Service and Quality, People and Process – How to Make

1 ©2010 Jay Kaplan, M.D.

Service and Quality,People and Process –

How to Make YourHow to Make Your Emergency Department

a Great Place

Jay Kaplan, MD, FACEP

Practicing Clinician and Director, Service/Operational Excellence, CEP America

Member, ACEP Board of Directors

“The future viability of our organization will be dependent on our ability to deliver Service Excellence.”

Mayo Clinic

“And importantly . . . A Commitment to Excellence will not manifest without theExcellence will not manifest without the leadership, support and example set by physicians.”


How We Need to Feel

Upfront Questions

What do you want?

A tti it?Are you getting it?

Do you love what you are doing?

Are there things getting in the way of yourin the way of your loving it more?


Department Workday AssessmentWork should be enjoyable. We want to make every workday satisfying and fulfilling.

Please rate TODAY’S workday.1=not worth it at all 2=poor 3=fair 4=good 5=fabulous

1. Overall enjoyment of the workday 1 2 3 4 5

What got in the way or contributed to being a great workday?__________________________________________________________________________________________________________________________________________________If not a great day, please give suggestions for preventing recurrence of the same

hassle/problem.___________________________________________________________________________________________If a great day, please say why and how we can ensure you have more of the same.___________________________________________________________________________________________2. I was treated with respect/courtesy by all members of the health care team. 1 2 3 4 5

3. Others were approachable with questions and/or suggestions. 1 2 3 4 5

4. Ease of working with other members of the Department. 1 2 3 4 5

5. Communication regarding patient plan of care treatments/tests. 1 2 3 4 56. I felt a cooperative attitude from hospital departments outside of mine. 1 2 3 4 5

©

7. I felt like I was a part of a team working together for everyone’s benefit. 1 2 3 4 5(our staff, patients, medical staff, etc.)

8. I felt appreciated/recognized for my efforts. 1 2 3 4 5Date: ____________ Other comments:Department: ____________Job title: ___________Shift (optional): _________________Name (optional): _______________

“ER”


Lessons Learned

Blame Nobody, Expect Nothing, Do Something (Bill Parcells, NY Post 1999)

Change starts at home – first me, then thee (Leadership)

It’s not the ideas, it’s the implementation (Accountability)

Perception is all there is (Almost)

Simple Truth #1: We Live in a Service Economy


Patient SatisfactionPatient Satisfaction

is

irrelevant.

We must create “memorable”We must create memorable experiences for our patients.

“Astonish” them.

Differentiate ourselves.


Key Words for Us

Satisfyto please, to be adequate to an end in view, to meet an obligation

Astonishto strike with sudden and usually great wonder or surprise

Memorableworth remembering


Workforce Shortage

Risk Management


Relationship between patient satisfaction, complaints and lawsuits

Physicians with lower patient satisfaction results are more likely to have patient complaints (RR 1.79;95% CI 1.38-2.33; p<.001)y p p

Each one point decrement in patient satisfaction scores is associated with a –

6% increase in complaints (RR 1.06, 95% CI 1.03 – 1.08;p<.0001)

5% increase in risk management episodes (RR 1.05, 95% CcI 1.01 – 1.09;p< .008)

Lower performing physicians were at greater risks for lawsuitsLower performing physicians were at greater risks for lawsuits (RR = 2.10;p 95% CI 1.13 – 3.90; p<.019)

75% of complaints were related to communication issues

Stelfox HT, et al, The American Journal of Medicine 2005; 118: 1126 – 1133

The Transparent Environment –Quality On-Line


Patient Satisfaction Measurement On-Line: HCAHPS

During your hospital stayDuring your hospital stay, how often did doctors/nurses:

treat you with courtesy and respect?

listen carefully to you?

explain things in a way you could understand?

Never/Sometimes/

Usually/ Always

Pay for Performance Coming Soon . . .

Value-Based Purchasing (VBP)= a specified percentage of hospital payment will g y

be conditional on performance– Reimbursement currently: 100% public reporting– Reimbursement FY 2013: 1% based on

performance (70% clinical quality/30% patient experience)

– Reimbursement FY 2017: 2% (at least)( )

Calculating Reimbursement– Will need to either be at 50%ile or show

improvement from previous score to earn points for that dimension


The New Paradigm

Outcome = Income

What Can You Do to Astonish . . .

