Quality Improvement Project Guide

Acute Care Hospital Experience Quality Improvement Guide A resource designed to guide you through the 3 phases of an improvement project: Improving the Planning Project management for QI: developing a blueprint for success Reflecting Analyzing current processes: where to begin and what you can do to make change Executing Strategies, tools, and tips for turning ideas into action

Atrium Building, Innovation Place 241-111 Research Drive Saskatoon, SK S7N 3R2 Canada P: 306-668-8810 F: 306-668-8820 E: info@hqc.sk.ca W: www.hqc.sk.ca ISBN 1-897155-17-4 Some of the material in this quality improvement guide was supplied by and is used with the kind permission of other organizations, who retain copyright over their original work. © 2006 Health Quality Council Please contact the Health Quality Council for written permission to distribute or copy this document, in whole or in part. Permissions do not extend to any materials within this document that are used with the permission of a third party. Please use the following citation style when referring to this document: N Wohlgemuth, S Oosman, S Furniss. Improving the Acute Care Hospital Experience: Quality Improvement Guide. Saskatoon: Health Quality Council. June 2006. Health Quality Council also wishes to acknowledge the valuable contributions of other team members to the development of this guide: • Catherine Delaney, Knowledge Exchange Consultant • Laurie Gander, Program Director • Mary Smillie, Senior Knowledge Exchange Consultant • Katherine Stevenson, Senior Knowledge Exchange Consultant

Project Checklist Are you ready to launch a quality improvement project? You may find this checklist a helpful reference in planning your improvement project. As you go through the list, check the box if you can answer “YES” to the statement. This will quickly identify areas where you might need some further planning before you get started. We have a clear goal and scope of the project. We have agreement in the senior clinical and management community that there is a gap between where we are now and where we could be. We have active support from senior clinical and managerial leaders. We have completed the Blueprint for Success or project plan. A leadership team is established and members are aware of their roles and responsibilities. (LIST) Our project sponsor(s) is confirmed. We have explicitly described the necessary commitment required and specific roles and responsibilities of front-line team members. As well, we have described our expectations and the expected benefits for the organization and the front-line team(s). (LIST) We have measurement and reporting systems set up. We know how and when we will involve patients, caregivers, and other users of the system we want to improve. We have a process for recruiting the front-line team(s). We have recruited the required front-line team(s) with a designated team leader. a. The front-line team(s) and the team leader(s) is: b. The team(s) will be assembled by: (DATE) Patient Experience Survey: Quality Improvement Guide Health Quality Council 2006

Project Checklist The team(s) is able to focus on the project and not get side tracked by other demands. We have secured the necessary budget and other resources required to support all elements of the project. We have completed a “quality improvement skills” training needs assessment for front-line team(s) members. We have support available for the front-line team(s) members to develop the necessary quality improvement skills and to complete the project Improvement Charter. We have the necessary support available to enable the front-line team(s) to analyze current care processes. For example, using such tools as process mapping or cause/effect diagram. We know how we are going to launch the project. We are already planning how we will acknowledge the quality improvement achievements made by the front-line team(s). We are already planning how to ensure that the improvements made are continued. We are already planning how to spread the improvements to other parts of the organization. Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/reading/collaborative.pdf Patient Experience Survey: Quality Improvement Guide Health Quality Council 2006

Phase One Included in this section is information on: • Key elements of an improvement project • Creating a “blueprint for success” • Developing effective teams Patient Experience Survey: Quality Improvement Guide P—1 Health Quality Council 2006

Introduction to QI Planning Lloyd Provost (co-author of the Model of Improvement and the Improvement Guide) identifies three key elements to achieve significant improvement: • The will to do what it takes to change to a new system; • Ideas on which to base the design of the new system; and, • A clear plan of execution of the ideas. (L. Provost, Telehealth Presentation, October 5, 2005) While we often have a strong will to improve and many ideas (from the literature and our own experiences), execution—organizing, supporting, sustaining and spreading improvement—is a challenge we all share. This section of the QI Guide provides a blueprint for success: an outline of the key elements needed to organize and support an improvement project in the acute care setting. This blueprint combines project management and improvement science principles. You may already have your own project planning tool; use the format you prefer. To better plan for success, you might want to ensure that your plan includes: • An explicit statement of what is expected from the improvement effort; • What supports the improvement team can expect from the organization; • Any limitations or constraints that must be taken into consid- eration; and, • An individual or team providing overall regional leadership for the improvement of patient experience. After completing this form, you should have a good start on your improvement journey. The next steps will be working with facility/unit level teams in analyzing current processes, identifying opportunities for improvement, and testing ideas on a small scale. Patient Experience Survey: Quality Improvement Guide P—2 Health Quality Council 2006

Blueprint for Success Please see the Notes to the Blueprint on page P—5 for more information on completing this form. 1. Determine priority area (s). You may wish to look at survey results and your organizational goals. 2. Identify RHA leadership team members. Name: Role: . Name: Role: . Name: Role: . Name: Role: . Name: Role: . 3. Improvement aim(s) for region. Aim should be clear, specific, measurable, time-specific, and patient-centred. 4. Project deliverables. What will success look like? a. What numerical target are you striving for on repeat survey (patient perspective)? b. What changes in the system are you expecting (provider behavior perspective)? Patient Experience Survey: Quality Improvement Guide P—3 Health Quality Council 2006

Blueprint cont’d Please see the Notes to the Blueprint on page P—5 for more information on completing this form. 5. Outline project scope. What are the project boundaries? a. Time frame of project: Start date: End date: b. Number of teams necessary to achieve aim: c. Number of facilities and units to be involved: d. Staff time limits for the duration of the project: Hours per week FTE per month e. Cost limits: $ 6. Determine project sponsor(s). 7. Expectations for reporting between RHA leadership team and front-line team(s). 8. Project links to broader RHA goal(s). Project linked to the following RHA goal(s): Patient Experience Survey: Quality Improvement Guide P—4 Health Quality Council 2006

Notes to the Blueprint 1. Determine priority area Consider your results from the Patient Experience Survey, as well as broader organizational/regional goals. Examples of priority areas from the survey include discharge planning, provider- patient communications, pain management, etc. 2. Identify RHA leadership team members Some key points to keep in mind when establishing your team: • Ideal team size is 6-12 people • Try to find a range of expertise • Include both the “keen” and “not so keen” More information on teams is included in Additional Information, starting on page P—7. 4. Project deliverables What will success look like? Consider both: • An outcome goal, or numerical measure. For example, if your improvement area is discharge planning your goal might be: 100% of our patients will know what side effects to watch for at home. • A process goal, something that will show you if changes to process are resulting in more effective care. For example, if your improvement area is pain management, your goal might be: All patients will have a pain management plan completed and at- tached to their chart. 5. Project scope Determine how many resources (money, time) can be devoted to the project to achieve your aim. Consider: • Project timeframe—when does it start and end? • How many front-line teams need to be established? • How many facilities will be involved and which ones? • Staff time limits—how many FTE hours? 6. Project sponsor(s) The project sponsor can be an individual or a group. The role of the sponsor is to be the liaison between the front-line team and RHA leadership, and to help teams overcome obstacles. Patient Experience Survey: Quality Improvement Guide P—5 Health Quality Council 2006

Additional Information Patient Experience Survey: Quality Improvement Guide P—6 Health Quality Council 2006

Additional Information: Team Development 1. Team size It’s important to consider size when developing QI teams. A team that is too large may have difficulty coordinating schedules for meetings, and meetings may involve lengthy discussions and little consensus. On the other hand, a team that is too small may be missing representa- tion from key groups, and might feel overwhelmed by having to accomplish so many tasks with so few resources. The optimal team size is between 6 and 12 members. Optimal team size: not too big, not too small—just right! Patient Experience Survey: Quality Improvement Guide P—7 Health Quality Council 2006

Additional Information: Team Development 2. Types of expertise Including the right people on the QI team is critical to successful improvement efforts. Recruit staff and care providers from all aspects of the patient experience you are trying to improve. For example, if your improvement focus is on discharge planning, your team might include: nurses, physicians, occupational therapists, physiotherapists, social workers, and pharmacists. Each discipline will provide a unique perspective on the processes of care involved in safely transitioning patients from hospital to home. There are three basic areas of expertise that should be part of any team. These include expertise in organizational authorization, clinical or technical expertise, and someone with knowledge about the system of care. You may have one or more individuals with each kind of expertise, or an individual with expertise in more than one area. Regardless, try to ensure that all three types are represented on your team. Team Sponsor The Team Sponsor should have enough authority in the organization to implement suggested changes and overcome barriers. The Team Sponsor understands the implications of the proposed change on the various parts of the system, as well as the more remote consequences a change might trigger. It is important that the Team Sponsor have authority in all areas affected by the change, and the authority to allocate resources (time, people, money) needed to achieve the aim. Clinical/Technical Experts A Clinical or Technical Expert is someone who knows the subject matter intimately and who understand the processes of care. For Patient Experience, you may want to consider team members who are Technical Experts in your priority area (see page P—11 for a provider-priority area chart). Brainstorming about the process should help you in selecting appropriate team members. Indi- vidualize your teams to ensure they represent your region/facility/ unit and the variations in the processes of care. Patients should also be considered Technical Experts; your pro- Patient Experience Survey: Quality Improvement Guide P—8 Health Quality Council 2006

Additional Information: Team Development ject will be stronger if the patient voice is included on the team. Please see page P—10 for more information on involving patients. Day-to-Day Leaders The Day-to-Day Leader is the driver of the project; they ensure that tests are implemented and data are being collected. It is important that the Day-to-Day Leader understands not only the details of the system, but also the effect changes will have on the system. For Patient Experience, the Day-to-Day Leader may be someone within the unit who is knowledgeable about staff and care processes, but also has the authority to make decisions regarding care and staffing (for example, a nurse or unit manager). Helpful Tool! Assess Your Team This team assessment tool can help your Regional Leadership team in brainstorming members for the facility/unit QI team. As each name is suggested, add them to the following matrix and determine their areas of expertise. This will show you at a glance if your team is well-rounded, and give you an idea of your team’s strengths and potential gaps. Name Team Sponsor Technical Expert Day-to-Day Leader Additional Strengths Jane Doe √ √ John Smith √ You may want to begin by suggesting a few names at the Re- gional Leadership level, then ask these front-line people to select the rest of the team. Used with the permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http:// www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/formingtheteam.htm Patient Experience Survey: Quality Improvement Guide P—9 Health Quality Council 2006

Additional Information: Team Development 3. Involving patients Your efforts to improve the patient experience will be more successful if you include the patient voice on your team. The National Health Services (NHS), based in the United Kingdom, has done extensive work in the area of the “expert patient”. Some of their tips on approaching patients or caregivers to participate on a QI team: • Have clear aims and objectives • Explain project constraints and potential outcomes • Involve more than one patient/caregiver on the team • Be clear about the role of the patients/caregivers on the team • Be aware that involving current or recent patients may present some difficulties • Identify patients/caregivers who will help you meet your aims • Involve patients/caregivers early on in the project Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.cgsupport.nhs.uk/Patient_Experience/4@How_to_involve_people.asp Web site resource The NHS has resources and tips for working with patients on quality improvement. Go to: www.cgsupport.nhs.uk and click on the Patient Experience hotlink. Patient Experience Survey: Quality Improvement Guide P—10 Health Quality Council 2006

Additional Information: Team Development 4. Matching team members to priority areas When developing your QI teams, it may be helpful to consider your priority area. The chart below shows health care providers who might be included on a team that is planning to focus on a specific priority area. Role Provider-Patient Pain Discharge Hospital Food Communications Management Planning Patient √ √ √ √ Physician √ √ √ Nurse Manager √ √ √ √ Front-line Nurse √ √ √ √ LPN √ √ √ Pharmacist √ √ √ Unit Clerk √ √ Dietary Staff √ Director of Food Services √ Dietitian √ Food Services Manager √ Others (e.g., physiothera- √ √ √ √ pists, occupational therapists, social workers, etc.)– depending on priority areas and processes within specific facilities Patient Experience Survey: Quality Improvement Guide P—11 Health Quality Council 2006

Additional Information: Team Development 5. Stages of team development After members are selected, participants must move from being a group to becoming a team. The three stages of team development are forming, storming, and performing. Each stage is described in the table below. Stage What it looks like Forming • Members are concerned with inclusion and acceptance. • Interactions are polite and superficial—overt conflict is rare. • Conformity tends to be high. • Group struggles to define its boundaries; establish who is or isn’t part of this group. • Members rely on leader for direction and support. • Goals are not clear. Storming* • Members are concerned with having their unique contributions recognized. • Participation increases; members want to exercise some influence in the group. • Conformity and compliance decrease. • Open conflict increases. • Members begin to take a critical look at the power structure in the group and question how decisions are made. • Members may challenge the leader directly or indirectly. • Members begin to wonder if they can trust others to “pull their weight,” to make meaningful contributions. • Clarification of roles and goals begins. • Ground rules are established. Performing • Members have built a sense of trust and safety within the group. • Members are more friendly and supportive of one another. • All contributions are recognized and appreciated. • Members are clear about their roles and responsibilities. • Conflict is handled openly and constructively. • Members develop a sense of cohesiveness and group identity. • Leader’s role has become less directive and more supportive as members actively take responsibility for setting and achieving group goals. * As uncomfortable as this stage may be, the conflict is a prerequisite to effective group functioning in the final stage. Groups unwilling to work through the storming phase remain dependent on their leader, maintain relatively superficial relationships, and are unable to work effectively because no one is willing to voice differing opinions or points of view. Adapted from: Renz, MA and Greg, JB (2000). Effective small group communication theory and practice. Toronto: Allyn and Bacon Canada. Patient Experience Survey: Quality Improvement Guide P—12 Health Quality Council 2006

Additional Information: Team Development 6. Effective meetings Team meetings are an important part of a quality improvement project. Holding both traditional and informal meetings (known as “huddles”) will help move your project forward. The tips listed below can help make your meetings more effective. Starting the meeting It is essential to start meetings with some type of Introduction Exercise or Icebreaker. When you have a large group, or you have a very full agenda, it may seem like a waste of time to conduct personal introductions. But introductions are crucial to the overall comfort, trust, and risk- taking ability of the group. Introductions give group members a way to: • Get to know one another. • Gain a deeper appreciation of each other as individuals. • Understand the mindset of different group members on the meeting day. Some examples of introduction or icebreaker activities: • Have participants meet the person sitting next to them; they then introduce each other to the larger group. • Have each person take something out of his or her wallet, pocket or bag, and explain why it is important. • Have each person in the group identify themselves with a musical instrument, cartoon character, animal, etc (choose one) and explain why. • Ask people to identify themselves and then tell what they had for breakfast that morning. Getting organized It’s important to have an agenda, to make sure that all the necessary discussion takes place, and that the meeting stays on track. The agenda is usually set before the meeting—most often by the person who will lead the meeting. It helps meetings run more smoothly if the agenda is posted in a visible place. An agenda can be changed during the meeting. Sometimes items are added or deleted, or the order of discussion is changed. The chairperson should ask group members if they have additions or changes to the agenda at the beginning of the meeting. It’s also a good idea to assign Patient Experience Survey: Quality Improvement Guide P—13 Health Quality Council 2006

Additional Information: Team Development times to each item so that you will know approximately how long the meeting will take. Agendas come in various formats and styles; choose the one that will work best for your meeting and group. For example, you might want to use a grid style that includes “person responsible” and “outcome needed” for each item. Roles and responsibilities • Chairperson. The chairperson takes responsibility for many tasks that keep the meeting running smoothly. The role may be assigned based on position in group or may be shared and rotated among the members. Responsibilities include: • Arranging for the room and refreshments • Setting and distributing the agenda • Starting on time • Leading the meeting • Keeping the group on track • Ending on time • Note-taker. The note-taker records the important comments and decisions that the group makes during the meeting. Notes may be written discretely during the meeting, but many groups prefer to take notes on large flipcharts, so that notes are visible to everyone throughout the meeting. Members can repeat or reword statements for accuracy and better understanding. It’s important for the notes to be distributed to the group before the next meeting. • Timekeeper. The role of the timekeeper is to keep track of time during the meeting. If an item is taking longer than planned to discuss, the timekeeper would flag this so that the group can decide to defer an item, speed up discussion, or take another tack. Sometimes the chairperson functions as timekeeper, but often this is a separate role. Setting the stage Every meeting should have ground rules. Ground rules are the expected rules of conduct that are important for the group’s full participation and success. Involve the group members in setting the ground rules, Patient Experience Survey: Quality Improvement Guide P—14 Health Quality Council 2006

