six sigma approach to effective communication to improve patient safety and satisfaction
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Six Sigma Approach to Effective Communication
to Improve Patient Safety and Satisfaction
Lois Yingling, RN, MSN, CPHQPatient Safety Officer, Florida Hospital Winter Par k Memorial Hospital
WCBF’s 9 th Annual Lean Six Sigma and Process Improvement Healt hcare Summit
May 12, 2010
1908 Florida Sanitarium
2008 Florida Hospital Orlando
• Founded by Seven-day Adventist Church in1908
• Faith based health system committed to providing whole person care
• 2188 acute care beds on seven campuses in tri-county area– Children’s Hospital under construction will be 8th
hospital• Over 16,000 employees• Over 1900 physicians on staff• Over 2900 volunteers
The Hospital That Winter Park Built
• Civic minded citizens shared a vision for a community hospital
• 1951 non-profit Memorial Trust Organization incorporated to accept donations
• Fifty-eight bed WPMH opened in 1955 at a cost of $660,000
• One-hundred beds added in 1960
The Hospital That Winter Park Built
• Medicare Participation 1966 • Columbia partnership 1994 to 2000
• Purchase by FH in 2000• Dr. Phillips Baby Place opened June 2007
• New tower for Dr. Phillips Baby Place due to open Mother’s Day 2010
Current State 2010• 330 beds after May 2010• 225 physicians on staff• 1,428 employees• 215 Volunteers • 15,872 annual admissions • 39,319 annual ED visits• 9,109 annual surgeries• 2,377 annual deliveries
DMAIC
Define
Opportunity Statement:
• The Top Box Winter Park Nurse Communication Score for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) in September 2009 is 71% (25 th
percentile).
• The Top Box for Willingness to recommend is 65% (40 th percentile)
*Top Box = Always
Goal:
• Improve *Top Box NurseCommunication to 80% (80th Percentile)
• Improve *Top Box Willingness toRecommend to 69%(50th Percentile)
*Top Box = Always
Why is focus on communication?
• Communication root cause of 66% of all Sentinel events (The Joint Commission)
• Sentinel Event unexpected occurrence causing death or harm or the risk thereof signaling need for immediate investigation
Why is communication important?
• Improve Safety for all patients
• Nurse communication is perceived asa key driver of “Willingness toRecommend ” in our organization
• “Willingness to Recommend keyaccountability
Scope:
• 50% of eligible patients randomly selected to receive a survey in the mail
• Metrics limited to patients who respond to the survey in the designated time frame (window is 8 weeks)
• Response rate is 31 to 33%
HCAHPS:
• Standardized survey designed & tested by AHRQ & DHHS to measure patient perceptions of hospital care for comparison to other hospitals in 2002
• Endorsed by NQF in 2005
• Implemented by CMS in 2006
HCAHPS:
• Public reporting 2008
• Hospital submission voluntary
• Medicare payment reduced by 2 percentage points if choose not to submit
HCAHPS Aspects of Care:
•• *Communication with nurses*Communication with nurses & physicians• Responsiveness of staff• Cleanliness & quietness•• *Communication about medication*Communication about medication•• *Discharge information*Discharge information• Overall rating• Willingness to recommend
* Communication Metrics in control of nursing
DMAIC
Measure
SeptemberAugustJulyJuneMayAprilMarchFebruary
0.72
0.70
0.68
0.66
0.64
0.62
0.60
Nurse Communication MAPE 3.66600
MAD 0.02390
MSD 0.00072
A ccuracy Measures
A ctual
F its
Variab le
TOP Box Nurse CommunicationLinear Trend Model
Source: HCAHPS February through September 2009
SeptemberAugustJulyJuneMayAprilMarchFebruary
0.25
0.20
0.15
0.10
0.05
Percentile
MAPE 42.5704
MAD 0.0455
MSD 0.0025
A ccuracy Measures
A ctual
F its
Variab le
Trend Analysis Plot for Percentile Nurse CommunicationLinear Trend Model
Source: HCAHPS February through September 2009
SeptemberAugustJulyJuneMayAprilMarchFebruary
0.65
0.64
0.63
0.62
0.61
0.60
0.59
0.58
0.57
0.56
Willingness to Recommend
MAPE 3.64435
