1. THE “ALWAYS RESPONSIVE”
QUALITY DEMONSTRATION PROJECT
Gaurdia Banister, RN, PhD; Sharon Badgett-Lichten, LICSW; Edward Coakley, RN, MSN;
Ronald Doncaster, MS; Richard Evans, MA; Brian French, RN, PhD(c); Debra Frost, RN, MS;
Colleen Gonzalez, RN, MS; Cindy LaSala, RN, MS; Liza Nyeko, MS; Kate Roche, RN, MS;
Jennifer Sargent, RN, MSN; Meridale Vaught Baggett, MD
Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.” —Florence Nightingale
AIM STATEMENT
• The specific aim of the “Always Responsive” Demonstration Patient & Family Centered Interventions Staff Centered Interventions
Project is to ensure patient and family needs are met in a routine • Hourly rounding • Care team communication boards
and timely fashion by caregivers who are “always responsive.” • Care team face sheets • Support service report cards
• Seven interventions were designed to show measurable change • Patient & family white boards • Learning coach role for staff support
in one year. • Welcome video
BACKGROUND/ SETTING & POPULATION
SIGNIFICANCE
PROJECT DATES: JULY 1, 2011–JUNE 30, 2012 • This project is implemented and has
• 20 beds, private rooms
been evaluated on two adult inpatient Unit A
• Nursing staff: RN & PCA
medicine units at Massachusetts
General Hospital (MGH) in Boston,
• The Institute of Medicine’s report, Crossing the Quality Chasm • 26 beds, private/semi-private
Massachusetts. A third unit is used for Unit B
(2001), the public reporting of the Health Consumer Assessment of • Nursing staff: RN & PCA
comparison.
Healthcare Providers and Systems (HCAHPS), and the evolving
use of patient experience measures in accreditation and pay-for- • Patients on all 3 units are admitted Control • 25 beds, private/semi-private
performance programs, have motivated hospitals and healthcare with both acute and chronic medical Unit • Nursing staff: All RN
systems to strive to become more patient and family centered. problems.
• The Picker Institute, dedicated to advancing the principles of
patient-centered care, has reframed the “Never Events” concept in
order to promote the idea of Always Events®, a quality organizing
principle designed to promote the delivery of patient and family
centered care.
• Always Events® are aspects of the care experience that should
always occur when patients and families interact with health care
PROJECT DESIGN & STRATEGY
professionals.
• Guiding Themes • The ultimate goal is to encourage self-agency at the unit level so the interventions
– Communication: The interactions and exchange of become embedded in the unit culture.
information between patients and providers, as well as among
• An interdisciplinary project team designed and implemented the interventions.
the team of providers responsible for a patient’s care, must
involve the patient in an appropriate patient-centered way. • Interventions were piloted and adapted to the care unit and patient population.
– Care transitions: Patients need an appropriate level of • Monthly team meetings and weekly ad hoc work group meetings ensured clear
communication when moving from one provider or health care communication and adherence to the project timeline.
setting to another. • A rolling, staged approach was used to implement the seven interventions to facilitate
• This pre/post test quality demonstration project was designed to: effective change management.
– Improve patient satisfaction with their care • A pre/post test design was used to measure the impact of the organizational
– Reduce the number of patient falls development strategies on the quality and safety of care as measured by:
– Reduce the incidence of hospital acquired pressure ulcers – Patient satisfaction (HCAHPS staff responsiveness) scores
(HAPUs) – Rate & incidence of patient falls
– Prevalence rate of HAPUs
INTERVENTIONS
Hourly Safety Rounds Care Team Face Sheets Patient/Family White Boards MGH Support Card
Hourly Safety Rounds Tool Kit:
• Coaching for
Hourly Safety
Rounds
• Staff Guide for
Hourly Safety
Rounds
Patient and Family Interviews:
• “My care seems to be more
seamless and comprehensive.” • Internet-based software
application developed and
implemented at Newton-
Additional Interventions Wellesley Hospital, Newton, MA.
• Allows the clinical teams to rate
• Patient Care Team Communication the service they receive from
Boards were designed to Provides an “anchor” by clarifying • Facilitate two-way communication MGH departments
communicate key quality data to staff. the structure and roles of the between interdisciplinary team – Specimen Transport
• Learning coaches stimulated primary care team members and the patient and family – Materials Management
discussions with unit leadership and • Inform the interdisciplinary team Customer Service
Patient and family interviews: of the patient’s and families’ – Pharmacy
staff, conducted education or
remediation, and guided group • “I like the face sheet because needs, preferences, and priorities • Designed to improve efficiency
decision-making. some staff already looked • Enhance coordination and so the staff has more time to
• A 6-minute welcome video is available familiar to me when they came integration of the plan of care spend with patients
in English and Spanish. The video into the room.” leading to discharge
includes open captioning for patients • “Very helpful to know who is • Tool Kit:
who are deaf or hearing impaired. caring for you.” – Staff guide for White Boards
OUTCOME MEASURES PRACTICAL IMPLICATIONS &
& RESULTS LESSONS LEARNED
Patient Survey Data (n = 92) • Several of the interventions have been embedded into 12 “innovation units” and some
• 75% of patients found the face sheets helpful in identifying have been expanded to all care units at MGH. The service changes include:
caregivers – Hourly safety rounds, a core part of the “Always Responsive” project, has renewed
• 90% reported that they were satisfied with the white boards. focus across MGH. Work continues to assure wider adoption of this best practice.
Patient/family centered white boards are being installed in all patient rooms.
– “Whenever I press the call button, people come immediately.”
– “The attentiveness of the nursing staff was excellent” – Care team face sheets are now included in the Patient & Family Notebook utilized
on the Innovation Units. A similar notebook is planned for use throughout MGH
– “The nurses were excellent. They were right there with me
later this year.
when I was having a bad day. They came in and took the time
to sit with me and help me get through my tough times.” – The staff communication boards are being promoted throughout MGH to ensure
– “Caregivers are communicating better and on the same page.” staff is informed of quality data.
– “White Board is great! Keep it updated.” – Implementation of multiple interventions in a short time frame proved challenging.
– Tight scheduling of multiple intervention roll outs when combined with other
Staff Survey Data (n=44) hospital wide initiatives was difficult for administration and staff.
• Staff focus groups and surveys indicated a positive response to
the use of face sheets (66%), care team communication boards
(80%), hourly safety rounding (92%) and patient and family
centered white boards (100%) in delivering patient care.
HCAHPS
• The staff responsiveness
indicators on the HCAHPS
survey show significant
improvement.
Falls & HAPUs
• The pre/post intervention
results for rate of falls and
HAPUs are mixed. One
intervention unit and the control unit experienced a decrease in the
rate of falls and HAPUs. The second intervention unit had an
increase in both areas. These variations may be due to differences Project Team
in staffing pattern, competing initiatives during the same time
period, resignation of the Clinical Nurse Specialist on one
intervention unit, and the level of successful implementation of the
“Always Responsive” interventions, particularly safety rounds.
Thank you to the Picker Institute’s Always Events®
initiative for supporting this project.