Additional Information: Team Development and then post them on a large piece of paper in the meeting room. This will serve as a visual reminder of what the group has agreed on for meeting conduct. It is not unusual for people to get side-tracked during a meeting. When people either talk about or have questions about something that is not on the agenda, you can write it down on a large piece of paper marked “Issues Bin” or “Parking Lot”. Later, when you have time, the group can return to the “parked” issues. It can be difficult to decide when issues belong to the Parking Lot or if they need to be discussed immediately. The chairperson needs to exercise judgment, but can also ask the group for their opinion. It’s very important to include break time on the agenda. People lose interest if they sit too long, so set aside time to stretch and grab a snack or drink. If it’s a short meeting, people may choose not to take a break. It should always be up to the group to decide. You will also find that providing refreshments for the meeting fosters a caring, relaxed atmosphere. Closing the meeting Renegotiating time and agenda It’s not unusual to find that there is not enough time to discuss all the items on the agenda, or that important items (not on the agenda) come up for discussion during the meeting. The group may decide to defer items to another meeting, meet for a longer time, eliminate items from the agenda, or take some other action. Next steps or action planning It’s a good idea to spend some time at the end of a meeting to clarify any action that needs to be taken, and who will be responsible for taking that action. Important decisions/action items can be recorded in the meeting notes. Evaluation techniques Meeting evaluation can be simple or complex. A very simple technique is to have a large piece of paper divided into two columns: “What Was Good About the Meeting” and “How To Improve the Meeting”. The chair elicits and records comments from the group. Patient Experience Survey: Quality Improvement Guide P—15 Health Quality Council 2006

Additional Information: Team Development More formal techniques include a written set of questions with a rating scale, agree/disagree, or open-ended formats for members’ responses. Typical questions include: Do you think we met our objectives for meeting? Did we abide by our ground rules? Another option is to use imagery for creative and somewhat humorous evaluation. For example, ask participants to rate the meeting with reference to different cars: • Did this meeting operate like a Cadillac DeVille— smooth, easy perfection, purring right along? • Or was it like a Ford Escort—predictable, dependable, chugging but getting the job done? • Or was it like the old Edsel—dysfunctional, poorly planned, and unproductive? Was your meeting an Edsel? Ask the group! Adapted from the System for Adult Basic Education Support (SABE) guide, Running Effective Meetings and Facilitating Groups (July 2002). Available from URL: http://www.sabes.org/resources/facilitationguide.pdf Patient Experience Survey: Quality Improvement Guide P—16 Health Quality Council 2006

Additional Information: Team Development Huddles Huddles are designed to keep teams informed about the project progress, review previous accomplishments, and make plans for the next steps. Because huddles are more informal than traditional meetings, they can occur more frequently. They allow for greater participation of front-line staff, who often can’t arrange schedules to attend longer meetings. They are great for keeping the momentum going. Many teams use them for reviewing and revising Plan-Do-Study-Act cycles. Keys to successful huddles: • Discuss the huddle concept with the team and explain how huddles can be used as a tool to speed improvement. • Agree on a time and place where regular huddles will occur. • Choose a huddle location that is convenient for the team members, particularly those who have the least time available for meetings. • Have a clear set of objectives for every huddle. • Limit the duration of the huddle to 15 minutes or less. • Review the objective of the huddle for that day, then review the work done since the last huddle. Act on the new information and plan next steps. • Huddle frequently, even daily—particularly when many PDSA cycles are being tested and the team needs to share information regularly. If you want people to attend meetings, try to make them more convenient! Used with the permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http:// www.ihi.org/NR/rdonlyres/74A9CD6C-B15A-45A1-87DE-FD7E6CE1F23C/654/Huddles1.pdf Patient Experience Survey: Quality Improvement Guide P—17 Health Quality Council 2006

Additional Information: Team Development 7. Ten essential ingredients for successful teams Although conflict is to be expected in any team, some common group difficulties can be prevented when teams ensure they have the following essential ingredients: 1. Clarity in team goals. A team works best when everyone understands its purpose and goals. If there is confusion or disagree- ment, effective teams work to resolve the issues rather than ignore or sidestep them. 2. Established ground rules. Highly effective teams outline how they will work together and establish behavioural expectations for team members. 3. A work plan. Successful teams outline who will do what and when. Clear action plans help the team identify what resources, materials or training are needed throughout the project so that they can plan accordingly. Work plans also flag uneven distribution of tasks among team members. 4. Clearly defined roles. Teams operate most efficiently if they tap everyone’s talents and all members understand their duties and know who is responsible for what issues and tasks. Roles may need to be re-visited periodically (e.g., as new tasks come to light, member workloads shift, etc.) 5. Balanced participation. One or two members taking responsibility for the team’s efforts is neither effective nor sustainable. All members should participate in discussions and decisions, share commitment to the project’s success, and contribute their talents. 6. Open communication. Effective teams share information, thoughts and ideas in an open and direct manner. Team members seek to understand one another’s perspectives. 7. Beneficial team behaviours. Successful teams encourage all members to use behaviours that make discussions and meetings more effective, such as initiating discussion, listening to others, and working through conflict. Patient Experience Survey: Quality Improvement Guide P—18 Health Quality Council 2006

Additional Information: Team Development 8. Established decision-making methods. A team should always be aware of the different ways it reaches decisions, and the consequences of using those methods. For example, when the designated leader makes the decision, others may not fully understand the decision or feel committed to implementing it. 9. Experimentation/creativity. An effective team experiments with different ways of doing things and is creative in its approach. 10. Evaluation. Successful teams evaluate both their functioning and their accomplishments. Portions of these materials are copyrighted by Oriel Incorporated, formerly Joiner Associates Inc and are used here with permission. Further reproductions are prohibited without written consent of Oriel Incorporated. Call 1-800-669-8326. Patient Experience Survey: Quality Improvement Guide P—19 Health Quality Council 2006

Reflecting Phase Two This section has information on analyzing current processes, including: • Process mapping • Brainstorming • Focus groups • Fishbone diagrams Patient Experience Survey: Quality Improvement Guide R- 1 Health Quality Council 2006

Introduction to Reflecting Understanding Systems To make effective changes, first we need to understand how our system currently works. We don’t intentionally design systems that are flawed, but a well-designed system can become unsatisfactory over time Anyone who has not kept up with the changes in telephones, for example, knows that a rotary dial telephone limits easy access to services within many organizations. As our culture and technology changes, our systems also need to change. What Is a System? Systems exist all around us: The cardiovascular system; the London underground subway system; the hockey draft system. Systems are defined as a collection of parts and processes organized around a purpose. All systems have three components: • Structures: Things you can touch and see, such as equipment, facilities, committees, roles. • Processes: Steps or actions to achieve the outcome, such as patient pathways. • Patterns: Repetitive features, often cultural, such as behaviours, conversations, and waiting times. Often we get caught up in the “do”; implementing changes without a complete understanding of where change will be most effective. Analyz- ing your current processes can help to make your improvements more meaningful and effective. Remember: All improvement involves change, but not all change will lead to improvement. This section has information on methods to analyze and understand your processes: • Process mapping • Brainstorming • Focus groups • Fishbone diagrams Patient Experience Survey: Quality Improvement Guide R- 2 Health Quality Council 2006

Process Mapping Overview Every process has a start and an end. In order to map a process, it is essential to clearly define each of these points. Processes can be simple and short, or complex and long. Processes are usually governed by rules, and they are usually linked with other processes. For example, a process might begin with the symptom and end with resumption of good health. Similarly, a process might begin with the request for an X-ray and end with the results. When examining a process, it is important to detail every point in the chain of action. Be sure to include everyone involved in that process, so that no point of action is missed. Often, no one person knows the entire process. By including everyone in the discussion, we may find that what we think is going on may not, in fact, be what is actually happening! By analyzing the process from start to finish, we identify all the opportunities to make improvements. We also avoid the pitfall of focusing on just one perspective. When mapping a process, it is important to consider the view of all stakeholders, including patients and caregivers: • The only one who knows the whole process is the patient. • Up to 50% of process steps involve a hand-off, leading to the possibility of error, duplication, or delay. • 30 to 70% of what we normally do does not add value for the patient. (Dr. John Bibby) Start by gathering together representatives of all the stakeholders, i.e., everyone who takes part in the process from start to finish. Using a white board or sticky notes, write down the task and the name of the person who carries out that task. Arrange the steps in order, but feel free to add new steps and move steps around at any point. Watch the patterns emerge that may indicate the root of a problem. You may be surprised! Please see the next page for a diagram of a process map. Patient Experience Survey: Quality Improvement Guide R- 3 Health Quality Council 2006

Process Mapping Record each step of the process from start to finish. Write down the steps in the sequence they occur. Request Complete Results START FINISH for chest x-ray X-ray communicated Complete req. Take films X-rays to Dr. MD Tech Patient Pt info process films Determine plan Receptionist Tech Dr Begin by defining where the process starts and Undress Bill Sask Health ends. Patient Secretary Pay for services Sk Health Each step may have several sub-steps. Capture these and list them under the main step. Why Process Map? A map of the patient’s journey will give you: • Key starting point to any improvement project, large or small, which is tailored to suit your own organization or individual style. • The opportunity to bring together multi-disciplinary teams and bring together people from all roles and professions to create a culture of ownership, responsibility, and accountability. • An overview of the complete process, helping staff to understand, often for the first time, how complicated the system can be for patients. For example, how many times a patient has to wait (often unnecessarily), how many visits they make to hospital, and how many different people they meet. • An aid to effectively plan where to test ideas for improvement that will likely have the greatest impact on the improvement aims. Patient Experience Survey: Quality Improvement Guide R- 4 Health Quality Council 2006

Process Mapping • Brilliant ideas, especially from staff who don’t normally have the opportunity to contribute to service organization, but who really know how things work. • An event that is interactive, that gets people involved and talking. • An end product, a process map which is easy to understand and highly visual. Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/4.htm# How To Run A Process Mapping Session Setting up the meeting • Identify the scope of the process you want to map, including patient group, start point and end point. • If you are unsure which part of the patient’s journey you want to map, start by mapping a high “macro” level process, to identify parts of the process that require more attention. For example – general patient journey from presentation in the ED to discharge from hospital. (You might then follow this up by looking more closely at the decision to admit general medicine patient to when patient arrives on ward.) • Identify all stakeholders. It is essential that all the stakeholders involved in any part of the patient’s journey develop the process map. If the map is reflective of what actually happens, it will be easier to secure “buy-in” when it comes to improvements. • Convene a workshop. Allow at least 3 hours for the workshop, in order to carry out both a high “macro” level map, and a low “micro” level map. You will need a suitable meeting room where the team can work free of interruptions. • Send out invitations. In the invite, clearly explain the purpose of the meeting. Include contact information so invited participants can reply, but make sure the contact is someone who can answer questions or concerns prior to the event. • Facilitation. You will need a facilitator for the session, ideally someone who is viewed as being independent. The facilitator’s role is to keep the session on time and to identify any issues or solutions as they arise. He or she does not directly provide input into the process map, but ensures everyone makes a contribu- Patient Experience Survey: Quality Improvement Guide R- 5 Health Quality Council 2006

Process Mapping tion. It might also be useful to have another person on hand to take notes. • Shortly before the meeting, follow up with people who have not yet responded. On the day • Gather your resources. You will need: post-it notes, pens, name labels, white board/large paper. • Group introductions. • Introduce the ground rules: No blame, respect diversity of opinion. Limit discussion on a particular issue to 5 minutes, then park it for follow up later. Focus on what happens 80% of the time. Focus on patient experience. • At the beginning of the session: gain agreement from the group on the scope of the map and record this on the paper. Map the process • Ask participants to individually record each step of the process from their own perspective – what they know happens 80% of the time. (See Pareto Principle, bottom of page.) • Participants should then stick the post-it notes on the wall. Duplicate steps should be placed under one another. Participants should move steps around until they are happy with order. • The facilitator should review each step with the group and transfer each step to the white board, to form an agreed upon map. Pareto Principle The Pareto Principle describes the 80:20 relationship of cause and effect, efforts and rewards, inputs and out- puts. It is a way to focus your improvement efforts: • Look at any complaints about your service. The Pareto Principle predicts that most of the complaints (80%) will be for a few causes (20%). So that is probably the place to start. • Look at the types of requests a department receives e.g. pathology and radiology. The Pareto Principle predicts that most of the requests (80%) will be for relatively few of all the examinations or tests the department offers (20%). Again, showing you where you might start and have the most effect. So the 80:20 rule, or Pareto Principle, will help you and your improvement aim focus on the areas that will have the biggest impact when improved. Patient Experience Survey: Quality Improvement Guide R- 6 Health Quality Council 2006

Process Mapping • As a group, analyze each step in the process (either during or at the end of the mapping). Identify: Decision points and hand-offs; main bottlenecks and delays – how long does this process take?; gaps; necessary and unnecessary steps; problems for patients; problems for staff. Next steps—where to now? • Ask yourself: Is the map accurate? Or do you need more input from others? What issues were identified? What are the areas for improvement? • With your redesign team, look at the process map. Discuss how the process can be simplified, what steps can be modi- fied and deleted. Prioritize the issues and develop an action plan for how you are going to tackle them. Source: Clinical Excellence Commission website. Available from URL: http:// www.health.nsw.gov.au/nursing/pdf/moc-cec-prcss_mpng_guide.pdf Handy Tip! Use different coloured post-it notes to differentiate the process (yellow) from problems/issues (purple) and solutions/ideas (blue). This will help keep the focus on the current process while captur- ing all the comments. Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/ improvementguides/process/4.htm# Key Messages for Participants • Processes are all around us, but in healthcare our roles limit us to seeing only one small part of the whole patient process. • It’s not about blaming or criticizing anyone or any department. • It’s only the starting point and will lead to lots of other improvement tools and techniques. • It’s fun. Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/4.htm# Patient Experience Survey: Quality Improvement Guide R- 7 Health Quality Council 2006

Process Mapping Analyzing the Process Map Once the process is mapped, analyze it. For each step, answer these questions: • Can it be eliminated? • Can it be done in some other way? • Can it be done in a different order? • Can someone else do it? • Can it be done somewhere else? • Can it be done in parallel? • Can any “bottlenecks” be removed? • Is the most appropriate person doing it? After you have mapped and analyzed the process, it is time to turn to the Model for Improvement and devise a plan to test ideas for positive change. It’s best to try a small change in one step of the process and see if it leads to an improvement. Several small PDSAs can be run con- currently, and each one should spark a hunch for a new PDSA. Other Process Analysis Questions • How many steps are there for the patient? This is often a real revelation for staff. • How many times is the patient passed from one person to another (handed-off)? • What is the approximate time taken for each step (task time)? • What is the approximate time between each step (wait time)? • What is the approximate time between the first and last step? • How many steps add no value for the patient? Imagine that you, or your parent or child, is the patient. What steps add nothing to the care being received? • Where are the problems for patients? What do patients complain about? • Where are the problems for staff? Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/6.htm Patient Experience Survey: Quality Improvement Guide R- 8 Health Quality Council 2006

Process Mapping Other Ideas for Process Mapping Activity and Role Lane Mapping For the parts of the process that are causing problems, consider activity and role lane mapping. To do this, take the role out of the activity so that “nurse records vital signs” becomes “record vital signs”. List the process activities and the roles involved and ask, “who does this now?” as in the diagram below. This could be followed by a discussion around who could do each activity if it were redesigned. Activity and role lane mapping – current situation in outpatient clinic Activity/role Clerk Nurse Porter Doctor Move patient X X Record details X X Record vitals X X Take history X X Examine patient X Write imaging request X Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/6.htm Tracking the Patient Journey Tracking the patient journey through the health care system is a simple way of understanding where problems are and how the service looks through the eyes of a patient. This exercise complements the process mapping exercise and allows you to identify waits and delays in real life. There are two ways of doing this: • Physically walking through the patient’s journey with a patient. Determine with your team the start and end point of the journey you want to track. In order to gain a true picture of the journey, it is recommended to track patients who arrive both in and out of regular hours. It might also be beneficial to dress in the clothes you would wear as a patient so as not to draw attention. You will need to gain permission from the patient in order to accompany them. During the walk through, note both the positive and the negative experiences, as well as any surprises. What was frus- trating? What was confusing? (See sample tool, next page.) Patient Experience Survey: Quality Improvement Guide R- 9 Health Quality Council 2006