Every Patient . . .

Every Colleague . . .Every Colleague . . .

Every Time?


Every Patient

Every Time

•“I am careful to make eye contact with every patient so that they know I am giving them my attention.”

•“I put a blanket over and under every elderly patient to preserve their body heat.

•“I tell seriously injured patients that they are at Vanderbilt, and that they are safe now”.

•“I keep patients informed and carefully explain their treatment to them.”

•“I turn the TV to the education channel, when it can help them.”

•“I tell the patient that it has been my honor to care for them.”

•“I use fun bandaids or decorate them!”

•“I always sit down when I talk to my patients”

•“I like to use warm blankets and footies to keep the patient comfortable.”

•“I remember to put my name on the white board.”

•“I keep a bag of angels. I wear one, and pass them on when I’m asked about them.”

•“I ask the patient about their family, pets, etc. to personalize the relationship.”

•“I teach the patient about taking their BP and make sure they understand their meds.”

•“I give patients a foot massage if they have had a long wait”

•“I spend as much time as possible using comfort measures, propping patient.”



Simple Truth #2: We All Believe We Give Great Service

We assume

= =Patient Satisfaction

Employee Satisfaction

Simple Truth #3: Simple Truth #3: It Just Isn’t So . . . It Just Isn’t So . . .


How Is It Really?

74% of patients are interrupted by physicians p p y p y

giving the initial history, average time of

interruption: 16.5 seconds.

The Effect of Physician Solicitation Approaches on Ability to Identify Patient. Concerns. J Gen Intern Med. 2005 March; 20(3): 267–270

Simple Truth #4: No Rest For The . . .

“If the other guy’s getting better, g y g g ,

then you’d better be getting

better faster than that other

guy’s getting better . . . or

you’re getting worse.”you re getting worse.-- Tom Peters

The Circle of Innovation


It’s Getting Harder to be Great

Simple Truth #5:The Best Definition of Madness is

To keep doing things To keep doing things

the same way the same way

and expect different and expect different

resultsresults . . .


Carpe Diem?

“I’d like to seize the day, but f ’unfortunately I’m

in middle management –

I’m just a physician/nurse -

and we’re notand we re not allowed to . . . ”

“And I’m already too busy just

seeing patients.”


Change Is Not Easy . . .

Without challenge there is no change.there is no change.

If you are always in your comfort zone, you are not where you need to be.

We have got to get comfortable with being uncomfortable.

Just because you can ride in spin class . . .

Have the Conversation: What Do We Want To Be Known For?


Have the Conversation: What Do We Want To Be Known For?

Exceptional Care, Extraordinary Servicein a Safe & Efficient Environment

To Change or Improve Anything

Systems People

PatientsStaffProcess Outcomes

PhysiciansFlow

Staff Engagement

Alignment of Behaviors


People - For Our Patients

Think Bakery

Key Words/Manage Up

Rounding on Patients

Discharge Follow Up Phone Callsg p

Perception & Expectation

P ti f CGolden=

Perception of Care

>Expectation

Perception of CareDead=

Perception of Care

<Expectation


Strategy #1: Think Bakery

What Do Our Patients See?



Is There A Difference?


Warm Up the Environment



What Do Our Patients Feel?

Sit Down


Sit Down

To Sit or Not to Sit?(A l E M d 2007))(Annals Emerg Med 2007))

Sitting: time overestimated 15%

Standing: time underestimated 7%

ProvidersProviders overestimated time 6%

What Do Our Patients Hear?

People (Patients) will not hear all of your words . . . Use Key Words or Phrases to express your caring.


Key Strategy #2: Key Words

“We’re going to do our best to keep you f t bl d i f d ”comfortable and informed.”

“We’ve got more pain medicine than you have pain.”

“You will be involved in the decisions made about your treatment.”

“Do you have any questions? Is there anything I can do for you right now ?”

Do Not Assume Our Patients Know . .

Who we are;

How good we are;

How much we care

How long some process takes;

What the process will involve;

What will follow.