MAD 0.02205
MSD 0.00058
A ccuracy Measures
A ctual
F its
Variab le
Top Box Willingness to RecommendLinear Trend Model
Source: HCAHPS February through September 2009
SeptemberAugustJulyJuneMayAprilMarchFebruary
0.40
0.35
0.30
0.25
0.20
Percentile
MAPE 20.5667
MAD 0.0516
MSD 0.0035
A ccuracy Measures
A ctual
F its
Variable
Trend Analysis Plot for Percentile Willingness to RecommendLinear Trend Model
Source: HCAHPS February through September 2009
SeptemberAugustJulyJuneMayAprilMarchFebruary
0.62
0.60
0.58
0.56
0.54
0.52
0.50
0.48
0.46
Medication Communication
MAPE 5.10400
MAD 0.02708
MSD 0.00094
A ccuracy Measures
A ctual
F its
Variab le
Top Box Medication CommunicationLinear Trend Model
Source: HCAPS February through September 2009
SeptemberAugustJulyJuneMayAprilMarchFebruary
0.82
0.80
0.78
0.76
0.74
0.72
0.70
DC Inform
ation
MAPE 4.82035
MAD 0.03562
MSD 0.00177
Accuracy Measures
Actual
F its
Variable
Top Box Discharge Information InformationLinear Trend Model
Source: HCAHPS February through September 2009
DMA IC
Analyze
Key Words: Accountability & Intentional
Stake HolderMinimal
EngagementModest
Engagment NeutralModerately Engaged
Strongly Engaged Influence strategy
Administration X
Intentional Rounding by Administration
Clinical Directors X
Accountability to administration for Assigned Intentional Rounding by Clinical Directors
Non-Clinical Directors X
Accountability to administration for Assigned Intentional Rounding by Non-Clinical Directors
Nurse Mangaers X
Accountability to Directors for Daily Intentional Rounding on units
Assistant Nurse Managers X
Accountability to NMs for Daily Intentional Rounding on units
Front line staff X
Accountability to NMs & ANM's for Intentional Best Practice Behaviors
X = current state = level of commitment to succeed
Stake Holder Analysis
D is-S atisfiers
P atien t
Misce llaneous
Equipm ent
Sta ff
Env ironm ent
Measurem ents
r e turn r a te
samp le si ze va r ie s
50% of e l ig ib le pa tie nts
r e sponde r (pa tient/ fam i ly)
ma i led survey
clea nl ine ss
n ight no ise
construction new towe r
one phone l ine fo r 2 pa tients
one TV for 2 pa tients
may no t have shower in r oom
sma l l ba throoms
most r oom s SP
o ld bui ld ing
slow re sponse time
is dr ive rpe r cep tion tha t o ld bui ld ing
wrong pe r son on the bus
supe rvi sorla ck o f a ccountab i l i ty to
a ccountab i l i tyla ck o f pe r sona l
o ld beds
la ck o f a l l in ones a l l r ooms
EMR de tr a ctor
capa city
room ma tes
visi to r s
food
Barriers to Patient Satisfaction
In Control:
•Personal Accountability
•Accountability to supervisor
•Intentionality
•Scripting
•People: Right people on the bus
•Response time
? Control
•Noise
•SP Rooms
•Visitors
•Rm Mate
•EMR detractor
•Phone Lines
•Food
•All in ones
•Equip
Out of Control
•Age of building
•Room/BR size
•Construction
•Survey process
•TVs
DC Information
Medication Communication
Nurse Communication
Willingness to Recommend
85.00%
80.00%
75.00%
70.00%
65.00%
60.00%
55.00%
50.00%
Data
Boxplot
DMAIC
Improve
Multi-Modal Strategies for Change
The Patient Experience • Clinical Excellence
– National Patient Safety Goals– Clinical competence– Sacred Trust
• Customer Service– Treating the patient with respect & dignity– Common courtesy
• Clinical Excellence + Customer Service =Patient Experience
Multi-Modal Strategies for Change
Appreciative Inquiry (October 2009)• Pays special attention to “the best of the past
& present” in order to “ignite the collective imagination of what might be” Dr. David Cooperrider
• Leverage strengths in an organization to make change
• Appreciative inquiry questions for staff (personal responsibility)
Multi-Modal Strategies for Change
Appreciative Inquiry Example questions• What can I personally do to improve our
Patient Service scores?• What do I like best about my job?• What can I do to promote positive employee
attitudes on my unit?• What have I done to recognize a co-worker
this week?• How do I deal with a difficult “unloveable”
patient?