Process Mapping Sample Patient Tracking Tool Date/Time: 04/04/04, 11:00 am Start Point (location): ED Triage End Point (location): Patient leaves ED for home Patient Presenting Problem: Foreign body in eye Time Activity Where Who Additional Comments All time needs Where was the Who Positives/Negatives/Surprises/ to be activity carried undertook the Frustrations accounted for out activity e.g. waiting 11:00 Patient sees Triage office ED nurse Nurse friendly and cheerful but am ED triage called away halfway through the nurse consultation as someone came in by ambulance. 11:30 Patient filled in Standing at Patient and am info form reception clerk • • Asking patients to keep a diary of their journey. The patient diary allows patients to track their journey and comment about their experiences along the way. It is particularly useful for in-patients, where it is not possible for them to be tracked by a staff member. We have included a sample patient diary tool; patients can carry this form on a clipboard throughout their visit. (See sample, below.) Sample Patient Diary D a te T im e A c tiv ity a n d L o c a tio n C o m m e n ts 0 5 /0 4 /0 4 9 :15 a m A d m itted to w a rd M , n u rse took H a d a lrea d y g iv en m ed ica l history . m ed ica l history in E D la st n ig h t d on ’t k n ow w hy sh e cou ld n ’t rea d th a t 9 :2 5 a m A t en d of h istory n u rse sa id I I d on ’t k n ow w h en I w ill n eed ed ch est x-ra y , d octor w ou ld h a v e th e chest x-ra y , n u rse refer m e. sa id sh e w asn ’t su re 10 :0 0 a m A sk ed for cu p of tea 11:3 0 a m M y d a u g hter a rrives 12 :0 0 pm M y d a u g h ter a sk ed th e n u rses T h ey w ere v ery v a g u e th is w h en th e d octor w ou ld be com in g to a ftern oon , bu t th is n u rse see m e. w a s v ery polite a n d frien d ly Source: Clinical Excellence Commission. Available from URL: http://www.health.nsw.gov.au/nursing/pdf/moc-cec- prcss_mpng_guide.pdf Patient Experience Survey: Quality Improvement Guide R- 10 Health Quality Council 2006

Process Mapping Some Final Tips and Questions Tips for Successful Process Mapping • DO analyze the current process, NOT your ideal process. • DO focus on what happens to most of the patients most of the time. OMIT the one-off cases that aren’t normal. The faciliatator will need to pull people away from drilling down into too much detail. • DO include every stakeholder in the process, including patients and caregivers. • DO respect all contributions. • DO raise issues and questions. Debate is good. • DON’T assign blame. Frequently Asked Questions What happens if we can’t get everyone together at the same time? Consider any of the following variations on process mapping: • Process mapping can take place with very small groups or even getting one or two people to walk through and record the patient’s journey. Then take this map to other small groups or individuals for their comments. • Issue the instructions on how to map and set up the blank map in a place where people go for their coffee breaks. En- courage them to keep adding to the map over a two-week period and then produce a tidied up version for final amend- ments. • Organize a process mapping day, inviting all relevant staff to “drop in” at any point within a given timeframe. Cakes and chocolate are always a powerful way to draw people. How do I persuade colleagues of the value of spending time mapping the service? Explain that this is the best way to start making improvements and perhaps refer them to other services/colleagues who have done it. Stress the importance of understanding their contribution to the work of the service. Also consider if the team is ready for change and whether the problem with arranging a meeting is really a reluctance to be involved. In which case, engage your change agents, champions or sponsors. Patient Experience Survey: Quality Improvement Guide R- 11 Health Quality Council 2006

Process Mapping How will all this really help us? The combination of process mapping and analysis, measurement for improvement, matching capacity and demand and improving flow will result in system improvements for patients. Seeing improvement is a great boost for the team and gets other people interested. All process steps needing improvement are identified. The results of your improvement activities may also provide the necessary information to support the business case for extra resources. What if the team can’t agree on the process map? • Check that you are mapping the current process, not the ideal. • Check that you are mapping what happens 80% of the time. • Are there actually two different processes? Does the morning team work differently than the evening shift? If so, capture both of these processes. • Gather information on the current process. For example, use the patient tracking tool (see page R—10) to see how patients move through the system. You do not need to track a significant number of patients—just enough to satisfy the team they have accurately captured the process. Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/9.htm Case Studies Case Study #1 An Example of a Patient Journey Map Who does what to the patient? • GP tells patient that they are being referred to the hospital • GP tells patient to go home and wait • Appointment letter is delivered via mail to patient • Patient arrives at the hospital for the appointment • Clinic Clerk receives the patient and checks their details • Nurse checks the patients details before they see a doctor • Doctor examines patient • Doctor refers the patient to the relevant department(s) for diagnostic tests Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL: http://www.modern.nhs.uk/improvementguides/process/5_3.htm Patient Experience Survey: Quality Improvement Guide R- 12 Health Quality Council 2006

Process Mapping Case Study #2 Discharge Process – University Hospital Lewisham The University Hospital in Lewisham, England wanted to reduce the vari- ability of the discharge process for patients on the orthopedic ward. They began by measuring number of patients discharged each day from the ward, and the average length of stay for 80% of patients discharged each week. The measures helped them see two interesting things in their current process: • There were very few patients discharged on Saturday and Sunday – clearly there were two different processes in place for weekdays versus weekends, but there was no real benefit to having two systems. • The current process did not ensure that patients waiting for transport (hospital or relative) were transferred to the discharge lounge by 10 AM. Since typically emergency patient demand peaked after 2 PM, this meant that although patients were leaving, there still weren’t any free beds. Used with permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://www.ihi.org/ IHI/Topics/Flow/PatientFlow/ImprovementStories/ ImprovingPatientFlowbyReducingVariabilityintheDischargeProcessatUniversityHospitalLewisham.htm Resources The web sites listed below have helpful resources for process mapping: • BOLO (Been On Look Out For). This is a list for analyzing the process map. http://www.isixsigma.com/library/content/ c040301a.asp • Process Mapping Case Study. This article looks at the process Valley Baptist Medical Center in Harlingen, Texas went through to improve their discharge planning. http:// healthcare.isixsigma.com/library/content/c040915a.asp • TeamFlow software - a free software download for creating an electronic process map. Great for putting together a final agreed up on version of the process map. http://www.teamflow.com/ downloads.html • Running A Process Mapping Session Guide – includes patient diary and Patient Tracking Tool. http://www.health.nsw.gov.au/ nursing/pdf/moc-cec-prcss_mpng_guide.pdf • Improvement Leaders Guide for Process Mapping, National Health Services. http://www.modern.nhs.uk/improvementguides/ process/ Patient Experience Survey: Quality Improvement Guide R- 13 Health Quality Council 2006

Brainstorming Overview What Is Brainstorming and How Can It Help? Brainstorming is an idea-generation tool designed to produce a large number of ideas through the interaction of a group of people. Some of the positives to using this tool include: • It allows every member of the group to participate. • It encourages many people to contribute, instead of just one or two people. • It sparks creativity in group members as they listen to the ideas of others. • It generates a substantial list of ideas, rather than just the few things that first come to mind; categorizes ideas creatively; and allows a group of people to choose among ideas or options thoughtfully. Brainstorming Steps Step 1: Getting Started • The session leader should clearly state the purpose of the brainstorming session. • Participants call out one idea at a time, either going around the room in turn, which structures participation from everyone, or at random, which may favour greater creativity. Another option is to begin the brainstorming session by going in turn and after a few rounds, open it up to all to call out ideas as they occur. • Refrain from discussing, complimenting, or criticizing ideas as they are presented. Consider every idea to be a good one. The quantity of ideas is what matters; evaluation of the ideas and their relative merit comes later. This tool is designed to get as many ideas generated in a short period of time as possible. Discussing ideas may lead to premature judgment and slow down the process. • Record all ideas on a flipchart, or self-adhesive notes, so that all group members can see them. • Build on and expand the ideas of other group members. Encourage creative thinking. • Keeping going when the ideas slow down in order to create as long a list as possible and reach for less obvious ideas. • After all ideas are listed, clarify each one and eliminate exact duplicates. Patient Experience Survey: Quality Improvement Guide R- 14 Health Quality Council 2006

Brainstorming • Resist the temptation to “lump” or group ideas. Combining similar ideas will come next. Step 2: Affinity Grouping The next step in brainstorming is for participants to organize their ideas and identify common themes. • Take the list of ideas from Step 1 and write each one on individual cards or adhesive notes. • Randomly place cards on the table or place notes on flip chart paper taped to the wall. • Without talking, each person looks for two cards or notes that seem to be related and places these together, off to one side. Others can add additional cards or notes to a group as it forms, or re-form existing groups. Set aside any cards or notes that become contentious. • Continue until all items have been either grouped or set aside. There should be fewer than 10 groupings. • Now discuss the groupings as a team. Generate short, descriptive sentences that describe each group and use these as title cards or notes. Avoid one or two-word titles. • Items can be moved from one group to another if a consensus emerges during this discussion. • Consider additional brainstorming to capture new ideas using the group titles to stimulate thinking. Step 3: Multivoting The final step in brainstorming is multivoting. Multivoting is a structured series of votes by a team, in order to narrow down a broad set of options to a few actionable ones. • Take the combined similar items (grouped in affinity grouping) and number each item. • Each person silently chooses one-third of the Multivoting Table items. Tally votes. Group size (number of people) Eliminate items with less than “x” votes • Eliminate items with few votes. The table be- 4 to 5 2 side will help you determine how to eliminate 6 to 10 3 items. Repeat the multivoting process with 10 to 15 4 remaining items, if necessary. 15 or more 5 Used with permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://www.ihi.org/ IHI/Topics/Improvement/ImprovementMethods/Tools/Brainstorming+Affinity+Grouping+Multivoting.htm Patient Experience Survey: Quality Improvement Guide R- 15 Health Quality Council 2006

Brainstorming Frequently Asked Questions How many people should you include? The ideal group size is between six and ten. Fewer than six and you might not have enough diversity of input. More than ten and you may have problems managing the flow of ideas – people get frustrated in larger groups because they cannot be heard and the quieter ones will give up. If you have groups of more than ten, you may want to divide into smaller groups. What sort of people should you invite? The key is diversity. If you put together the same group who has always looked at this issue, they will probably come up with the same ideas. Sprinkle in a few “outsiders”. It is good to have young and old, male and female, fresh into the organization and experienced. Look to include a “maverick” who will challenge your thinking. How long should it last? It depends on how complex the issue is, how many methods you plan to use and whether you need to do some problem analysis work first. For a regular brainstorm meeting where the problem is reasonably well defined, then an hour is plenty. In any event, it is better to have a short, high-energy meeting than a long rambling one. People are generally brighter and fresher in the morning. Consider starting with coffee and muffins before the team gets distracted with emails, phone calls, and today’s crisis. Who should facilitate? It’s best to have a skilled external facilitator. This is someone who is experienced, neutral, enthusiastic and with good handwriting. He or she manages the flow of ideas by encouraging everyone to contribute and intervenes if someone becomes too dominant or the meeting heads in the wrong direction. The facilitator can use a variety of methods to keep the ideas flowing. How will you capture the ideas? The traditional method is to write all ideas on flip chart or post-it notes. Post-it notes can be messy during the idea generation phase, but they are handy during group affinity and multivoting. A third option is to use software. One person enters the ideas on a laptop that Patient Experience Survey: Quality Improvement Guide R- 16 Health Quality Council 2006

Brainstorming projects onto a large screen for everyone to see. Software packages specifically for this purpose are available. Should the department manager be present? It depends on the issue and the manager. A forceful, dominant manager can inhibit people from voicing unorthodox ideas. On the other hand, when evaluating which ideas go forward it is important to have the person who can assign resources as part of the process, so that you can move quickly to action. If the manager is present he/she must make it clear by words and actions that any idea is welcome no matter how unconventional or challenging to current policy. How can you ruin a brainstorming meeting? Some of the best ways to ruin a brainstorm meeting are: • Early criticism of ideas • Manager acting as scribe, facilitator, and censor • No evaluation, actions, or follow up • Having no clear focus or objective • Getting sidetracked into feasibility discussions too early • Settling for too few ideas Used with permission by Paul Sloane. Available from URL: http://www.innovationtools.com/Search/ recommended_details.asp?a=221 Working Through Stuck Spots Scott Berkun provides some great suggestions on how to keep the ideas coming: Rotate Anyone, at any time, can call out “rotate” and everyone in the room has to get up from where they are sitting and move to the chair to their left...It’s usually the facilitator who calls this out when people get stuck, or the energy doesn’t feel right. Roadblock Removal Eliminate assumed constraints. Tell the group there are no limits on costs, time, or other resources. They can think as big or expensive as their minds allow. Think of other constraints that the group is as- suming...take the biggest ones you can find and get rid of them. Re- moving a roadblock might free new directions of ideas that wouldn’t have been considered otherwise. Patient Experience Survey: Quality Improvement Guide R- 17 Health Quality Council 2006

Brainstorming Roadblock Introduction Come up with some ridiculous new constraint to the problem. The goal isn’t to make it harder, just to force people’s creative muscles to work differently...Make the problem as difficult as possible...Don’t let people cop-out; push them to work with the problem. This can often shake people into action, challenged by the insanity of the problem, and protected by the feeling that since it’s a ridiculous situation, there are no bad answers. ..they will be stretched creatively, find news ways of thinking about the work, and will be relieved and ener- gized to return to the real constraints. For example, you may have your team imagine that they have one week to make improvements, instead of one year. If the project is about improving provider-patient communications, you may ask the team to pretend they can only use non-verbal communication. Scottberkun.com [website on the Internet]. USA: c2005 [accessed 2006 May 23]. How to run a brainstorming meeting. Available from: http://www.scottberkun.com/essays/essay34.htm Negative Brainstorm This technique uses the human tendency to see the negative side of things. When an idea is put forward, it’s often easier to come up with reasons why it won’t work rather than looking for what’s good about the idea. Negative brainstorming works like this: • The problem is written on the flipchart. • Instead of brainstorming for possible solutions, the team brain- storms for everything that could make the problem worse. • The output from this brainstorm is then taken and explored to see if any new ideas for a solution are suggested. Example: Information was getting lost between the day and night shifts in a hospital. The team came up with these negative brainstorm ideas: • Do not have anywhere to write information down. • Stop shifts from seeing each other. • Make sure you always blame the other shift. • Assume that everybody knows information is important. When the brainstorm is complete, the idea is to explore each negative to see if it suggests any further ideas for improvement. Ideas for solutions Patient Experience Survey: Quality Improvement Guide R- 18 Health Quality Council 2006

Brainstorming that could develop from the negative brainstorm in the above example would be things such as: • Maintain a proper log book. • Have shift changeover meetings. • Have a designated person on each shift responsible. Used with permission from the NHS Modernisation Agency, subject to Crown copyright protection. Available from: http:// www.tin.nhs.uk/index.asp?pgid=1377 Case Studies Case Study #1 Using Team Problem Solving to Improve Adherence with Malaria Treatment Guidelines in Malawi A team at the Lifuwu Health Center decided that its first problem- solving experience would focus on reducing the number of people who return with malaria symptoms within a week of receiving treatment for malaria. The team used a Fishbone diagram (see page R—25 for more information on Fishbone diagrams) to determine that lack of compliance with malaria treatment stemmed from treatment, the environment, patient/family, and/or staff/ provider. Twenty days of data collection (covering 761 clients, 173 of them re-attendants), including interviews with re- attendants, convinced the team that improving patient/community understanding of the importance of adhering to treatment and how to do so would go a long way in reducing re-attendance. So- lutions were brainstormed, selected on the basis of utility, and implemented. Some of the ideas they put into action: • Provide health education to the community on the importance of taking recommended treatments. • Assign two dispensers to give the treatment dose at the health center as directly observed treatment (DOT). • Check all re-attendants with malaria blood slide to confirm they have malaria. • Assign a health worker to look for discarded drugs along the paths to the villages. • Assign a health worker to follow up door-to-door with patients to ensure they take medication . The action plan yielded some impressive results. Re-attendance Patient Experience Survey: Quality Improvement Guide R- 19 Health Quality Council 2006

Brainstorming dropped from 31 percent of patients to 5 percent within a year and stayed down for the next year, saving enough in drug costs alone to treat over 2000 malaria patients (savings in personnel time were not calculated). Shabahang, J. 2003. Using Team Problem Solving to Improve Adherence with Malaria Treatment Guidelines in Malawi. Quality Assurance Project Case Study. Published for the U.S. Agency for International Development (USAID) by the Quality Assurance Project (QAP): Bethesda, Maryland, U.S.A. Resources The web sites listed below have helpful resources for brainstorming: • Article: How to Run a Brainstorming Meeting, by Scott Berkun: www.scottberkun.com/essays/essay34.htm • Article: Take the Brainstorming Quiz, by Paul Sloane: www.innovationtools.com/Search/recommended_details.asp?a=221 • Reverse Brainstorming: An Innovative Approach to Brainstorming (Gleneagles Hospital): www.gleneagles.com.sg/innovation8.jsp • Negative Brainstorming, NHS Improvement Leaders Guide: www.tin.nhs.uk/index.asp?pgid=1377 • Case Study: Using Team Problem Solving to Improve Adherence with Malaria Treatment Guidelines in Malawi. www.qaproject.org/ pubs/PDFs/MalMalariaAd.pdf • Case Study: Engaging kindergartners in making a hospital waiting room child friendly. http://nationalserviceresources.org/epicenter/ practices/index.php?ep_action=view&ep_id=598 Patient Experience Survey: Quality Improvement Guide R- 20 Health Quality Council 2006