Communication Strategy: Think Baseball -Touching All the Bases

I Introduce

The Fundamentals of Communication

C

A

Connect

Acknowledge

R

E

Review

Educate/Exit


II IntroduceIntroduce self with title, Service recovery if self with title, Service recovery if

needed, needed, InspireInspire confidence, Manage upconfidence, Manage up

CC Connect Connect -- with the patient & family, with the patient & family,

ContactContact –– Verbal/Visual/NonVerbal/Visual/Non--MedicalMedical

AA AcknowledgeAcknowledge h t th ti t h idh t th ti t h idAA AcknowledgeAcknowledge what the patient has said, what the patient has said,

ArticulateArticulate what you have found and what what you have found and what you think is going on you think is going on -- Use Key Words Use Key Words

RR ReviewReview the plan of care, what tests and the plan of care, what tests and treatments are to be accomplished, and how treatments are to be accomplished, and how long it is going to take, long it is going to take, RememberRemember touch touch g g g ,g g g ,all the bases and discuss durationall the bases and discuss duration

EE Educate Educate What to Expect/Home Care, What to Expect/Home Care,

EnsureEnsure UnderstandingUnderstanding--Ask “What Ask “What questions do you have? Is there anything questions do you have? Is there anything else I can do for you?”, else I can do for you?”, ExitExit -- Say GoodSay Good--ByeBye

Key Strategy #3: Rounding

Rounding by Leaders/Charge Nurses

Rounding by Staff q ½ - 1 hour

Rounding by Physicians/Residents/MLP’s


Rounding Log

Patient Perception Quality


Rounding by Staff: 30-Minute and Hourly Rounding

-Use opening key words and/or actions to introduce

-Conduct environmental assessment. (call light, warmand/or actions to introduce

yourself, your skill set, your experience and others.

-Perform scheduled tasks.

-Address PPD – Pain, Plan of Care and Duration (wait times)

assessment. (call light, warm blanket, side rails up, etc)

-Use closing key words and/or actions.

-Explain when you or others will return.

D t th d th)

-Assess additional comfort needs. (warm blanket, pillow, etc)

-Document the round on the log or chart.

Hourly Rounding (ED) –Journal Emergency Medicine July 2010

Operational Efficiency: Call lights reduced 34.7%

Operational Efficiency: Patients/Families approaching the nursing station reduced 39.4%

Finance: LWOBS reduced 22.6%

Clinical Quality: Falls reduced 58.8%

Patient Satisfaction: Increased 20%ile points


Key Strategy #4 - Follow Up Phone Calls

Type of Adverse Events

Other

“Nearly 1 in 5 patients”*

62%16%

5%

13%

4%

Adverse Drug Event

Procedure Related

Nosocomial Infection

Fall

Other400 patients surveyed

76 (19%) had adverse events after discharge

* 81 events occurred in 76 patients

* “Adverse Events After Discharge from Hospital”, Annals of Internal Medicine, February 2003

How To Complete the Patient Experience: Follow Up Phone Calls

Engel K, Heisler M, Smith D, Robinson C, Forman J, Ubel P, “Patient Comprehension of Emergency Department Care and Instructions: Are Patients Aware When They Do Not Understand?,” Annals of Emergency Medicine. July 11, 2008•78% did not have full understanding•80% of that 78% did not understand that they did not understand


Post Visit CallsLikelihood of Recommending - ED

Source: New Jersey Hospital, Total beds = 775; 3Q2007 – 2Q2010 Courtesy Studer Group

Improves Physician Performance… (January-June 2008, Press Ganey National %tile rank)

97th 94th97th 94th

81st72nd

51st

28th40

50

60

70

80

90

100

Doctorsmaking d/ccalls

Other callsbeingmade28th

0

10

20

30

40

Doctors Section Likelihood ofRecommending

made

No call


Sit Down/ before you get up, use a key phrase(e.g., “Do you have any questions? Is there

Summary – For Our Patients

( g , y y qanything else I can do for you? or “Does this all make sense to you?”Think ICARE- Touching all the basesRounding – by charge nurses, by staff, by docs/PA’sFollow up Phone Calls – start with 2 per shift or per day

Summary

We live in an experience economy.p y

“Satisfy” is not enough.

If the other guy’s getting better . . .

Q lit t i thQuality gets you in the game.

Service helps you win.


Thank you.Jay Kaplan MD, [email protected]

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Service and Quality, People and Process – How to Make