (on Notes Master) Patient-Centered Care Delivery Model Hourly Rounding Bedside Shift Report Nursing and Patient Care Excellence Individualized Patient Care Discharge Phone Calls These are the four nursing strategies that provide a solid model for safe, quality patient care. All of these strategies force nurses to be at the bedside. When nurses are at the bedside, they engage the patients and we improve our delivery of Patient-centered care. © Studer Group

5 What Do Staff “Think” About Hourly Rounds?
Scripts are fake We don’t have time This is about patient satisfaction not quality Patients get annoyed with us checking on them every hour Logs are stupid Managers don’t care about us, they just care about their dumb reports to the Studer Group What else? One of the best tips I learned in speaking about a particular process is to review the arguments AGAINST it. I read the “forums” on and I am actually appalled and angered by some of the comments. © 2012 Studer Group

6 Myth #1: Hourly Rounding Was “Invented” By The Studer Group
Throughout the night, she would move through the dark hallways carrying a lamp while making her rounds, checking on each patient and providing care if needed. The soldiers were comforted by her compassion, earning her the nickname, "The Lady with the Lamp." Her care would forever change the way hospitals treated patients. Most consider Nightingale the founder of modern nursing. For our source of inspiration on this call, I have turned to Florence Nightingale. Probably the most important thing we can all remember is that Hourly Rounding is not NEW. It is not an initiative we do on top of everything else. It is How we deliver care and just like Florence, it can forever change the way hospitals treat patients. The Studer Group did not invent hourly rounding… what we did do was clearly define what it is so we could reduce variance around the behaviors that impact results. © 2012 Studer Group

7 High Reliability Demands Simplicity
If we asked five front line staff this question – what would we hear? “What is hourly rounding and why do we do it? One of the questions Dr. Reiser has asked the HEN Groups is “can five front line employees clearly articulate the strategy?” So again, we must reflect honestly, would our staff be able to answer with these key words? Can they automatically link the WHY to safe quality care? © 2012 Studer Group

8 What is Hourly Rounding?
What is it? A plan to proactively interact with patients every hour during the day using focused key words to assess needs (pain, position, personal needs and patient education) A care model to return care to the bedside, truly patient-centered A plan to help achieve our goal to “always” deliver exceptional clinical quality care in a safe and compassionate environment Why do it? Evidence supports a decrease in patient anxiety, falls, skin breakdown, and nursing steps as well increased patient satisfaction It allows nurses to provide more care at the bedside It reduces anxiety, worry and waiting It is just good patient care There is no other initiative that impacts the patient perception of quality care as this ONE does. No matter what the initiative we are trying to hardwire and ensure reliability, we must ensure we have consistency among all staff. … why do you do it… what results do you expect and more importantly, what results have you seen. Here are a few key words that describe hourly rounding. As you talk about it, lead with the WHY of hourly rounding first. It is a Safety initiative, it is proactive, it is how we deliver quality care…

9 Eight Behaviors of Hourly Rounds – More Than 3 P’s
Meeting Title Here (on Notes Master) Eight Behaviors of Hourly Rounds – More Than 3 P’s 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. Improves patient satisfaction on teamwork and communication 7. Tell each patient when you will be back 8. Document the round Quality and accountability Understanding the eight behaviors is the place to start when discussing effective hourly rounding. Each behavior is designed to achieve a particular results and they must be done together. The behaviors that staff most often leave out are numbers 1,2,4,5,7. Each of these drive efficiency- so when they leave them out they are essentially shooting themselves in the foot because they are not gaining the efficiency which is what drives them to want to keep the rounds going. Leaders need to ensure they are monitoring and validating all 8 behaviors are being performed The original premise of the study was not quality and safety – it was the opportunity to help nurses gain control over their work flow and get some relief and time back (reinforces last slide) © Studer Group

10 Myth #2: We Don’t Have Time For Hourly Rounding
“I am of certain convinced that the greatest heroes are those who do their duty in the daily grind of domestic affairs whilst the world whirls as a maddening dreidel.”  As I read the “resistance” to hourly rounding… one of the biggest barriers was “we don’t have time.” This tells us that it was not introduced to staff as a safety initiative, if it was – nobody would say they don’t have time for safe patient care. We also know from looking at top And we also know that in EVERY organization, there are some who are doing it everyday…. “Notes on Nursing” Florence Nightingale 1854 © 2012 Studer Group