Focus Groups Overview The Patient Experience survey gave some indication of patient concerns with acute care, but to more fully understand those concerns and develop quality improvement initiatives that address those concerns, more in-depth information from patients may be needed. Holding focus groups with recently discharged patients may be a useful method for obtaining detailed feedback on potential improvement areas and change ideas. How To Run a Focus Group: • Identify the major objective(s) of the focus group. • Plan for the session to last 1 to 1.5 hours. • Develop five to six questions – determine what problem or need will be addressed by the information gathered during the session. • Develop agenda. The agenda should include: • Welcome and introductions • Review of agenda • Review of goal(s) of the meeting • Review of ground rules • Questions and answers • Wrap up • Recruit 6-10 patients who are related by their experience, expertise, or role. • Call potential patients to invite them to the meeting: • Send them a follow-up invitation with a proposed agenda, session time and the list of questions the group will discuss. • About three days before the session, call patients to confirm attendance. • Recruit a co-facilitator to take notes of the session. • Facilitate the session. • Introduce yourself and the co-facilitator or note taker. • Explain the means to record the session. • Ensure patients understand that the session will be kept confidential, and that they are partially responsible for the confidentiality of the session. • Carry out the agenda. • Allow a few minutes after each question for members to think about their answers. Then facilitate discussion Patient Experience Survey: Quality Improvement Guide R- 21 Health Quality Council 2006

Focus Groups around the answers to each question. • After each question is answered, carefully reflect back a summary of what you heard (the note taker may do this). • Ensure even participation. If one or two people are dominating the meeting, then call on others. Consider using a round-table approach: going in one direction around the table, giving each person a minute to answer the question. • Closing the session - tell members they will be sent a summary of the information obtained from the focus group, thank them for coming, and adjourn the meeting. • Write down any observations made during the session. Benefits of Focus Groups • Gives patients an opportunity to be involved in decision making processes. • Opportunity for patients to be valued as experts. • Opportunity for patients and health care professionals/ facilitators to work together collaboratively. • Way to obtain several perspectives about the same topic within a short time. • Allows you to solicit feedback from a group of people in one sitting. • Small group discussion offers participants give-and-take exchange. • Interaction between participants produces data as well as insight. • Focus groups can provide ample information at a reasonable cost. Challenges of Focus Groups • There is a potential for participants to influence one another’s opinions. • Participants’ opinions may not be shared by all of your patients; you must be careful when making generalizations based on focus group feedback. • You can only ask a limited number of questions. • Data are more difficult to analyze than quantitative data. Patient Experience Survey: Quality Improvement Guide R- 22 Health Quality Council 2006

Focus Groups • Facilitator must be skilled to ensure good quality information is gathered. • The social context may influence the participants. • Can be difficult to conduct with participants who are hearing, cognitive or communication impaired. Tips for Successful Focus Groups • Start the session off with a question designed to put the patients at ease. • Hold sessions in a conference room, or other setting with adequate air flow and lighting. • Configure chairs so that all members can see each other. • Provide nametags for members. • Provide refreshments. • Have some basic ground rules: • Keep focused. • Maintain momentum. • Get closure on questions. • Tape recording the session may be helpful so facilitators can Remember to provide listen to the tapes following the session in order to remember nametags for participants! what was said, if missed in the notes. Ask the participants for permission and test equipment prior to recording the session. • Have an additional co-facilitator to take notes of the session. Patient Experience Survey: Quality Improvement Guide R- 23 Health Quality Council 2006

Focus Groups Resources • Dawson, S., Manderson, L., & Tallo, V. T. A Manual for the Use of Focus Groups. 1993; International Nutrition Foundation for Develop- ing Countries (INFDC), Boston, MA, USA. http://www.unu.edu/ Unupress/food2/UIN03E/uin03e00.htm# (Contents accessed May 19, 2006.) • Goss J.D., Leinbach T.R. ‘Focus groups as alternative research practice’, Area 28. 1996; (2): 115-23. • McNamara, C. Basics of Conducting Focus Groups, Free Manage- ment Library. Accessed May 18, 2006. http:// www.managementhelp.org • Morgan D.L. Focus groups as qualitative research. 1988; London: Sage. • Powell R.A. and Single H.M. ‘Focus groups’, International Journal of Quality in Health Care. 1996; 8(5): 499-504. • Race K.E., Hotch D.F., Parker T. Rehabilitation program evaluation: use of focus groups to empower clients, Evaluation Review. 1994; 18(6): 730-40. • Smith J.A., Scammon D.L., Beck S.L. Using patient focus groups for new patient services, Joint Commission Journal on Quality Improve- ment. 1995; 21(1): 22-31. • The Health Communication Unit, Centre for Health Promotion, University of Toronto. http://www.thcu.ca/infoandresources/publications/ Focus_Groups_Master_Wkbk_Complete_v2_content_06.30.00_format_aug03.pdf Patient Experience Survey: Quality Improvement Guide R- 24 Health Quality Council 2006

Fishbone Diagrams Overview What They Are A cause-and-effect or Fishbone diagram is a tool that helps identify, sort, and display possible causes of a specific problem or quality characteris- tic. It shows the relationship between a given outcome and all the factors that influence the outcome. This type of diagram is sometimes called an “Ishikawa diagram” because it was invented by Kaoru Ishikawa. The Fishbone diagram can help your team: • Identify the possible root causes—the basic reasons—for a specific effect, problem, or condition. • Sort out the interactions among factors affecting a particular process. • Analyze existing problems so that corrective action may be taken. Benefits of Using Fishbone Diagrams The structure provided by the Fishbone diagram helps team members think in a very systematic way. Some of the benefits to using it are that it: • Uses a structured approach. • Encourages group participation. • Uses group knowledge of the process. • Uses an orderly, easy-to-read format to diagram cause-and- effect relationships. • Identifies areas where data should be collected for further study. How to Create a Fishbone Diagram When you develop a Fishbone diagram, you are constructing a pictorial display of a list of causes organized to show their relationship to a specific effect. Step 1 : Identify and clearly define the outcome or effect to be analyzed. • Decide on the effect to be examined. Effects are stated as particular quality characteristics, problems resulting from work, planning objectives, etc. • Use Operational Definitions for the effect to ensure that it is Patient Experience Survey: Quality Improvement Guide R- 25 Health Quality Council 2006

Fishbone Diagrams clearly understood. • Remember, an effect may be positive (an objective) or negative (a problem), depending the issue being discussed. Step 2 : Create the diagram. • Position the flipchart so that everyone can see it. • Draw a horizontal arrow pointing to right; this is the spine. • To the right of the arrow, write a brief description of the effect or outcome which results from the process. Draw a box around the description of the effect. Spine Effect Step 3: Identify the main causes contributing to the effect. • These are the labels for the major branches of your diagram and become categories under which to list the many causes related to those categories. • Use category labels that make sense for the diagram you are creating. Some commonly used categories include: • 3Ms and P: methods, materials, machinery, people • 4Ps: policies, procedures, people, and place • Write the main categories your team has selected to the left of the effect box, some above the spine and some below it. • Draw a box around each category label and use a diagonal line to form a branch connecting the box to the spine. Human Resources Material Resources Delays in patient discharges caused by problems related to documents sent with patients. Material Method Environment Step 4: For each major branch, identify other specific factors which may be the causes of the effect. • Identify as many causes or factors as possible, and attach them to the sub-branches of major branches. Patient Experience Survey: Quality Improvement Guide R- 26 Health Quality Council 2006

Fishbone Diagrams • Fill in detail for each cause. If a minor cause applies to more than one major cause, list it under both. Human Resources Material Resources Doctor not available to Photocopier not available. produce documents. Delays in patient discharges caused by problems related to documents sent with patients. Documents Documents prepared Admin office far incomplete. day of discharge. from ward. Material Method Environment Step 5: Identify increasingly more detailed levels of cause. Organize them under related causes or categories. Keep asking why to get to underlying causes. (See “The Five Whys”, below.) The Five Whys Analyze a process by asking the question “Why” up to five times. You may find yourself moving from what you think the problem is, to what it really is. In this simple example, a co-worker describes a problem at the medical clinic where you both work: Co-worker: “Patients picking up prescriptions at our pharmacy at noon hour have to wait too long.” You: “Why?” Co-worker: “It’s a busy time of the day in the pharmacy and the second pharmacist is on a lunch break.” You: “Why?” Co-worker: “Because that’s how we’ve always scheduled lunch breaks in the pharmacy.” You: “Why?” Co-worker: “Good question! I can’t think of a reason why. Maybe we should reschedule lunch breaks so that both pharmacists work during the busy lunch hour.” Step 6: Analyze the diagram; this will help you identify causes that warrant further investigation. • Look at the “balance” of your diagram, checking for compara- ble levels of detail for most of the categories. Patient Experience Survey: Quality Improvement Guide R- 27 Health Quality Council 2006

Fishbone Diagrams • A thick cluster of items in one area may indicate a need for further study. • A main category having only a few specific causes may indicate a need to identify further causes. • If several major branches have only a few sub- branches, you may need to combine them under a single category. • Look for causes that appear repeatedly. These may represent root causes. • Look for what you can measure in each cause so you can quantify the effects of any changes you make. • Identify and circle causes you can take action on. Used with permission of the Department of Defense Quality Management Program. Available from: http://quality.disa.mil/ pdf/bpihndbk.pdf Fishbone Diagram Sample Patient Experience Survey: Quality Improvement Guide R- 28 Health Quality Council 2006

Fishbone Diagrams Additional Information • An effect may be positive (an objective) or negative (a problem), depending on the issue that’s being discussed. • Using a positive effect which focuses on the desired outcome tends to foster pride and ownership over productive areas. This may lead to an upbeat atmosphere that encourages the participation of the group. When possible, it is preferable to phrase the effect in positive terms. • Focusing on a negative effect can sidetrack the team into justifying why the problem occurred and placing blame. How- ever, it is sometimes easier for a team to focus on what causes a problem than what causes an excellent outcome. While you should be cautious about the fallout that can result from focusing on a negative effect, getting a team to concen- trate on things that can go wrong may foster a more relaxed atmosphere and sometimes enhances group participation. • Take care to identify causes rather than symptoms. Used with permission of the Department of Defense Quality Management Program. Available from: http://quality.disa.mil/ pdf/bpihndbk.pdf Resources The following web sites may be helpful in constructing your own Fishbone diagrams: • National Health Services, Trent Improvement Network. This site includes a word version of a completed Fishbone diagram. www.tin.nhs.uk/index.asp?pgid=1132 Patient Experience Survey: Quality Improvement Guide R- 29 Health Quality Council 2006

Executing Phase Three This section has information on strategies, tools, and tips for turning ideas into action. Topics covered: • Pain management • Provider-patient communications • Discharge planning • Food Improving the Acute Care Hospital Experience: Quality Improvement Guide E—1 Health Quality Council 2006

Pain Management INTRODUCTION Pain management is a major health care concern in Saskatchewan and Canada. Despite the various pain management guidelines published in the past decade, patient satisfaction with pain management has not improved dramatically. Twenty-two percent of respondents to HQC’s 2004/05 acute care patient experience survey indicated staff did not do everything they could to control their pain – certainly room for improvement. A review of the literature revealed several methods and approaches for addressing the complex issue of appropriate pain management. These strategies may be incorporated into current practices or used to focus regional quality improvement initiatives. The Pain Management topic area contains four main sections: Change package overview E—3 Change concepts and ideas E—4 Resources E—12 References E—17 Improving the Acute Care Hospital Experience: Quality Improvement Guide E—2 Health Quality Council 2006

Change Package Overview The following change concepts and ideas are based on evidence from the literature. These are not the only changes that could potentially be made in the area of pain management but are examples of what has worked in other health jurisdictions. You are encouraged to design your own approaches to meet your organization's needs. The concepts and ideas are expanded in the next section, Change Concepts and Ideas. 1. Develop effective multi-disciplinary teams. Examples of change ideas: • Convene a pain management committee with members from different health care backgrounds. • Use a multi-disciplinary team approach. 2. Be systematic about monitoring patient pain. Examples of change ideas: • Standardize pain measurement. • Use standardized forms and pain rating tools to monitor changes in patient pain levels over time. • Complete a comprehensive pain assessment as clinically necessary and repeat as needed at regular intervals. • Incorporate “reminders” to assess and monitor pain. 3. Improve patient communication about pain. Examples of change ideas: • Improve patient description of pain. • Educate patients about their pain management. 4. Engage patients in developing pain management plans. Examples of change ideas: • Integrate the patient’s perspective in goal setting. • Provide patients with alternatives or adjuncts to drug therapy. • Use patient-controlled analgesia. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—3 Health Quality Council 2006

Develop effective multi-disciplinary teams. Convene a pain management committee with members from different health care backgrounds. Pain management committees can systematically study and improve processes within health re- gions or facilities1. These committees should include individuals from a variety of health care backgrounds with diverse experience in pain management. Patients should also be invited to sit on the committee. Use a multi-disciplinary team approach. Medications given for pain control may vary depending on the reasons and methods of delivery decided upon by the physician and care providers. Techniques from various disciplines can influence a patient’s pain experience. Pharmaceuticals are not the only means of managing pain; neuraxial, regional and sympathetic blocks can be performed if indicated. As well, techniques from disciplines such as physical therapy, massage therapy and psychology can greatly decrease patient pain levels2. Medical social workers can also have great impact on patient well-being and total pain. Team conferences should include patients and all health care professionals1. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—4 Health Quality Council 2006

Be systematic in monitoring patient pain. Use standardized documentation and protocols for assessing pain; this allows health care professionals to continuously monitor patient pain levels more accurately. The following ideas have been used in other health care settings to remind providers to assess, document, and re-assess patient pain. Standardize pain measurement. Monitoring and reporting/recording pain levels continuously, and evaluating the effect of interventions may help to promote better outcomes for patients. Ongoing discussions between health care providers, and between health care providers and patients, are important to ensure the changing needs of the patient are met. Treat pain as you would blood pressure, temperature, or any other vital sign: this is the idea behind the “Take 5: Pain as the 5th Vital Sign” support tool, developed by the Department of Veteran’s Affairs3. The tool promotes monitoring pain at regular intervals (every 3-4 hours), as you would when monitoring other vital signs. Standardized assessment and monitoring forms should have a specific space for recording pain levels, interventions, and pain relief levels. To assess pain, “Take 5” promotes the use of the numeric rating scale (NRS). The NRS is scored 0 through 10 and may be used either verbally or visually. Figure 1: Numeric Rating Scale An example of how the pain assessment could be incorporated into your standard vital signs flow sheets (clinical record sheets) is included below. Figure 2. Example vital signs flow sheet Patient Vital Signs Flow Sheet Patient name: _______________________________________ DOB: ____/____/____ MRN: _____________ Date Time BP P R T Pain Analgesics given, Nurse additional notes Initials Improving the Acute Care Hospital Experience: Quality Improvement Guide E—5 Health Quality Council 2006

Be systematic in monitoring patient pain. Use standardized forms and pain rating tools to monitor changes in patient pain levels over time. Use the same standardized tool to obtain information on patient-perceived levels of pain over a period of time during hospitalization. This allows baseline data to be collected prior to implementing pain management and allows health care professionals to track patient levels of pain throughout the pain management regime4. All staff should use the same rating scales, in the same preferential order, and note which scale they are using for a patient if it is different than the preferred scale. Some examples of different pain rating scales are presented in Figure 3 (below). The scales may be laminated and left in easily accessible areas, such as on medication carts or the ‘chart cart’ at the nursing station. Figure 3. Sample pain rating scales (From Department of Veteran’s Affairs: Pain as the 5th Vital Sign Toolkit. 2000; Geriatrics and Extended Care Strategic Health Group, National Pain Manage- ment Steering Committee, Washington. Copyright, used with permission.) Improving the Acute Care Hospital Experience: Quality Improvement Guide E—6 Health Quality Council 2006

Be systematic in monitoring patient pain. Certain patient populations, such as pediatrics, geriatrics, the cognitively impaired, or critically ill patients, are at higher risk of experiencing inadequate pain management because they are less able to communicate their pain to others6. Socio-cultural characteristics also influence the expres- sion of pain and pain behaviour5. It may be helpful to use different types of pain rating scales for different patient populations. For example, the 0-10 pain rating scale may not be appropriate for a child, but the Wong-Baker Pain Faces rating scale7 (see Figure 4) might help them describe their pain. Figure 4. Wong-Baker FACES Pain Rating Scale (From Hockenberry MJ, Wilson D, Winkelstein ML: Wong's Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. Copyright, Mosby.) The pain rating scale needs to be used appropriately, by both the health care practitioner and the patient to ensure accurate pain level information1. The following are a few tips to help ensure accuracy: • Providers and patients must fully understand how to use the pain rating scales in order to obtain valid and useful information. • Patients need to know that their input is the most important factor in choosing pain management strategies. • Try using an alternative pain scale if attempts to get a person to accurately use a pain scale are unsuccessful. • Use the pain scale frequently throughout the patient’s hospital stay; this has been shown to provide health care professionals with a better understanding of how the patient’s pain levels are being managed. Complete a comprehensive pain assessment as clinically necessary and repeat as needed at regular intervals. Only through initial and repeated comprehensive pain assessments will caregivers know the patient’s pain relief needs are met3,8. A comprehensive pain assessment should include the following components: • Patient report of pain using standardized scale • Location of pain • Description of pain (i.e. burning, stabbing, aching, squeezing, etc.) Improving the Acute Care Hospital Experience: Quality Improvement Guide E—7 Health Quality Council 2006