Multi-Modal Strategies for Change
Call Backs (October 2009
Intentional Rounding by Administrative Team (November 2009)
• Administrators assigned to specific units• Currently Monday through Friday
– Currently day shift
Multi-Modal Strategies for Change
Daily Communication to Nurse Managers
• HCAHPS Scores• Accolades • Feed back loop specific to issues not
addressed at unit level• Scores & accolades
– Communicated daily to staff– Posted on units
Multi-Modal Strategies for Change
Intentional Rounding by Nurse Managers (December 2009)
• Mentoring by Directors• Currently Monday through Friday
– Currently day shift– All new patients on all units– Service recovery
• Immediate follow-up with staff– Positive feed back– Opportunities for improvement
Multi-Modal Strategies for Change
Intentional Rounding by Assistant Nurse Managers (January 2010)
• Mentoring by Directors & Nurse Managers• Every patient
– Every day– Every shift
• Immediate follow-up with staff– Positive feed back– Opportunities for improvement
Multi-Modal Strategies for Change
Daily Communication to Patient by Frontline Staff (January 2010)
• Today’s Plan (Plan of Care)– Automatic computer printout from electronic
medical record
• Frontline staff nurse reviews with patient– Nurse can add additional information (time a
procedure might be done)
• Encourage patient to write down questions for the physician
Multi-Modal Strategies for Change
Introductions at shift change (January 2010)• Departing nurse at end of shift
– It has been my pleasure to care for you during my shift
– This is “Anne” who will be caring for you after I leave
• Anne is one of our best nurses
• Oncoming nurse– I am pleased to meet you– Writes phone number on white board
Multi-Modal Strategies for Change
Transition to all RN Model (January 2010)• First Unit transitions to all RN model
– 21 bed progressive care unit– All semi-private rooms with exception of one
private room– Oldest part of building– Space constraints– New manager
Multi-Modal Strategies for Change
Scripting (February 2010)• Welcome Mr. Jones, we’ve been expecting
you.• Mrs. Jones, Can I do anything else for you
before I leave?• Thank you for allowing us to care for you
today, Miss Jackson.• Would you like me to pray with you?
DMAIC
Control
March
February
January
December
November
October
September
August
July
JuneM
ayApr il
March
February
0.74
0.72
0.70
0.68
0.66
0.64
0.62
0.60
Nurse Communication
MAPE 3.74163
MAD 0.02493
MSD 0.00085
Accuracy Measures
Actual
F its
Variable
Top Box Nurse CommunicationLinear Trend Model
Source: HCAHPS February 2009 through 2010
March
February
January
December
November
Oc tober
S eptember
August
July
JuneM
ayApr il
March
February
0.675
0.650
0.625
0.600
0.575
0.550
0.525
0.500
Willingness to Recommend
MAPE 5.30697
MAD 0.03054
MSD 0.00177
A ccuracy Measures
A ctual
F its
Variab le
Top Box Willingness to RecommendLinear Trend Model
Source: HCAHPS February 2009 through March 2010
Nurse CommunicationW illingness to Recommend
75.00%
70.00%
65.00%
60.00%
55.00%
50.00%
Data
Boxplot of Willingness to Recommend, Nurse Communication
March
February
January
December
November
October
September
August
July
JuneM
ayApr il
March
February
0.65
0.60
0.55
0.50Medication Communication
MAPE 5.02837
MAD 0.02807
MSD 0.00130
A ccuracy Measures
A ctual
F its
Variable
Top Box Medication CommunicationLinear Trend Model
Source: HCAHPS February 2009 through March 2010
Medication CommunicationWillingness to Recommend
65.00%
60.00%
55.00%
50.00%
Data
Boxplot of Willingness to Recommend, Medication Communication
March
February
January
December
November
October
September
August
July
JuneM
ayApr il
March
February
0.82
0.80
0.78
0.76
0.74
0.72
0.70
DC Inform
ation MAPE 4.23569
MAD 0.03158
MSD 0.00133
Accuracy Measures
Actual
F its
Variable
Top Box Discharge InformationLinear Trend Model
Source: HCAHPS February 2009 through March 2010
DC InformationWillingness to Recommend
85.00%
80.00%
75.00%
70.00%
65.00%
60.00%
55.00%
50.00%
Data
Boxplot of Willingness to Recommend, DC Information
Lessons Learned• Clinical Excellence & the Patient Experience
is a journey not a destination
• Culture change – Awareness & accountability
• Process– Standardized– Intentional
• Right people on the team
Lessons Learned
• Construction night noise especially disruptive
• Families able to respond for patient
• Early service training does not yield success
• Embed accountability & process improvement before service training
• Innovation is copying a good idea
Lessons Learned
Small tests of change are working and moving in the right direction
HCAHPS Department 2009 4th QT 2009 1st QT 2010
WP Hospital 59% 58% 65%
Ortho (1960) 67% 66% 73%
Women's (2620) 51% 50% 58%
SCU (4010) 53% 55% 46%
MSU (4040) 51% 46% 50%
SPCU (4050) 56% 63% 51%
SW 1 (4055) 48% 46% 76%
MPCU (4070) 58% 58% 59%
M/B (4090) 68% 59% 85%
South 1 (9991) 50% 45% 56%
The Effectiveness (E) of the Result Is Equal to the Quality (Q) of the Solution Times the Acceptance (A) of the Idea …
“A” is Critical to Effectiveness
Q x A = EQ x A = EQ x A = E
What makes Change Successful?
10 X 1 = 10
10 X 8 = 80
It takes time to gain acceptance by 1,428 employees
Jim Collins
“I don’t care how hard this period is. You have to have the combination of believing that you will prevail, that you will get out of this, but also not be the Pollyanna who ignores the brutal facts. You have to say that we will be in this for a long time and we will turn it into a defining event, a big catalyst to make ourselves a much stronger enterprise.”
Thank You
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