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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.”
2 ©2010 Jay Kaplan, M.D.
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?
3 ©2010 Jay Kaplan, M.D.
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”
4 ©2010 Jay Kaplan, M.D.
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
5 ©2010 Jay Kaplan, M.D.
Patient SatisfactionPatient Satisfaction
is
irrelevant.
We must create “memorable”We must create memorable experiences for our patients.
“Astonish” them.
Differentiate ourselves.
6 ©2010 Jay Kaplan, M.D.
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
7 ©2010 Jay Kaplan, M.D.
Workforce Shortage
Risk Management
8 ©2010 Jay Kaplan, M.D.
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
9 ©2010 Jay Kaplan, M.D.
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
10 ©2010 Jay Kaplan, M.D.
The New Paradigm
Outcome = Income
What Can You Do to Astonish . . .
Every Patient . . .
Every Colleague . . .Every Colleague . . .
Every Time?
11 ©2010 Jay Kaplan, M.D.
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.”
12 ©2010 Jay Kaplan, M.D.
13 ©2010 Jay Kaplan, M.D.
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 . . .
14 ©2010 Jay Kaplan, M.D.
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
15 ©2010 Jay Kaplan, M.D.
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 . . .
16 ©2010 Jay Kaplan, M.D.
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.”
17 ©2010 Jay Kaplan, M.D.
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?
18 ©2010 Jay Kaplan, M.D.
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
19 ©2010 Jay Kaplan, M.D.
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
20 ©2010 Jay Kaplan, M.D.
Strategy #1: Think Bakery
What Do Our Patients See?
21 ©2010 Jay Kaplan, M.D.
22 ©2010 Jay Kaplan, M.D.
Is There A Difference?
23 ©2010 Jay Kaplan, M.D.
Warm Up the Environment
24 ©2010 Jay Kaplan, M.D.
25 ©2010 Jay Kaplan, M.D.
What Do Our Patients Feel?
Sit Down
26 ©2010 Jay Kaplan, M.D.
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.
27 ©2010 Jay Kaplan, M.D.
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.
28 ©2010 Jay Kaplan, M.D.
Communication Strategy: Think Baseball -Touching All the Bases
I Introduce
The Fundamentals of Communication
C
A
Connect
Acknowledge
R
E
Review
Educate/Exit
29 ©2010 Jay Kaplan, M.D.
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
30 ©2010 Jay Kaplan, M.D.
Rounding Log
Patient Perception Quality
31 ©2010 Jay Kaplan, M.D.
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
32 ©2010 Jay Kaplan, M.D.
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
33 ©2010 Jay Kaplan, M.D.
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
34 ©2010 Jay Kaplan, M.D.
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.
35 ©2010 Jay Kaplan, M.D.
Thank you.Jay Kaplan MD, [email protected]