Be systematic in monitoring patient pain. • Aggravating factors • Psychological effects of pain • Social and cultural influences on reports of pain • Clinical interview • Physical examination • Previous treatments and their effectiveness • Diagnostic procedures when indicated • Interdisciplinary consultations when indicated A comprehensive pain assessment should also include patients’ short and long term pain management goals. Patient satisfaction is closely linked to patient’s quality of life. Pain can impact greatly on an individual’s quality of life if it prevents them from participating in activities that are required for daily living or those activities patients find meaningful. Health care professionals may be able to educate their patients in setting reasonable goals related to their activities of interest1. The use of comfort-function goals may help in this process9. Incorporate “reminders” to assess and monitor pain. The acronym “PQRST”- Precipitating/Quality/Radiation/Severity/Timing can be used to cue health care professionals to systematically evaluate patients’ pain levels on a regular basis10. The Veteran’s Administration in Los Angeles added an additional reminder to the PQRST, the U, which stands for unacceptable, and cues health care providers to assess patients’ comfort-function levels. An O could be added to the acronym to cue professionals to ask about the onset of the pain. In some instances, the P may stand for Palliates/Provokes. By having the PQRSTU available at all times on a laminated card, providers are reminded of all different aspects of pain that must be assessed11. Patients who have high, unrelieved pain levels could be given a “red flag” to prompt clinicians to further investigate the use of more appropriate or effective analgesics12. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—8 Health Quality Council 2006

Improve patient communication about pain. Patient report of pain is the most accurate assessment of a patient’s level of pain3. This is followed, in descending order, by reports of patient's pain by family or friends, patient behaviours, and physiological parameters. Knowing your patient’s pain rating, his/her level of pain control, and his/her understanding of the pain are necessary for effective pain management. Improve patient description of pain. Patients must be aware that their pain can only be managed when they are informing health care professionals of the effectiveness of their pain management6. Quality care involves encouraging patients to “have a voice” in their own care, including management of their pain. Recognize that patients use many different terms to talk about pain (e.g., ache, soreness). Health care providers must clarify and use the patient’s pain terminology when discussing pain management13. Educate patients about their pain management. Patients may refuse taking analgesics because they are either afraid of becoming addicted to the medication or are concerned about potential side effects. Educating patients about the risks associ- ated with taking analgesics may alleviate this reluctance, thereby leading to improved pain management6. Patients need to understand the goal is not to please, but to work in partnership with the caregiver to obtain optimal pain control. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—9 Health Quality Council 2006

Engage patients in developing pain management plans. Encouraging patients to take responsibility for their own care, including being involved in decisions about pain management, is an important concept in improving patient experience. The following are ideas shown to be effective in encouraging patients to participate in their pain management. Integrate the patient’s perspective in goal setting. Involve patients in goal setting. This allows for the development of specific, individualized goals, rather than generic goals to which your patients may not be able to relate14. Working with patients to develop individualized comfort-function goals helps ensure that patients set realistic, attainable goals. It provides an opportunity for educating patients that not all activities can or need to be performed pain-free12. Re-evaluate and re-set goals as necessary. For sample patient education materials related to setting pain management goals, see “Pain Management: Understand Your Aches and Pains. And Take Control” by the University of Michigan Health System (http:// www.med.umich.edu/1libr/aha/PainMgmt.pdf). Provide patients with alternatives or adjuncts to drug therapy. Patient satisfaction with pain management increases when they have non-drug therapy options for pain control. Giving patients alternatives encourages them to be directly involved in their own pain management6. Alternative therapies, such as physical therapy modalities, can enhance the effects of pharmacological pain management2. Psychological techniques, such as distraction and relaxa- tion, have been found to improve post-operative pain recovery15. Patient satisfaction is directly improved by offering patients independent ways to manage pain that give them more control over their pain levels16. Use patient-controlled analgesia. Patient-controlled analgesia (PCA) can be effective for post-operative pain relief. PCA allows patients to be independent in administering their own pain medication when they feel the need. PCA can reduce pain to a lower level over 24 hours compared with conventional analgesia strategies. Patients who understand how to use PCA appropriately have higher rates of satisfaction related to pain management17. Some key points to keep in mind when using PCA are: • Patient education is critical. • In order to use PCA safely, patients must clearly understand the technique. • Patients must be instructed that no unauthorized person (including family members) should push the demand button. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—10 Health Quality Council 2006

Engage patients in developing pain management plans. Over-sedation can be an issue. Common causes of over-sedation include mistaking the PCA for the nurse call-button, unauthorized family pushing the demand button, and repeatedly using the PCA at the end of the lockout period18. Medication dose, lockout interval, and the type of medications used are all parameters that can be adjusted thereby allowing individualized drug therapy. It is important for the health care team to monitor patient status regularly to determine whether the initial prescription needs to be adjusted to achieve optimal benefits. PCA is not a “one size fits all” type of therapy and success depends on how well it is used18. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—11 Health Quality Council 2006

Resources This section has resources, including samples of AIM statements and PDSA cycles. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—12 Health Quality Council 2006

Sample AIM statements • By February 2007, 96% of patients who are discharged from acute care facilities within the ABC- Regional Health Authority will state: “Hospital staff definitely did everything they could to control pain”. • By February 2007, 100% of acute care facilities within the ABC-RHA will implement a patient pain management education program. • By February 2007, 95% of acute care nurses within the ABC-RHA will use standardized pain rating scales frequently and according to exactly what the patient feels and not what the health professional interprets; using different types of scales for different populations. • By February 2007, 100% of patients within the ABC-RHA will rate their pain using a standardized pain rating scale provided to them by their health care provider. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—13 Health Quality Council 2006

Sample PDSA cycle This PDSA cycle is one that will help work towards the AIM statement: “By December 2006, 100% of acute care nurses within the ABC-RHA will use standardized pain rating scales appropriately.” OR 100% of patients within the ABC-RHA will rate their pain using a standardized pain rating scale provided to them by their health care provider. PLAN Objective: To have 2 RNs from the surgical ward of the A-1 hospital What is the objective of this improvement cycle? use the 1-10 numerical pain-rating scale with their patients. Who is involved? Plan: To teach 2 surgical ward RNs how to use the 1-10 numerical What? When? Where? Why? pain-rating scale and encourage them to use it initially on 5 patients per What do we predict will happen? shift. What additional information will we need to take Specifics: Instruction on how to use the “1-10” numerical pain rating action? scale will be given by a previously trained instructor. Then both RNs on the surgical ward will use this tool on 5 patients. Predictions: 2 surgical ward RNs will use the 1-10 pain scale on 5 patients for 3 weeks – we predict that patients will have improved satisfaction with pain management. Measures: Monitor the patient experience by using 2 survey questions from the survey previously given. DO 2 RNs on the surgical ward were taught the appropriate way to use the Was the test carried out as planned? 1-10 numerical pain rating scale; they then used the 1-10 numerical What did we observe that was not part of the pain-rating scale on 5 patients (per shift) for 3 weeks. plan? STUDY Both surgical ward RNs recorded and understood patient pain levels (on How did or didn’t the results agree with the 5 patients per shift), over a 3-week time frame. Nurses found it easy to predictions we made earlier? administer and the patients felt that their pain was managed effec- What new knowledge was gained through this tively. cycle? ACT Several ideas for future PDSA cycles were developed from this PDSA Now what? cycle: Do we abandon? Adjust? Adopt? • Try to incorporate the patient satisfaction survey for all sur- Are there forces in our organization that will help gical ward patients to determine if their satisfaction has im- or hinder these changes? proved with the use of the numerical 1-10 pain rating scale. Objective of next PDSA? • Take a larger step towards using the 1-10 numerical pain rating scale on all surgical ward patients. • If surgical ward patients are satisfied with the use of the 1- 10 numerical pain rating scale then the A-1 hospital will train all RNs to use this tool so it can be used throughout the whole hospital (not just on the surgical ward). • Examine whether pain management is improved in patients whose pain rating scores are greater than 4/10. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—14 Health Quality Council 2006

Resources TARGET AREA or SPECIFIC TOOLS AND RESOURCES GROUP Pain • Brief Pain Inventory: Tool for use in assessing patients’ overall level of pain, location Assessment of pain (including diagrams), and how pain interferes with activities of daily living. http:// www.ama-cmeonline.com/pain_mgmt/module05/pop_up/pop_bpi.htm • City of Hope Pain/Palliative Care Resource Center Website. A large selection of links to different pain assessment and management tools, including: pocket reference cards, rating scales, assessment packets, chart forms, database tools, home health flow sheets, chart documentation packets, and tools for infant and pediatric pain assessment. http://www.cityofhope.org/prc/pain_assessment.asp • The Faces Pain Scale - Revised. Tools designed to assess pain in pediatrics available in English, French and twenty-two other languages. http://www.painsourcebook.ca/ docs/pps92.html • UCLA Universal Pain Scale Tool. Tool containing Verbal Descriptor Scale, Wong- Baker Facial Grimace Scale, Activity Tolerance Scale, and scales to assess pain in seven languages other than English. http://www.anes.ucla.edu/pain/Faces Scale.pdf • Children's Hospital Eastern Ontario Pain Scale (CHEOPS). Pain assessment tool for children ages 1-7, including potential indicators of pain such as: crying, facial expres- sions, verbal indications, torso activity, and leg position. http://www.anes.ucla.edu/pain/ assessment_tool-cheops.htm • Partners Against Pain. Pain assessment forms and scales, pain diaries, and guides for implementing pain assessment. http://www.partnersagainstpain.com/index- mp.aspx?sid=3 • US Department of Veteran’s Affairs Office of Quality and Performance. Tool designed to measure the adequacy of pain relief and patient functioning. http:// www.oqp.med.va.gov/cpg/PAIN/pain_cpg/content/algann/algann_l_anno.htm • Stratis Health. Quality resources kit for pain assessment, including assessment tools, pain descriptions, educational resources, and guidelines for pain management. http:// www.stratishealth.org/Tools_Kit_pain.html Special • Pediatric Pain Sourcebook of Protocols, Policies, & Pamphlets. Standard pediatric Populations pain management protocols, assessment tools, forms, and policies and procedures. http://pediatric-pain.ca/index.html • City of Hope Pain/Palliative Care Resource Center Website. These sites include patient and family educational books and pamphlet and policy statements from professional organizations on pain management for special populations. Reference lists and resources are also included. ⇒ Pediatrics: http://www.cityofhope.org/prc/pediatrics.asp ⇒ Pain in the Elderly: http://www.cityofhope.org/prc/elderly.asp ⇒ Pain & Culture: http://www.cityofhope.org/prc/elderly.asp Improving the Acute Care Hospital Experience: Quality Improvement Guide E—15 Health Quality Council 2006

Resources TARGET AREA or SPECIFIC TOOLS AND RESOURCES GROUP Provider • American Medical Association CME Online. American Medical Association guide to Education managing pain in elderly patients, including assessment and management of pain. http://www.ama-cmeonline.com/pain_mgmt/module05/02intro/index.htm • Beth Israel Department of Pain Medicine & Palliative Care. Topics in Pain Manage- ment – A Slide Compendium: This website contains downloadable Powerpoint® mod- ules developed for professionals to use in delivering lectures on pain-related issues. http://www.stoppain.org/for_professionals/compendium/ • City of Hope Pain/Palliative Care Resource Center Website. ⇒ Site containing professional competencies and educational programs available for nursing staff. http://www.cityofhope.org/prc/nurseknow.asp ⇒ Survey to determine nurses’ knowledge and attitudes regarding pain. http:// www.cityofhope.org/prc/pdf/Knowledge and Attitudes Survey.pdf • VA Greater Los Angeles Healthcare System. Clinician Pocket Tool designed to prompt pain evaluation and assessment. Slaughter ABRC, Pasero CM, Manworren RM. Unacceptable Pain Levels: Approaches to prompting pain relief. American Journal of Nursing 2002 May; 102(5): 75-7. A summary of what is included on the pocket tool is available at: http://www.ic.sunysb.edu/Stu/sumusso/pain.htm Patient • City of Hope Pain/Palliative Care Resource Center Website. Educational materials Education for patients regarding assessing, managing, and living with pain. http:// www.cityofhope.org/prc/patiented.asp • Massachusetts General Hospital. Patient and Family Guide explaining causes of pain, ways to treat pain, how to talk about pain, and many other useful tips for patients in understanding and dealing with their pain. http://www.massgeneral.org/painrelief/ mghpain_guide.htm#guideone • Pledge to Patients from the staff at the MGH. A good example of how patients can become part of the care team. http://www.massgeneral.org/painrelief/ mghpain_pledge.htm • Greenwich Hospital. Patient/family information sheet regarding the use of patient- controlled analgesia. http://www.greenhosp.org/pe_pdf/pain_PCA.pdf Improving the Acute Care Hospital Experience: Quality Improvement Guide E—16 Health Quality Council 2006

References 1. Miaskowski, C. Monitoring and improving pain management practices: A quality improvement approach. Critical Care Nursing Clinics of America. 2001; 13(2), 311-7. 2. Institute for Clinical Systems Improvement (ICSI). Health Care Guidelines. 2004. 3. Department of Veteran’s Affairs. Pain as the 5th Vital Sign Toolkit. 2000; Geriatrics and Extended Care Strategic Health Group, National Pain Management Steering Committee, Washington, DC. 4. Schmidt, K. L., Alpen, M. A., Rakel, B. A., & Titler, M. G. Implementation of the agency for health care policy and research pain guidelines. AACN Clinical Issues Advanced Practice in Acute Critical Care. 1996; 7(3), 425-35. 5. Young, D. M. Acute pain management protocol. Journal of Gerontological Nursing. 1996; 25(6), 10-21. 6. Ashburn, M. A., Caplan, R. A., Carr, D. B., Connis, R. T., Ginsberg, B., Green, C. R., Lema, M. J., Nickinovich, D. G., & Rice, L. J. Practice guidelines for acute pain management in the perioperative setting. Anesthesiology. 2004; 100, 1573-81. 7. Wong, D., & Whaley, L. Clinical Handbook of Pediatric Nursing. 2nd ed. 1986; St. Louis, Mo: Mosby. As cited in Schmidt, K. L., Alpen, M. A., Rakel, B. A., & Titler, M. G. Implementation of the agency for health care policy and research pain guidelines. AACN Clinical Issues Advanced Practice in Acute Critical Care. 1996; 7(3), 425-35. 8. American Pain Society Quality of Care Task Force. American Pain Society recommendations for improving the quality of acute and cancer pain management. Archives of Internal Medicine. 2005; 165, 1574-80. 9. Pasero, C., & McCaffery, M. Accountability for pain relief: use of comfort-function goals, Journal of PeriAnesthesia Nursing. 2003; 18(1), 50-2. 10. Morton, P. G. Health Assessment in Nursing. 1989; Springhouse (PA): Springhouse. As cited in Slaughter, A., Pasero, C. & Manworren, R. Unacceptable pain levels: approaches to prompting pain relief. American Journal of Nursing. 2002; 102(5), 75-7. 11. Slaughter, A., Pasero, C. & Manworren, R. Unacceptable pain levels: approaches to prompting pain relief. American Journal of Nursing. 2002; 102(5), 75-7. 12. American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. Journal of the American Medical Association. 1995; 274 (23), 1874-80. 13. Miller, J., Neelon, V., Dalton, J., Ng’andu, N., Bailey, D., Layman, E., & Hosfeld, A. The assessment of discomfort in elderly confused patients: a preliminary study. Journal of Neuroscience Nursing. 1996; 28(3), 175-82. 14. Sterman, E., Gauker, S., & Krieger, J. A comprehensive approach to improving cancer pain management and patient satisfaction. Oncology Nursing Forum. 2003; 30(5), 857-63. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—17 Health Quality Council 2006

References 15. Sherwood, G. D., McNeill, J. A., Starck, P. L., & Disnard, G. Changing acute pain management outcomes in surgical patients. AORN Journal. 2003; 77(2), 374-95. 16. Van Kooten, M. E. Non-pharmacologic pain management for post-operative coronary artery bypass graft surgery patients. Image: Journal of Nursing Scholarship. 1999; 31, 157. As cited in Sherwood, G. D., McNeill, J. A., Starck, P. L., & Disnard, G. Changing acute pain management outcomes in surgical patients. AORN Journal. 2003; 77(2), 374-95. 17. Ballantyne, J. C., Carr, D. B., Chalmers, T. C., Dear, K. B., Angelillo, I. F., Mosteller, F. Postoperative patient-controlled analgesia: meta-analyses of initial randomized control trials. Journal of Clinical An- esthesia. 1993; 5, 182-93. 18. Macintyre, P. E. Safety and efficacy of patient-controlled analgesia. British Journal of Anaesthesia. 2001; 87(1), 36-46. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—18 Health Quality Council 2006