11 Track By Low/Solid/High Performers
Date: Average call light response time High # of calls Call Rate 25-Jul-12 1:21 3:34 20 26-Jul-12 2:16 5:55 24 6 calls/pt. 2-Aug-12 2:07 5:18 22 5.5 calls/pt. 3-Aug-12 3:15 7:23 17 4.35 calls/pt. 12-Aug-12 4:25 13:53 14-Aug-12 1:09 3:18 15 3.0 calls/pt. 15-Aug-12 1:12 1:34 13 0.75 calls/pt. 21-Aug-12 1:15 10 2.0 calls/pt. 22-Aug-12 1:13 3:06 5 1 call/pt. Some organizations are tracking their number of call lights by high middle and low performers and what do you know… they correlate. This gives you metric based data to coach your staff to a higher level of performance. The chart on the left shows where counseling took place on August 13 and look at how the staff behavior changed. Sometimes raising awareness and pointing out gaps in performance aligns behaviors very quickly and you cannot argue with the data. © 2012 Studer Group

12 Most Common Reasons for Call Light Use
This study formed the foundation for the 3 P’s – pain, position and potty and many hospitals have added that 4th P as Pumps. While positioning was significantly lower in terms of call lights, we know that forcing repositioning will reduce pressure ulcers and other complications that are important to quality metrics. Every time a call light goes off, or we give the call light to the patient and tell them to call us when they need us, we are giving them permission to disrupt our day. I am not saying don’t do that, I am saying be more proactive in preventing them from going off in the first place. © Copyright 2002 12

13 $36,660/yr 700 calls/wk= 46 hrs Time is Money
And those calls translate to money. More importantly, they translate to TIME. Effective hourly rounding is done to give nurses more time at the bedside and doing the things they like the most…. Like teaching and coaching patients to a higher level of compliance. One Call Light = 4 Minutes of Care Giver Time © 2012 Studer Group

14 Staff is Already in the Room
0800 1600 0900 1700 1000 1800 1100 1900 1200 2000 1300 2100 1400 2200 1500 We know when we are going to be in the room - our goal is to bundle tasks and earn the patients trust that we will return in a timely manner… Use call light example – you hand it to the patient, you are giving them control. © 2012 Studer Group

15 “Notes on Nursing” Florence Nightingale 1854
Myth #3: Hourly Rounding Is Implemented To Improve Patient Satisfaction “The very first requirement in a hospital is that it should do the sick no harm.”  Hourly Rounding is a QUALITY initiative – unfortunately it was rolled out as a patient satisfaction initiative and was seen as a way for executives to get results more than patients. What is was REALLY focused on was a staff initiative, we were trying to demonstrate that hourly rounding could reduce call lights. “Notes on Nursing” Florence Nightingale 1854 © 2012 Studer Group

16 Evidence-Based Quality
These are the results from the largest study done on hourly rounding in This study clearly demonstrated when nurses followed the recommended eight behaviors and actions during their hourly rounds the following results are achieved: Value to the staff is the reduction of call lights and proactively addressing needs so staff take some control back of their day. This is truly an initiative for staff satisfaction. This demonstrates that hourly rounding is a quality initiative – not a patient satisfaction or HCAHPS initiative.

17 Responsiveness: Correlates to Quality
Yes Yes Yes doubters! Correlation does not imply causation BUT we are all smart enough to know that if patients get that attention they need their outcomes will be better! © 2012 Studer Group

18 Responsiveness: Correlates with Readmissions
Talk money to me!! Sitting next to the CEO at a Leadership Development Session, presenter was talking about HCAHPS and VBP or whatever and I just did a little math and put a sticky in front of him with the money leaking out the doors from non-execution, non-implementation and basic lack of leadership. © 2012 Studer Group

19 Myth #4: Yup, We Are Doing Hourly Rounding
I think one's feelings waste themselves in words; they ought all to be distilled into actions which bring results. So as Florence would say Talk is cheap… Let’s look at results “Notes on Nursing” Florence Nightingale 1854 © 2012 Studer Group

20 Do Our Words = Results? 88% of Georgia HEN Hospitals report they “ARE doing hourly rounding”… but Georgia ranks 47th out of 50 states in improvement in pain management This data includes ALL of Georgia reporting hospitals. We can see that there is opportunity. Georgia ranks 47th our of 50 states in improvement in pain management. This shows we have opportunity to hardwire the words around pain control during each hourly rounds. © 2012 Studer Group

21 Georgia Hospitals GA Ranks 41st of 50 States in Responsiveness of Hospital Staff We also know that Georgia Hospitals Only– Hospitals with better results in “Responsiveness of Hospital Staff” have fewer HACs © 2012 Studer Group