Provider-Patient Communications INTRODUCTION Good communication between health care providers and patients is a major contributor to the overall patient experience and patient compliance with treatment protocols and regimes. Evidence suggests that the provider-patient relationship is improved when providers communicate effectively with their patients. Communication breakdown can lead to patient confusion, increased hospital readmissions, and poor patient health outcomes1. Good communication may also reduce adverse events and increase hospital efficiency. The Provider-Patient Communications topic area contains four main sections: Change package overview E—20 Change concepts and ideas E—21 Resources E—27 References E—32 Improving the Acute Care Hospital Experience: Quality Improvement Guide E—19 Health Quality Council 2006

Change Package Overview The following change concepts and ideas are based on evidence from the literature. These are not the only changes that could potentially be made in the area of provider-patient communications, but are examples of what has worked in other health jurisdictions. You are encouraged to design your own approaches to meeting your organization's needs. The concepts and ideas are expanded in the next section, Change Concepts and Ideas. 1. Facilitate open communication. Examples of change ideas: • Promote patient-centred visits. • Use plain language and avoid medical “jargon”. • Use literacy tools. • Limit the amount of information. • Enhance communication between multi-disciplinary team members. 2. Ensure information is shared between provider and patient. Examples of change ideas: • Set up regular opportunities for staff to hear patient stories. • Invite the patient perspective in the direct care relationship. • Encourage patients to take an active role in seeking information about their care. 3. Customize care based on patient needs and values. 4. Increase patients’ sense of control over health care decisions. Examples of change ideas: • Make patients and their families an active part of the health care team. • Anticipate patients’ needs. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—20 Health Quality Council 2006

Facilitate open communication. Promote patient-centered visits. Creating a patient-centered culture requires health care professionals to focus on addressing specific patient concerns. Providers may need to speak more slowly for patients to readily understand and must make time to listen to what their patients have to say. Communication can be improved when patients are encouraged to ask questions about their own health or condition. The provider should make sure patients feel comfortable asking questions, make statements such as “medical information can sometimes be very confusing and it is really important that you understand what is happening, so please feel comfortable asking me any questions if you don’t understand everything”. By modifying certain behaviours such as sitting instead of standing and listening rather than speaking, the health care provider creates the impression that he/she is focused on the patient1. The American Hospital Association and the Institute for Family Centered Care2 summarizes patient and family centred care (or patient engagement in care) using four basic principles. These include: • Dignity and respect – listening to and valuing patient perspectives and preferences. • Information sharing – ensuring patients and their families receive all information needed to competently make decisions about their care. • Participation – allowing and encouraging patients to participate in care decisions and changes to the overall health care system. • Collaboration – involving patients in changes to health policy and programs, quality improvement efforts, and the delivery of care. Use plain language and avoid medical “jargon.” To avoid confusion and prevent patients from feeling intimidated by the health care system it is important to communicate with them in a language they understand. Providers should avoid the use of “medical jargon” particularly when sharing important information. Empower patients by helping them to fully understand what to expect and to understand why they are taking medications or undergoing tests3. The American Medical Association offers a clinician resource, “Health Literacy: A Manual for Clinicians”, available at http://www.ama-assn.org/ama1/pub/upload/mm367/ healthlitclinicians.pdf. The manual may assist with strategies to ensure provider-patient communication occurs at appropriate literacy levels. A patient’s literacy level can be a barrier to patient understanding. Health care providers often rely on written material to further educate and explain a patient’s condition and its treatment. Research shows that written information is often at a literacy level too high for most patients5. Providers and facilities should ensure patient handouts are written no higher than a grade eight literacy level. Use literacy tools. Take patient literacy into account and ascertain patients’ understanding of care planning by using such techniques as “teach back” and “Ask me 3 TM.” “Teach back” is a technique where health care Improving the Acute Care Hospital Experience: Quality Improvement Guide E—21 Health Quality Council 2006

Facilitate open communication. providers ask patients to repeat information in their own words, rather than just asking the patient if they understood what was said. This is an excellent way for providers to determine if patients fully understood what was said to them. It gives the provider an opportunity to correct any misunder- standings or clarify any pertinent information. If the patient is not able to explain things correctly, the health care provider has an opportunity to re-teach the information and should do so using alternate teaching approaches1. “Ask me 3 TM” is a tool designed by the Partnership for Clear Health Communication4 to address the problem of low health literacy and improve health outcomes. It promotes three basic but important questions that patients are encouraged to ask their health care provider(s). It is recommended that practitioners help their patients understand answers to the following three questions: • What is my main problem? • What do I need to do? • Why is it important for me to do this? Limit the amount of information. Patient education about health or health conditions is more effective when the focus is on only one or two important pieces of information. People generally remember things better and are more likely to comply with treatment if the information is given in small pieces – particularly when the information is relevant to health needs. Repeating this pertinent information is also very effective in promoting patient learning and retention5. Enhance communication between multi-disciplinary team members. Initiating dialogue between health care professionals may not always be easy for everyone on the multi-disciplinary care team. In order to promote good communication between providers and patients, the communication between team members must be clear and concise as well. Research suggests that teams need to create a culture for open communication and find a common “critical language” that promotes such open communication. The SBAR (Situation-Background-Assessment-Recommendation) tool has proven to be a useful way to promote open communication among health care professionals in many different health care settings. SBAR was adapted from the military to create a standardized method for concise, factual communications between health care providers. When using the SBAR tool, situation is a summary of what is happening at the present time, background summarizes what the circumstances were leading up to the event, assessment is a summary of what the professional thinks the problem is, and recommendation includes the professionals ideas to correct the problem6. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—22 Health Quality Council 2006

Ensure information is shared between provider and patient. There must be effective communication between providers and patients, and between patients and providers, regarding each party’s needs in the care process. Set up regular opportunities for staff to hear patient stories. Tufts-New England Medical Center (Tufts-NEMC) implemented a program called the Patient Visits Program (PVP) to get regular input from patients about their care. In this program, teams (consisting of one senior physician or nurse paired with one senior administrator) completed one set of patient visits per month on one in-patient unit. During the visits, patients were asked to self- report on issues such as hospital staff responsiveness, pain, and food. Patients were also asked if there was anything they would like to see done differently, or if there was anything the facility could improve. Following the visits, PVP interviewers directly initiated a response to the patients’ requests, which led to many different improvement initiatives occurring over time7. Invite the patient perspective in the direct care relationship. One doctor suggests that by incorporating multiple dimensions of care into his conversations with his patients he addresses all their needs, not just their medical needs8. For example, he ensures that throughout his conversations with patients he inquires about: • Their values, and expressed needs. • Their information needs. • The integration of their care amongst various professionals. • Their physical comfort needs. • Their emotional needs. • Their feelings regarding the involvement of their family and friends in their care. • Their needs for when they return home from the hospital. In this way, all the patient’s needs are addressed throughout the care process8. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—23 Health Quality Council 2006

Ensure information is shared between provider and patient. Encourage patients to take an active role in seeking information about their care. “Speak Up” is a program developed by the Joint Commission on Accreditation for Healthcare Or- ganizations to encourage patients to take an active role in their own health care management9. Ex- amples of the advice “Speak Up” offers to patients are as follows: Speak up if you have questions or concerns, and if you don't understand, ask again. It's your body and you have a right to know. Pay attention to the care you are receiving. Make sure you're getting the right treatments and medications by the right health care professionals. Don't assume anything. Educate yourself about your diagnosis, the medical tests you are undergoing, and your treatment plan. Ask a trusted family member or friend to be your advocate. Know what medications you take and why you take them. Medication errors are the most common health care errors. Use a hospital, clinic, surgery center, or other type of health care organization that has undergone a rigorous on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by Joint Commission. Participate in all decisions about your treatment. You are the center of the health care team. Adapted from: http://www.jointcommission.org/NR/rdonlyres/484AD48F-C464-4B5B-8D70- AA79179B3970/0/Speakup.pdf. Joint Commission on Accreditation of Healthcare Organizations Improving the Acute Care Hospital Experience: Quality Improvement Guide E—24 Health Quality Council 2006

Customize care based on patient needs and values. Systems are often designed to meet the most common needs of patients, but care providers must always remember that each patient is an individual, and the needs and preferences of each patient must be assessed during each care episode2. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—25 Health Quality Council 2006

Increase patients’ sense of control over health care decisions. Give as many opportunities as possible for patients to make choices about their care in a way that enhances their feelings of involvement and responsibility. Make patients and their families an active part of the health care team. Actively involve patients and families in the problem-solving process. Invite them to participate in advisory councils responsible for all aspects of the care process, from individual patient care to policy and planning for the organisation. This results in ongoing patient contributions into the care process and organizational initiatives. This process also has the potential to lead to patient-initiated programs designed to improve care10. Anticipate patients’ needs. Try to anticipate, rather than react to, patients’ needs. By involving patients in the health care system and process, opportunity exists for care providers to learn about patients’ needs prior to their emergence8. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—26 Health Quality Council 2006

Sample AIM statements • By February 2007, 90% of patients admitted to the A-1 hospital will report “my health care provider discussed my fears and anxieties about my condition with me”. • By February 2007, 90% of patients admitted to the A-1 hospital will report that they were encouraged to ask questions related to their health condition. • By February 2007, 95% of patients in the A-1 hospital will report they read and understood the “Ask Me 3” pamphlet and felt comfortable asking these questions of their health care provider(s). • By February 2007, 90% of patients in the A-1 hospital will report that they understand their health condition and that their health care providers took the time to explain what was happening to them. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—28 Health Quality Council 2006

Sample PDSA cycle This PDSA cycle is one that will help work towards the AIM statement: “By February 2007, 90% of patients in the A-1 hospital will report that they understand their health condition and that their health care providers took the time to explain what was happening to them.” PLAN Objective: To improve patient understanding of their health condition by What is the objective of this improvement cycle? facilitating patient use of the Ask Me 3 tool. Who is involved? Plan: 2 medical ward patients will be educated on the Ask Me 3 tool What? When? Where? Why? and will be encouraged to ask these questions of their physician. What do we predict will happen? Specifics: An “Ask Me 3” pamphlet will be given to each of the 2 cho- What additional information will we need to take sen patients (by a nurse) – and the tool will be explained. action? Predictions: Both patients will ask their physicians the 3 questions and the physicians will answer appropriately thereby improving communication between provider and patient – further improving the patients’ understanding of their condition. Measures: Ask the 2 patients if they asked their health care providers the 3 questions. Determine level of patient understanding of their condition through the use of the “teach back” tool. DO 2 patients on the medical ward were given instructions on the purpose Was the test carried out as planned? and use of the “Ask Me 3” tool and had an opportunity to ask their physi- What did we observe that was not part of the cians the 3 questions. The patients were surveyed regarding their use of plan? the 3 questions and their understanding of their condition prior to being discharged from hospital. STUDY Both patients asked their physicians the 3 questions from “Ask me 3” How did or didn’t the results agree with the and had a better understanding of their health condition; both patients predictions we made earlier? felt as if their physicians took the time to listen to their concerns. What new knowledge was gained through this cycle? ACT Several ideas for future PDSA cycles were developed from this PDSA Now what? cycle: Do we abandon? Adjust? Adopt? • Incorporate the use of “Ask me 3” on the whole medical Are there forces in our organization that will help ward. or hinder these changes? • Continue to measure patient experience via original survey Objective of next PDSA? to determine if levels of patient satisfaction improve with the use of the “Ask Me 3” tool. • If improved patient experience, perform the same process for a different hospital ward Improving the Acute Care Hospital Experience: Quality Improvement Guide E—29 Health Quality Council 2006

Resources TARGET AREA or SPECIFIC TOOLS AND RESOURCES GROUP Provider • Institute for Healthcare Communication: Annotated bibliographies summarizing Resources and communication literature on informed consent, oncology, enhancing health outcomes, Education clinician influence and patient action, and difficult clinician-patient relationships. http:// www.healthcarecomm.org/index.php?sec=biblio • Picker Institute Europe. Improving Patients’ Experience newsletter regarding information and communication about the process of care. http://www.pickereurope.org/ Filestore/News/Information_newsletter_jan03.pdf • East Tennessee State University Family Medicine Interview Study Group. Guide- lines for Using Common Ground Rating Forms: Tool designed to assess extent to which provider uses core communication skills. http://qcom.etsu.edu/communication/ Guide.pdf • The Doctors Company. Summary of ways to ensure communication skills are effective. http://www.thedoctors.com/pdf/riskmanagement/j4238.pdf • General Practice Advisory Council Queensland. Principles of Quality GP/Hospital Communication: Global, quality, process, and organisational principles behind quality doctor-hospital communication. http://www.health.qld.gov.au/hssb/hou/integration/ GPAC_GP.pdf • Victorian State Government, Department of Human Services, Australia. Communi- cating with Consumers, Good Practice Guide to Providing Information: Kit that focuses on best practices for the processes of communication and information exchange between patients and hospitals. http://www.health.vic.gov.au/consumer/downloads/ dhs972.pdf • Mount Sinai Hospital. Techniques for engaging the patient during communications in order to provide a good foundation for a therapeutic relationship. http:// www.mtsinai.on.ca/IBD/caregiver/patient-engagement.htm • American Hospital Association & Institute for Family Centered Care. Strategies for Leadership: Advancing the Practice of Patient- and Family-Centered Care. A Resource Guide for Hospital Senior Leaders, Medical Staff and Governing Boards http:// www.aha.org/aha/key_issues/patient_safety/contents/resourceguide.pdf Improving the Acute Care Hospital Experience: Quality Improvement Guide E—30 Health Quality Council 2006

Resources TARGET AREA or SPECIFIC TOOLS AND RESOURCES GROUP Patient • Harvard Health Research. Nine tips for better provider-patient communication for Education and patients. http://www.couplescompany.com/advice/Jason/Harvard/9tips.htm Resources • HealthLink Medical College of Wisconsin. Tips for patients as to what to do if doctor—patient communication goes wrong. http://healthlink.mcw.edu/ article/1031002495.html • Steps to getting the most out of a hospital stay. http://healthlink.mcw.edu/ article/1023997649.html • Department of Veteran’s Affairs National Center for Patient Safety. Guide to assist patients in understanding what will happen before their surgery and the steps taken by doctors and nurses to make sure that everything goes as planned. http:// www.patientsafety.gov/SafetyTopics/CorrectSurg/CorrSurgPt.pdf Improving the Acute Care Hospital Experience: Quality Improvement Guide E—31 Health Quality Council 2006

References 1. Weiss, B. D. Health Literacy A Manual for Clinicians. 2003; American Medical Association Foundation and American Medical Association. http://www.ama-assn.org/ama1/pub/upload/mm/367/ healthlitclinicians.pdf Accessed May 5, 2006. 2. American Hospital Association & Institute for Family Centered Care. 2004; http://www.aha.org/aha/ key_issues/patient_safety/contents/resourceguide.pdf, Accessed January 12, 2006. 3. Schillinger, D., Grumbach, K., Piette, J., Wang, F., Osmond, D., Daher, C., Palacios, J., Sulllivan, G. D., & Bindman, A. B. Association of health literacy with diabetes outcomes. JAMA. 2002; 288(4), 475- 82. 4. Partnership for Clear Health Communication. Ask Me 3TM. http://www.askme3.org/pdfs/Patient_Eng.pdf Accesssed May 5, 2006. 5. Mayeaux EJ Jr., Murphy PW., Arnold C., Davis TC., Jackson RH., & Sentell T. Improving patient education for patients with low literacy skills. American Family Physician. 1996; 53(1), 205-11. 6. Leonard, M., Bonacum, D., & Graham, S. SBAR Technique for Communication: A Situational Briefing Model. 2006. Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/PatientSafety/ SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm Accessed May 5, 2006. 7. Sidhu M, Berg K, Endicott C, Santulli W, Salem D. The Patient Visits Program: a strategy to highlight patient satisfaction and refocus organizational culture. The Joint Commission Journal on Quality Im- provement. 2002; 28(11), 605-13. 8. Delbanco, T. L. Enriching the doctor-patient relationship by inviting the patient’s perspective. Annals of Internal Medicine. 1992; 116(5), 414-18. 9. Joint Commission on Accreditation of Healthcare Organizations. Speak Up: Help Prevent Errors in Your Care. http://www.jointcommission.org/NR/rdonlyres/484AD48F-C464-4B5B-8D70- AA79179B3970/0/Speakup.pdf accessed May 19, 2006. 10. Reid Ponte, P., Conlin, G., Conway, J. B., Grant, S., Medeiros, C., Nies, J., Shulman, L., Branowicki, P., & Conley, K. Making patient-centered care come alive – achieving full integration of the patient’s perspective. JONA. 2003; 33, 82-90. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—32 Health Quality Council 2006

Discharge Planning INTRODUCTION A patient’s journey through an acute care hospital stay can involve many transfers or transitions to different sites of care. Discharge or the transition to home is one stage of the patient journey that poses challenges for both patients and their health care providers. Saskatchewan is not unique; other parts of Canada, the United States of America, and the United Kingdom report similar difficulties in their health systems with the transition to home1,2. Transitional care is an under- recognized yet significant issue and because of its unique attributes, requires a specific strategy and agenda to address factors that will lead to improvement. The Discharge Planning topic area contains four main sections: Change package overview E—34 Change concepts and ideas E—35 Resources E—45 References E—50 Improving the Acute Care Hospital Experience: Quality Improvement Guide E—33 Health Quality Council 2006

Change Package Overview The literature on care transitions from hospital to home or other locations of care provides some insight into what can be done to enhance or change a facility’s current discharge planning process, and improve the overall patient experience. The following change concepts and ideas have been successfully used elsewhere to improve patient transitions. These are not the only changes that can be made; you may have your own practical approaches and examples to improve on these ideas. The concepts and ideas are expanded in the next section, Change Concepts and Ideas. 1. Develop effective multi-disciplinary teams. Examples of change ideas: • Form a multi-disciplinary discharge care team. • Identify a Discharge Planning Coordinator. • Incorporate daily multi-disciplinary rounds. • Develop partnerships with post-discharge care providers. • Engage patients in the problem-solving process. 2. Involve patients in the discharge process. Examples of change ideas: • Educate patients (or caregivers) about self-management tools and techniques. 3. Be systematic in discharge planning. Examples of change ideas: • Focus on simple discharges. • Schedule discharges. • Include follow-up support after discharge from hospital. • Use reminder systems. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—34 Health Quality Council 2006

Develop effective multi-disciplinary teams. It is not realistic to expect one care provider to have complete knowledge of every aspect of the patient’s care, because of its complexity and the involvement of different health care professionals with diverse scopes of practice1,2. Forming multi-disciplinary teams brings together various perspectives and allows for a more comprehensive approach to patient care. Multi-disciplinary teams consider all components and aspects of patient care and focus on making improvements that will impact the overall patient experience. Form a multi-disciplinary discharge care team. A multi-disciplinary team set up to manage and design the discharge process may be helpful in making improvements. The multi-disciplinary team must be organized and well-designed to create effective change. Some things to consider: • Roles and responsibilities: who will manage each aspect of the patient discharge? • Who will identify and document an estimated date of discharge? • Who will review the patient’s discharge plan? • How will the team determine when the patient is clinically stable and safe to transfer home3? To implement changes, the team can run Plan-Do-Study-Act cycles. They can start by focusing on a small group of patients and determine whether the decided-upon changes result in an improved patient experience and a more efficient discharge process. The team can then determine whether or not to implement similar changes for other patient populations or on other wards3,4. Creating an information/fact sheet describing the different care team members involved with the patient, their roles, and what the patient can expect from each team member is helpful in ensuring patients receive the most benefit from being cared for by a multi-disciplinary team3,5. Identify a Discharge Planning Coordinator. It may be helpful to identify a lead health care professional to initiate discharge planning, sometimes called a “Discharge Planning Coordinator”. The overall role of the Coordinator is not to act as a care manager, but to ensure a smooth transition as the patient moves from the hospital to home. The Coordinator should assist the patient in identifying critical questions and concerns to ask his/ her providers. Ideally the Coordinator would be available to initiate contact with the patient within the first 24 hours of admission, and continue to be involved once the patient is transferred home3. Who might be designated as a Discharge Planning Coordinator? The Coordinator does not have to be a physician. Consider nurses or other health care professionals (such as physical therapists, occupational therapists, etc.) who could assume more responsibility for initiating the discharge process. Several hospitals in the United Kingdom focus on a nurse-led patient discharge process, using agreed upon protocols that were developed by the multi-disciplinary team. When the nurse leader identifies the patient as stable and meeting all criteria (previously determined by the multi- disciplinary team) the patient is discharged. While physicians are not always directly involved in the Improving the Acute Care Hospital Experience: Quality Improvement Guide E—35 Health Quality Council 2006

Develop effective multi-disciplinary teams. patient discharge process, they are highly involved in identifying criteria for safe transfer home. Incorporate daily multi-disciplinary rounds. Improving communication amongst health care providers is important in discharge planning to ensure that information is neither duplicated nor completely missed5. Daily multi-disciplinary rounds are one way to improve both communication and team functioning. This process involves care teams conducting rounds together at the patient’s bedside. The team make-up may vary from hospital to hospital, but usually consists of physicians, nurse managers, staff nurses, pharmacists, social workers, nutritionists, and pastoral services. Daily goals can be set during rounds with the involvement of the patient or caregiver/family. These goals can be updated and posted in the patient’s room to act as a reminder for the patient, his/her caregiver(s), and all of the health care professionals involved in the patient’s care. The projected discharge date can be revised on a daily basis by regular review of the patient’s condition, and his/ her response to treatment, both of which influence discharge date and time4. Develop partnerships with post-discharge care providers. Continuity of care is critical when patients are discharged from one facility to another to prevent fragmented care, duplication of services, medication Ideas in Action errors, and patient and caregiver distress. It is imperative to ensure that the critical elements of a patient’s care plan be transferred to the next facility or Understanding the patient per- with patients when they are discharged home. To enhance communication spective more clearly helped between health care facilities, at least one team member should be identified several facilities tailor their care processes to be more as being responsible for ensuring patient information is transferred from one patient-focused. One group of facility to another6. health care professionals from Boston, USA chose to im- You may also want to consider improving communication with family physi- prove the area of continuity of cians and specialists. A team member could be given the role of ensuring care and transition of patients patients have follow-up appointments and that patients have all the neces- from their hospital. Prior to sary information about these appointments prior to leaving the hospital2,6. implementing any change at their facility, the hospital in- Engage patients in the problem-solving process. vited several patients to ex- In order to improve the transition process and make it more patient-centred, press their opinions on the current discharge process. it is helpful to incorporate ideas from patients. Invite recently discharged Patients and health care pro- patients to be members of the multi-disciplinary discharge team as a way for fessionals found this to be a health care professionals to learn how well prepared patients felt for the very positive experience and transition from hospital to home5. many of the patient opinions were considered in the discharge improvement process. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—36 Health Quality Council 2006

Involve patients in the discharge process. Nurturing a culture of patient safety and positive patient experience includes involving the patient or their family or caregivers in the process. The literature suggests patient involvement should occur throughout the whole patient journey, but particularly at the time of transfer from hospital to home. It is difficult to create a positive patient experience if the voices of patients and their families are not responded to or heard. The transition from hospital to home is a time patients tend to be the most vulnerable and feel the most overwhelmed because most do not have a follow-up visit with a health care professional. Successful care transitions usually become the responsibility of the patients themselves (and their caregivers). More vulnerable patients may require a health care professional follow-up when they get home, as well as tools in place to help them become more independent in their health management. Educate patients (or caregivers) about self-management tools and techniques. Patients or their caregiver(s) are often the only common factor in the journey across sites of care. Ensuring they understand what questions to ask and encouraging them to take the initiative in some parts of the care process could improve transitions2. Several consumer/patient fact sheets are available to educate patients about their care when leaving the hospital. Use of patient-centered records such as the Personal Health Record7 can help improve communication between patients and health care professionals in different care settings. Figure 5. From: An interdisciplinary team approach to improving transitions across sites of geriatric care. (University of Colorado Health Sciences Center. Used with permission.) Improving the Acute Care Hospital Experience: Quality Improvement Guide E—37 Health Quality Council 2006

Involve patients in the discharge process. Transition home teaching packages are another way to educate patients about self-management of their care. These packages help ensure certain aspects of discharge planning and preparation are completed and they should be facility-specific. In creating such a package, it is important to include patients’ opinions on what is needed to improve the discharge process. A facility-level multi- disciplinary discharge care committee could assume responsibility for the creation and distribution of “transition home” teaching packages5. The Institute for Health Improvement (IHI) suggests giving patients a written summary of their care at discharge to enhance their feelings about fully participating in their care, and to help ensure that patient safety is maintained upon discharge home. This summary could review what happened to the patient during the hospital stay, for example, the tests performed and the results of these tests, the reasons for and side effects of home medications, and the follow-up care or lifestyle changes recommended. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—38 Health Quality Council 2006

Be systematic in discharge planning. Focus on simple discharges. Simple discharges are those that involve patients who require minimal care after discharge and are generally discharged to their own home. These discharges generally make up 80% of total hospital discharges. Focusing initial improvement efforts in this area might yield the greatest impact from improvement efforts3. Schedule discharges. The majority of patients in acute care settings will require simple discharge planning; it is likely these patients will have a predicted length of hospital stay. Multi-disciplinary teams can work together to establish an estimated date of discharge (EDD), based on how long the team be- lieves the patient will need to stay in the hospital prior to the stabilization of their condition while still allowing enough time for necessary tests and interventions to be completed3. In predicting the date of discharge, timelines can be established to ensure the patient receives all necessary information prior to leaving the hospital. Scheduled discharges can also improve patient experiences by ensuring a more timely transition from the hospital, and assisting the patient’s family in being prepared for the patient to return home. Consider when discharges usually happen. For example, some hospitals find that many discharges occur in the late afternoon and evening. Changing the discharge time to mid-morning (when nursing staff have more time to spend with patients) has been an effective way for some facilities to improve the patient discharge experience. Ideas in Action Kaiser Foundation Hospital-Roseville Schedules Patient Discharges to Improve Throughput It makes sense when you think about it. Hotels establish a check-out time so they can plan for the next wave of visitors. Why can’t a hospital do the same? Discharge appointments are one of the tools IHI recommends for improving the flow of patients into, through, and out of the hospital. Kaiser Foundation Hospital-Roseville in Sacramento, California, a participant in the Transforming Care at the Bedside initiative, has put this and other flow improvement tools to good use. Patients at Kaiser-Roseville were sometimes “parked” in the Emergency Department or in recovery after surgery while they waited for a bed. “It was a huge patient dissatisfier,” says Sandy Sharon, RN, MBA, Assistant Administrator for Patient Care Services. Analysis of patient flow revealed that most discharges and admissions occurred on the evening shift. “So we set a goal of having 40 percent of discharges occur before 11:00 AM,” a goal the hospital achieved in Oc- tober 2005. Now, discharge rounds are conducted daily at 11:30 AM to start the ball rolling for the next day’s discharges. “We identify patients we think will be discharged the next day, and get any pending lab work going, get orders for discharge meds into the pharmacy, notify the family, and tie up any loose ends. PT knows which patients to see first the next morning. Housekeeping knows which rooms will turn over and when. It really benefits everyone.” Improving the Acute Care Hospital Experience: Quality Improvement Guide E—39 Health Quality Council 2006

Be systematic in discharge planning. Include follow-up support after discharge from hospital. Have one of the multi-disciplinary team members schedule follow-up appointments with the patient within the first week of being home after discharge from the hospital. For those patients unable to return to the hospital, consider phoning between 24 hours to 3 days post-discharge5. Incorporate a Discharge Planning Coordinator, who will take responsibility for providing patients with support and tools to promote self-management during the transition from hospital to home, into the discharge process6. Use reminder systems. Health care providers are often multi-tasking throughout the day. According to Dr. Michael Leonard, our short-term memory limits us to remembering between five and seven different items at one time; an individual will generally forget something if required to remember more than seven items. On average, nurses have between 17 and 20 items to remember 70% of the time. Reminders can be an effective way of ensuring that everything gets done with minimal pressure on care providers8. The following reminder ideas could be incorporated into currently used processes or forms: • Use a white-board in patients’ rooms that identifies the caregiver for the day, goals of the day, and long-term goals for discharge. Not only does this idea encourage patient involvement but it also provides a continuous reminder to the care team as to what needs to be completed prior to the patient being safely discharged home. • The National Health Service (NHS) in the United Kingdom has outlined some key questions care providers could ask themselves during the patient’s hospital stay. These questions could be put onto a card that the provider carries with them to remind them of what needs to be done prior to a patient being discharged. The simple discharge decision – questions to ask: • Has a date of discharge been estimated and documented? • Has the patient been involved or informed? • Is the patient clinically stable and fit for discharge? • Have transport arrangements been made? • Clothes for discharge and keys on ward area? • Tablets to take out dispensed and purpose, regime explained to patient? • GP, nurses, carers involved/informed? • Outpatient appointments made and given to patient? • Transfer time to discharge lounge agreed? • Patient given information about self-care and who to contact if symptoms return? Adapted from: Achieving timely ‘simple’ discharge from hospital: A toolkit for the multi-disciplinary team (Department of Health, 2004, pg.12). Used with permission. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—40 Health Quality Council 2006

Be systematic in discharge planning. • Document patient understanding of and compliance with medications as the ‘Sixth Vital Sign’9. This may involve allocating a space on assessments or discharge instruction forms specifically for medication instructions to act as a cue to health care professionals to ensure their patients understand the importance of taking their prescribed medications, and as a reference for patients to refer to once home. • Use a ‘Discharge Checklist’. Begin filling it out on the day of admission and revise 48 hours prior to discharge and on the day of discharge1. You may want to create your own facility- specific discharge checklist or use a one already created - see below and next 2 pages for examples: Figure 6: Discharge Information Sheet I (Adapted from: The Joint Commission on Accreditation of Healthcare Organizations, Journal of Quality Improvement, 1996, Vol. 22 (5) 311-22. Used with permission.) DISCHARGE INFORMATION SHEET I Doctor’s name:___________________ Phone:__________________________ Nurse’s name: ___________________ Phone:__________________________ Social worker’s name: _____________ Phone:__________________________ Other: ___________________ Phone:__________________________ The following instructions are included in this packet: General Instructions ________ Instructions included Activity ________ No limitations Diet ________ No limitations Medications ________ No limitations Other instructions included _______ Physical therapy _______ Respiratory care _______ Occupational therapy _______ Other Follow-up Appointments or Home Visits Doctor/clinic/agency Date Time ________________________ ________________ ________________ ________________________ ________________ ________________ ________________________ ________________ ________________ The above material has been reviewed with me. My questions have been answered and I understand the contents. Your signature: _____________________________________________ Discharge date and time: ______________________________________ Nurse’s signature: ___________________________________________ Improving the Acute Care Hospital Experience: Quality Improvement Guide E—41 Health Quality Council 2006

Be systematic in discharge planning. Figure 7: Discharge Information Sheet II (Adapted from: The Joint Commission on Accreditation of Healthcare Organizations, Journal of Quality Improvement, 1996, Vol. 22 (5) 311-22. Used with permission.) DISCHARGE INFORMATION SHEET II Activity Guidelines After discharge from Hospital X, I will be able to: Restrictions Yes No Yes, with: 1. Take a tub bath 2. Shower 3. Climb stairs 4. Lift heavy objects or children 5. Take walks/exercise 6. Resume sexual activity 7. Return to work 8. Drive a car 9. Other activities Call your doctor if: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ Improving the Acute Care Hospital Experience: Quality Improvement Guide E—42 Health Quality Council 2006

Be systematic in discharge planning. Figure 8: Example of a discharge checklist. (Obtained from the NHS: Achieving timely ‘simple’ discharge from hospital, 2004. Used with permission.) Improving the Acute Care Hospital Experience: Quality Improvement Guide E—43 Health Quality Council 2006

Be systematic in discharge planning. Provide simple, easy-to-understand information to patients at time of discharge. Literacy is a predictor of health status. Many quality improvement strategies encourage patients to be more highly involved and responsible for their own self-management, however, poor health literacy could be a barrier to successful self-management in some patient populations. It is essential to create patient fact sheets at a literacy level that is understandable by the majority of our population. Creating fact sheets at a grade eight level will help overcome the health literacy problem. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—44 Health Quality Council 2006

Sample AIM statements • By February 2007, 90% of patients at the A-1 hospital will be transferred home as soon as they are clinically stable and fit for discharge. • By February 2007, 90% of patients transferred from the A-1 hospital to home will report they received information regarding the potential side effects of the medication they’re taking. • By February 2007, 90% of all patients transferred from the A-1 hospital to home will receive a follow-up phone call or visit within 1-3 days after discharge. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—46 Health Quality Council 2006