22 GA HEN Hospitals Falls First do no harm as Florence says. Yet GA HEN hospitals are trending upward above the target which a huge spike in august. There are fewer hospitals reporting their data as well but certainly this graph shows the urgency needed to refocus on a tactic that will reduce falls. © 2012 Studer Group

23 GA HEN Hospitals HAPU Same thing with HAPU. We definitely want to reduce this trend so focusing on the important P of Positioning is critical. © 2012 Studer Group

24 Correlate Tactic With Results (ROI)
But we cannot ignore the hard facts. Each Pressure Ulcer and each fall is costing the organization money. I would be happy to share this form with you…. This has places to insert the actual numbers of HAC and it calculates the cost. This needs to be shared with all staff… not in a punitive way but just in a factual manner. It is not about the dollars but when the hospital operating margin is 2.2% and we are losing money on HAC’s, this is real. © 2012 Studer Group

25 “Notes on Nursing” Florence Nightingale 1854
Myth # 5 “We have to sign the logs or get written up…we document in the chart so the log is stupid.” “How very little can be done under the spirit of fear.”  Do you have the right environment for your staff to be successful in their role, not just with hourly rounding but in providing care. A culture of fear, writing up, disciplinary action, etc… will just lead to compliance with the process, not engagement. It will not be hardwired, it will be over as soon as the attention goes off that initiative and on to another one… lthe WHY has not been communicated if you are hearing this. Staff will not buy in – they will resist. A great example is the LOGS. Ask your staff WHY we have the logs and if you hear anything about compliance, you have an opportunity to improve. “Notes on Nursing” Florence Nightingale 1854 © 2012 Studer Group

26 Logs Are A Visual for FAMILIES and Patients
Meeting Title Here (on Notes Master) Logs Are A Visual for FAMILIES and Patients Are your logs a visual representation of your quality to the patient/family? Do they give you the information you need or are they duplicative charting? Logs serve two purposes. One is accountability system but the second and more important process is to create the promise and demonstrate to patients and families that we have fulfilled the promise. Describe the log as a visual representation of the quality of safe care delivered. The log is not for the staff, it is for the patient/family etc. to document attentive, proactive staff. © Studer Group

27 Nurse Leaders Round To Ensure Patients “FEEL” Quality Care
Nurse leader rounding with targeted questions: Tell me one of the questions that your care team asks you when they come into do their hourly rounds? We focus on meeting your needs, and with that in mind, the staff are to be in the room every hour asking about pain, position and bathroom needs. Has this been your experience? Have you had to use your call light to ask for pain medicine in the last 24 hours? Tell me what your nurse told you about our process for hourly rounding on this unit? Would your patients be able to respond in a way you are 100% confident that they FEEL like they are rounded on in a purposeful manner? It is not our actions, it is how we made our patients FEEL. Yes, they were in my room and they asked me these questions…. They really care about my safety here. This is very different from they check on me regularly…. © 2012 Studer Group

28 Your Turn Tell us about Hourly Rounding in YOUR hospital…
What is working well? Where are there opportunities to improve Hourly Rounding © 2012 Studer Group

29 Patient-Centered Care Delivery Model
Meeting Title Here (on Notes Master) Patient-Centered Care Delivery Model Hourly Rounding Bedside Shift Report Nursing and Patient Care Excellence Individualized Patient Care Discharge Phone Calls These are the four nursing strategies that provide a solid model for safe, quality patient care. All of these strategies force nurses to be at the bedside. When nurses are at the bedside, they engage the patients and we improve our delivery of Patient-centered care. © Studer Group

30 Myth #6: Scripting/Key Words Make Us Sound Robotic
“Always sit down when a sick person is talking business with you, show no signs of hurry, give complete attention and full consideration… Always sit within view so that when speaking to him, he does not have to painfully turn his head around in order to look at you. If you make this act wearisome, you are doing the patient harm. You cause harm also by continuing to stand to you make him continuously raise his eyes to see you.” Florence Nightengale had it right… she was PRESENT for the patient and we need to be able to do that… No more multi-tasking – truly listen to the patient. “Notes on Nursing” Florence Nightingale 1854

31 Our Goal is to Deliver Excellent Quality Care
Meeting Title Here (on Notes Master) Our Goal is to Deliver Excellent Quality Care Composite Question Summary Response Scale Nursing Communication Nurse courtesy and respect ALWAYS1, Usually, Sometime, Never Nurses listen carefully ALWAYS, Usually, Sometime, Never Nurse explanations are clear Doctor Communication Doctor courtesy and respect Doctors listen carefully Doctor explanations are clear Responsiveness of Staff Did you need help in getting to bathroom? 2 Yes No (screening question) Staff helped with bathroom needs Call button answered Pain Management Did you need medicine for pain? 2 Yes, No (screening question) Pain well controlled Staff helped patient with pain Communication of Medications Were you given any new meds? 2 Staff explained medicine Staff clearly described side effects Discharge Information Did you go home, someone else’s home, or to another facility? 2 Own home, Someone else’s home, Another facility (screening question) Staff discussed help need after discharge YES, No Written symptom/health info provided Individual Question Area around room kept quiet at night Room and bathroom kept clean Willingness to Recommend DEFINITELY YES, Probably Yes, Probably No, Definitely No Hospital Rating Question 0 to 10 point scale (percent 9 and 10 reported) 1Response used to calculate the question score is designated by capital letters 2For analysis purposes, it is important to know which areas have screening questions because the sample size will be lower than the other areas We need to engage staff in using key words to improve communication with patients Key words reflect a communication style that improves the quality of information provided. Key times are defining moments that: Occur during times of vulnerability like needing help to the bathroom or pain management Are what patients remember Affect the perception of the total hospital experience Share the WHAT and the WHY (not about scripting) © 2010 Studer Group

32 Tell the Patient the “Why” of Hourly Rounding
“On this unit, one of our care team members will be coming in to see you every hour during the day. You will see either me or Jackie, our certified nurse assistant. I have worked with Jackie for two years and she is excellent. We will be checking on your comfort such as we will make sure we are helping manage any pain you might have, help you change position, help you to the bathroom and make sure you have everything you need.” We call this hourly rounding and we do it to make sure you are safe and we are always meeting your needs.” Have you standardized the process of setting expectations of hourly rounding as part of how you deliver care? How do you know it happens every time? How do the staff explain the logs to the patient and family? When I am on site coaching for hourly rounding, one gap I see pretty consistently is setting the expectation that they do hourly rounds and why… here is an example of some key words to use with your staff in coaching. Also, I provided a sample patient card that explains hourly rounds and is included in the admissions packet. You just want to make sure that all wording is compliant with HCAHPS guidelines if you are putting something in print format. I suggest you review all written materials for any violations.

33 WRITTEN Key Words Here are some more examples of key words in the written format that just reinforce your goal to provide great care. I love the transition card from ICU to the floor. Notice they are managing up the floor as well as setting the expectation that they will be rounding on hourly by the staff on the floor. The goal is to reduce anxiety going from one: one care in the ICU to the floor. These are all examples of key words. © 2012 Studer Group

34 Pause Before Leaving “Is This Patient Safe?”
Bottom line, before leaving the room, key words to ask your self are – is this patient safe? If you pause before leaving the room and do the environmental assessment for safety as well as for cleanliness, the patient will feel like they are in a safer place, because they are.

35 Care Boards are FOR the PATIENT
The white boards – or CARE boards_ as I call them, are another under utilized tool for keeping patients informed and included in their care. These are great communication tools for families. Notice how the pain goal, next pain med is due at are on the white board… yet when I do random audits of white boards, I find this is often left blank. Many hospitals are incorporating the hourly rounding documentation right into the care board. I also gave you an example of a nice pain scale in multiple languages. Because this is so important to the HCAHPS results and the patient perception of quality, we must conduct random audits of these boards. I included a sample audit tool in your toolkit that will be at the link provided by the Georgia Hospital Association. © 2012 Studer Group

36 Your Turn Tell us some examples of using key words in YOUR hospital…
What is working well? Where are there opportunities on your unit to use key words to reduce anxiety? © 2012 Studer Group

37 Video Clip Hourly rounding and care boards What worked well
What are opportunities for improvement © 2012 Studer Group

38 Patient-Centered Care Delivery Model
Meeting Title Here (on Notes Master) Patient-Centered Care Delivery Model Hourly Rounding Bedside Shift Report Nursing and Patient Care Excellence Individualized Patient Care Discharge Phone Calls These are the four nursing strategies that provide a solid model for safe, quality patient care. All of these strategies force nurses to be at the bedside. When nurses are at the bedside, they engage the patients and we improve our delivery of Patient-centered care. © Studer Group

39 Myth # 7 Patients don’t like bedside shift report
Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion. Again, Florence says to first do no harm… And she describes apprehension, uncertainly, waiting and fear as doing more harm than exertion. “Notes on Nursing” Florence Nightingale 1854 © 2012 Studer Group

40 Bedside Shift Report (Handover)
The process of handing-over care delivery from one nurse to another at change of shift at the patient bedside. This process incorporates other concepts such as “managing up”, AIDET communication, teamwork and creating a safe patient environment. All necessary patient information is exchanged in the patient room such as patient identifiers, safety checks, medications, tests etc. This addresses basic patient rights by keeping them patient informed and involved in their care. The patient, and key caregiver/family members are INCLUDED in the conversation as a partner in their care. What is it? A study outlined by the Joint Commission in 2009 found that 37% of handovers are deemed ineffective meaning the oncoming caregiver could not safely care for that patient. When we factor this in with our goal to include patients as partners in their care, it just makes sense that we would do bedside handovers. This process “transfers the trust” to the oncoming caregiver and reduces patient anxiety. Through a real-time exchange of information, the patient is involved in their care as well as teamwork and accountability are strengthened with the care-giver team. It aligns with Magnet and Baldrige criteria and National Patient Safety Goals Why is it important?

41 Bedside Handover Lessons
Reinforce the WHY, connect to safe patient care and to nurse satisfaction Address all barriers/resistance in training and ongoing in huddles and other communication Show what RIGHT looks like which includes engaging the patient in their care – not just talking over their bed Train and validate all staff Reward top performance and coach opportunities Track impact and communicate results Patient satisfaction by unit and HCAHPS Nurse communication, pain, responsiveness Round on patients to confirm behaviors Post results from rounding – thank you notes The bottom line – this is really a leader dependent initiative. Variance in leadership will results in variance in results. As leaders, we have to hold ourselves accountable for lack of results. Here is a summary of the steps we discussed in this hour to hardwire results with hourly rounding. © 2012 Studer Group

42 Myth #8: We Do Bedside Handover
A want of the habit of observing conditions and an inveterate habit of taking averages are each of them often equally misleading. I find this quote from Florence especially true. As leaders we WANT to think that our staff care about safety, delivering patient centered care and setting expectations for quality. But sometimes we blink… it is hard work to coach every time we see variance. It is hard work to hold people accountable. We THINK they are doing something because we WANT them to do it. With a scale of always and a goal of every patient every time, there is no room for the law of averages. Even one hint at gaps in hardwiring hourly rounding, you have true variance and like Florence says, this can be very misleading. “Notes on Nursing” Florence Nightingale 1854 © 2012 Studer Group

43 Other Ways to Validate Directly observe the practice on the unit
Leader rounding on patients Verify bedside handover is occurring by asking patients and their families Leader rounding on staff Ask them what is working well Highlight a WIN during Huddles Discharge phone calls or survey RESULTS – especially nurse communication Here are some other ways to validate and keep top of mind awareness. The bottom line to effective hourly rounding is results… are you getting them? © 2012 Studer Group

44 Myth # 9: Management is in charge of how we deliver care
“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?”  Do you have the right environment for your staff to be successful in their role, not just with hourly rounding but in providing care. As you make your rounds, keep this advice from Florence in your head. As you diagnose your own gaps,, your own opportunities for improvement and hardwiring hourly rounding, your own culture… How can I provide for the right thing to be always done? And if we asked you to describe hourly rounding, the key behaviors, the expected results, the benefit to the patients and their families and your specific role in the outcomes… could you do it>? “Notes on Nursing” Florence Nightingale 1854 © 2012 Studer Group

45 Myth #10: It won’t work on our unit
“I attribute my success to this - I never gave or took any excuse.”  ― Florence Nightingale This is my favorite quote from Florence… what are the true barriers we can overcome on our units to be more effective with hourly rounding, and what are the excuses… how can we eliminate the excuses… and maybe even help those that have decided they like a culture of optionality better than a culture of accountability to leave…. © 2012 Studer Group

46 Thank Your For All YOU Do
“Were there none who were discontented with what they have, the world would never reach anything better.”― Florence Nightingale, Notes on Nursing: What It Is, and What It Is Not You each are striving for something better or you would not be on the call. Thank you so much for your time and interest. Now we have 30 minutes for questions and sharing. Let’s first start by asking the question that we started with: Who wants to share which of the quotes resonated with them the most? And why? And what is one thing you can do differently to change it…. © 2012 Studer Group

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