Sample PDSA cycle This PDSA cycle is one that will help work towards the AIM statement: “By December 2006, 90% of patients transferred from the A-1 hospital to home will receive information regarding the potential side-effects of the medication they’re taking.” PLAN Objective: To improve patient knowledge of medication side effects What is the objective of this improvement cycle? prior to transitioning home from hospital. Who is involved? Plan: 5 medical ward patients will have a scheduled appointment with a What? When? Where? Why? discharge nurse/discharge coordinator/pharmacist who will review the What do we predict will happen? potential side-effects to watch for with the medications these individuals What additional information will we need to take are taking. action? Specifics: A scheduled discharge appointment will be made along with a time for the nurse/discharge coordinator/pharmacist to review medication side effects. Predictions: Nurse will successfully review side effects with 5 medical ward patients and these patients will have an increased understanding of potential side effects of their medications. Measures: Monitor level of patient receipt of medication side effect information via mini-surveys administered on discharge. DO 5 patients on the medical ward will be scheduled for discharge over the Was the test carried out as planned? next 1-2 weeks and will receive an education session on the potential What did we observe that was not part of the side effects of their medications. plan? STUDY A review of medication side effects was done with 5 patients. Four out of How did or didn’t the results agree with the five patients reported they felt comfortable that they received appropri- predictions we made earlier? ate and adequate information on the potential side effects of their medi- What new knowledge was gained through this cations. One patient reported that he/she forget the information was cycle? presented. ACT Several ideas for future PDSA cycles were developed from this PDSA Now what? cycle: Do we abandon? Adjust? Adopt? • Evaluate patient experience with another survey when Are there forces in our organization that will help these changes are fully implemented on this medical ward or hinder these changes? • If improved patient experience, perform the same process Objective of next PDSA? for a different hospital ward • Do a PDSA cycle on incorporating a follow-up home visit with a transition coach on 1 patient • Repeat #2 on five patients • Evaluate efficacy of the discharge coordinator from patient perspective via patient survey Improving the Acute Care Hospital Experience: Quality Improvement Guide E—47 Health Quality Council 2006

Resources TARGET AREA or SPECIFIC TOOLS AND RESOURCES GROUP Provider • The Royal Women’s Hospital. Resources ⇒ Process guidelines for involving the GP in the discharge process. http:// www.rwh.org.au/emplibrary/discharge/ Care_Planning_and_case_conference_guidelines1.pdf ⇒ Patient information sheet regarding need for care planning and the discharge process. http://www.rwh.org.au/discharge/assessment.cfm?doc_id=3757&print=yes ⇒ Example of a discharge/community care plan case conference record sheet. http:// www.rwh.org.au/emplibrary/discharge/Care_Plan_template1.pdf • StratisHealth. Discharge planning resources including discharge planning strategies, data collection tools, medication reconciliation tools, policies and procedures, assessment tools, continuity of care resources, education resources, and follow-up resources. http://www.stratishealth.org/Tools_Kit_discharge_planning.html • Emergency Nursing World. Tips for ensuring the discharge teaching process is effective. http://www.enw.org/Discharge.htm • The Ottawa Hospital. Summary of the components of discharge planning, and options for where patients may be discharged. http://www.ottawahospital.on.ca/hp/dept/ socialwork/discharge-e.asp • Commonwealth Department of Veteran’s affairs. Discharge Planning Resource Kit, including tools for patients and providers. http://www.dva.gov.au/media/publicat/2003/ dprk/dprk.pdf • Institute for Healthcare Improvement. The ticket home: description of the use of a white board designed to ensure patients and their families are informed and engaged in discharge planning. http://www.ihi.org/IHI/Topics/MedicalSurgicalCare/ MedicalSurgicalCareGeneral/ImprovementStories/ShesGotaTicketToGoHome.htm • Australian Resource Centre for Healthcare Innovations. List of resources designed to assist with improving the efficiency of discharge practices. http://www.archi.net.au/e- library/managing_demand/discharge_strategies • National Health Service. Achieving timely ‘simple’ discharge from hospital: A toolkit for the multi-disciplinary team. http://www.dh.gov.uk/ assetRoot/04/08/83/67/04088367.pdf • Press Ganey. Leaving the Hospital: Satisfaction with the Discharge Process: Sugges- tions for techniques designed to improve the discharge process. https:// www.pressganey.com/products_services/readings_findings/satmon/article.php? article_id=47 Improving the Acute Care Hospital Experience: Quality Improvement Guide E—48 Health Quality Council 2006

Resources TARGET AREA or SPECIFIC TOOLS AND RESOURCES GROUP Special • British Columbia Schizophrenia Society. Discharge checklist designed to ensure Populations patients with schizophrenia and their families receive all information needed for a good discharge. http://www.bcss.org/Get_Information/hospital_discharge_planning.html • Elder Law of Michigan. Hospital discharge planning information for patients, including a checklist designed to assist in choosing a quality nursing home. http:// www.elderslaw.org/Hotline/brochures/HOSD-%20Hospital%20Discharge% 20Planning.pdf • Senior Survival School. Example of a fact sheet for seniors alerting them to the different factors to be aware of when being discharged form hospital. http:// www.seniorsurvivalschool.org/survival_sheets/PDF/Survival%20Sheet%2018.pdf • Massachusetts Department of Public Health Elder Health. Example of an information sheet for elderly patients regarding discharge from the hospital. http:// www.mass.gov/dph/fch/elderhealth/aarprev2.pdf Patient • Joint Commission on Accreditation of Healthcare Organizations. Pamphlet from Education and the Speak Up Safety Initiative alerting patients what they should know about their re- Resources covery process and needs. http://www.jointcommission.org/NR/rdonlyres/0A4A05CE- CA67-4F29-840D-E4C0CD5115F9/0/speakup_recovery.pdf • Aurum Post-Acute Network. Tips for patients about planning ahead for what they will need when they come home from hospital, how to involve themselves in the discharge planning process, and what to do when home. http://www.aurumnetwork.com/ resources/discharge.html • Thomas Jefferson University Hospital. Suggested questions for patients to ask their physician prior to being released from the hospital. http://content.jeffersonhospital.org/ content.asp?pageid=P01395 • National Alliance for Caregiving & United Hospital Fund. A Family Caregiver’s Guide to Hospital Discharge Planning. http://www.uhfnyc.org/usr_doc/ DischargePlan_Fam.pdf • Hospital Discharge Planning: Helping Family Caregivers Through the Process. http://www.carers.co.nz/files/pdf/HospitalPlanning.pdf Standards and • National Assembly for Wales. Hospital Discharge Planning Guidelines. http:// Guidelines new.wales.gov.uk/docrepos/40382/40382313/40382112/40382112/403821/NAFWC17- 05-e.pdf;jsessionid=35934A1FAF6DEBDCF7635C700B0E1DEE?lang=en Improving the Acute Care Hospital Experience: Quality Improvement Guide E—49 Health Quality Council 2006

References 1. Health and Social Care Joint Unit and Change Agents Team. Discharge from hospital: pathway, process and practice. 2003. Department of Health: London. http://www.dh.gov.uk/ assetRoot/04/08/83/67/04088367.pdf Accessed on May 5, 2006. 2. Coleman EA, Smith JD, Frank JC, Min S, Parry C, Kramer AM. Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention. Journal of the Ameri- can Geriatrics Society. 2004; 52(11):1817-25. 3. Department of Health. Achieving timely 'simple' discharge from hospital: A toolkit for the multi- disciplinary team. 2004. Department of Health: London. http://www.dh.gov.uk/ assetRoot/04/08/83/67/04088367.pdf Accessed on May 5, 2006. 4. Rutherford, P., Lee, B., & Greiner, A. Innovation Series 2004: Transforming Care at the Bedside. 2004. Institute for Healthcare Improvement. http://www.ihi.org/IHI/Results/WhitePapers/ TransformingCareattheBedsideWhitePaper.htm Accessed on May 5, 2006. 5. Reiley, P., Pike, A., Phipps, M., Weiner, M., Miller, N., Stengrevics, S. S., Clark, L., & Wandel J. Learn- ing from patients: A discharge planning improvement project. Joint Commission Journal on Quality Im- provement. 1996; 22(5): 311-22. 6. University of Colorado Health Sciences Center, Division of Health Care Policy and Research. An interdisciplinary team approach to improving transitions across sites of geriatric care. 2004. Denver, Colo- rado 7. University of Colorado Health Sciences Center, Division of Health Care Policy and Research. Personal health record. Care Transitions Program. 2006. http://www.caretransitions.org Accessed May 5, 2006. 8. Institute for Healthcare Improvement National Forum 2005. Dr. Michael Leonard, L18: Human Factors, Teamwork, and Effective Communication; December 11, 2005. 9. Rosenow, E. C. Patients’ understanding of and compliance with medications: the sixth vital sign? Mayo Clinic Proceedings. 2005; 80(8), 983-87. 10. Schillinger, D., Grumbach, K., Piette, J., Wang, F., Osmond, D., Daher, C., Palacios, J., Sulllivan, G. D., & Bindman, A. B. Association of health literacy with diabetes outcomes. JAMA. 2002; 288(4): 475- 82. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—50 Health Quality Council 2006

Hospital Food INTRODUCTION Literature on patient satisfaction consistently reports that patients’ perceptions of the quality of food they receive while in hospital are strongly linked to patients’ overall reports of satisfaction1. Further, patients who are ill or recovering from surgical procedures face a risk of malnutrition, which could affect their rate of recovery and increase their risk of complications2. Results from the Health Quality Council 2004/05 acute care patient experience survey3 found room for improvement in patient ratings of the overall quality of food. Only 29% of respondents gave a rating of “very good” or “excellent” when asked to rate the quality of the food based on taste, serving temperature and variety – the lowest of all patient experience quality indicators. The Hospital Food topic area contains four main sections: Change package overview E—52 Change concepts and ideas E—53 Resources E—59 References E—63 Improving the Acute Care Hospital Experience: Quality Improvement Guide E—51 Health Quality Council 2006

Change Package Overview A search of the literature revealed several methods and approaches to increase patient satisfaction with hospital food, which in turn may lead to better patient nutritional status. These strategies may be incorporated into current practices, or may be used as a way to drive region-specific quality improvement initiatives. The concepts and ideas are expanded in the next section, Change Concepts and Ideas. 1. Customize nutritional counselling. Examples of change ideas: • Make nutritional assessment part of the admissions process. • Ensure clear communication regarding diet and nutrition plans. • Ensure that the time and place of the presentation of information is suitable to the patients. 2. Increase patients’ choice about food services. Examples of change ideas: • Offer menus with a variety of choices. • Use a bulk food service delivery system. • Use a hotel-style room service system. • Offer between-meal snacks and beverages. 3. Ensure high standards of food quality. Examples of change ideas: • Serve food at the right temperature. • Consider presentation. 4. Design menus according to the needs of different patient groups. Examples of change ideas: • Have menus available in different languages or include pictures of the menu options. • Customize menus based on patient population. 4. Make food service a team effort. Examples of change ideas: • Make dietary staff part of the care team. • Establish protected mealtimes. • Ensure dietary staff members are well trained and friendly. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—52 Health Quality Council 2006

Customize nutritional counselling. Involve the patient in designing a nutritional plan that will meet his/her likes and dislikes as well as his/her health care and nutritional needs. Make nutritional assessment part of the admissions process2. The assessment should include the patient’s: • Likes and dislikes. • Food allergies. • Need for therapeutic diet. • Cultural, ethnic, and religious requirements. • Preferred mealtimes. • Need for assistance with eating. The care plan should be reevaluated as necessary and recorded in the patient chart2. Ensure clear communication regarding diet and nutritional plans4. Information should be presented to patients using terms they understand, in a friendly manner, and in ways that make the prescribed diet easy to follow once patients are sent home5. Ensure that the time and place of the presentation of information is suitable to the patients6. This may involve presenting information about the proposed diet plan prior to admission7. Another option is to present information to patients regarding their diet during the admission assessment, or along with daily menus. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—53 Health Quality Council 2006

Increase patients’ choice about food services. Give patients as much choice as possible regarding type and delivery of food. Presenting information on therapeutic diets, hospital menus, and procedures in a way that enhances patients’ perceptions of their responsibility in choosing a menu compatible with their food preferences and habits, as well as with their dietary requirements, may increase patients’ feeling of involvement in their care4. Offer menus with a variety of choices. A large body of literature suggests patients most desire variety and options in their hospital menu selections. This is especially important for patients with reduced appetites due to illness8. Ideas in Action Offering More Choice in the U.K. • In Scotland, one hospital has implemented a program where if patients do not see anything on the menu that appeals to them, they can write what they would like to eat on the menu card (e.g. scrambled eggs). The catering department tries to meet this request if possible, and if they cannot, they will speak with the patient about what other options may be available to them. This practice has been found to help maintain patients’ nutritional intake and increase their satisfaction9. • The NHS has implemented the Flexi-menu program, which involves offering patients a fixed menu for both lunch and dinner, allowing patients a large variety of meals to choose from every day, rather than having the menu change daily on a 1-3 week cycle giving patients a variety of choices over a week. This program also allows patients to select meals they enjoy more than once during their stay. This increased daily choice may help to reduce food waste10. Use a bulk food service delivery system. Recent literature reflects that the hospital food service industry is moving towards a “we will come to you” system. One example is using transferable re-therming carts, which deliver bulk food to the floors for individualized serving. With this system, patients may choose their meal on the spot, not hours or days before11. Another example is the cook-chill system: it uses re-therm units that bring food to the ward and hold it at the appropriate temperature until needed. In both systems, produc- tion can be done ahead of time, meals can be served at exactly the appropriate temperature when the patient desires, or when staff is available, and one staff member can deliver to entire units. Use a hotel-style room service system. This type of system involves patients accessing a restaurant-style menu and ordering food when they want it within set hours (e.g., between 7:00 a.m. and 9:00 p.m.). All foods are freshly cooked to order and delivered within 45 minutes of the patient request. This type of food delivery system reduces food waste. One main reason patients do not eat their food is because it arrives while they are sleeping or out of their room12. Room service is most suited to facilities with 200 or more beds13. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—54 Health Quality Council 2006

Increase patients’ choice about food services. To implement the room service model, one group used an electronic menu choice system. Nursing staff asked patients what they would prefer to eat and immediately entered patient choices into a portable computer system directly linked to the kitchen8. Offer between-meal snacks and beverages. Floor pantries or regularly scheduled nourishment carts allow patients to choose liquid or light solid refreshments of their choice at the time when they need them14,15. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—55 Health Quality Council 2006

Ensure high standards of food quality. Serve food at the right temperatures. Food quality and temperature correlates highly with overall patient satisfaction with food services. In order to ensure that patients receive adequate nutrition, it is important that food is served as soon as it is available in order to make it most appetizing to patients16. Consider presentation. Small changes can make a difference. For example, giving patients stainless flatware instead of plastic, using china instead of plastic, or delivering children’s meals in kid-oriented theme packag- ing can increase patients’ satisfaction with hospital food services13. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—56 Health Quality Council 2006

Design menus according to the needs of different patient groups. Have menus available in different languages or include pictures of the menu options. Patients who have difficulty understanding the menu because of language may not appreciate the full extent of the menu or be able to make appropriate choices. This may reduce ratings of satisfaction with hospital food8. Including family members or having translators available are other options for assisting patients in making menu selections. Customize menus based on patient population. Having food services cater to the specific needs of groups of patients may result in increased satisfaction with food services. Elderly patients often eat smaller, more frequent meals. Different religious and cultural groups may have food practices that are not addressed by current systems. Cancer patients may want only disposable dishes and utensils, as chemotherapy enhances any metallic taste12. Pediatrics requires a more child-friendly menu, including varying portion sizes. Ensuring the availability of menu options, which meet specific needs, may result in increased satisfaction for these different groups8. Support the family’s role in patient care by making opportunities available for families to identify appropriate food or bring in favorite foods. Figure 9: Example of a Flexi-Menu from the National Health Services, United Kingdom. Menu includes pictures of food choices, for patients with lower literacy levels. (Used with permission.) Improving the Acute Care Hospital Experience: Quality Improvement Guide E—57 Health Quality Council 2006

Make food service a team effort. Make dietary staff part of the care team. In Scotland, the Grampian University Hospitals NHS Trust introduced a twin system2. Each cook or assistant cook is twinned with an individual ward. This gives ward-based staff a single point of contact within the catering department, someone they can approach with queries or complaints. Overall, the aims are to help improve communication and the working relationship between ward and kitchen staff, leading to a better quality of service for patients. Establish protected mealtimes. Research shows that patients whose mealtimes are protected are better nourished, which may improve chances of recovery. Mealtimes should be a time when all non-urgent clinical activity on a unit is stopped. This allows patients time to eat without interruption and staff time to offer help to those who need it17. Making food services delivery a key component of the care plan allows meals to coincide with nursing care practices, such as medication administration, and avoid clinical care activities, such as diagnostic tests and nursing rounds. Ensure dietary staff members are well trained and friendly18. In order to ensure optimal levels of patient satisfaction with food services, food services staff should be trained on diets, how to interact with patients, and communication with nursing staff. Dietary staff may be trained as multi-skilled workers who can assist patients with food intake, such as removing lids, feeding, etc. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—58 Health Quality Council 2006

Sample AIM statements • By February 2007, 75% of patients who are discharged from acute care within the ABC-Regional Health Authority will state: “The quality of the food I received while I was in the hospital was very good or excellent” on the next round of the provincial patient experience survey. • By February 2007, 75% of acute care facilities within the ABC-RHA will implement protected mealtimes for all units. • By February 2007, 100% of the hot food served in acute care facilities within the ABC-RHA will be at a temperature of 150°F(66°C) when delivered to patient. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—60 Health Quality Council 2006

Sample PDSA cycle This PDSA cycle is one that will help work towards the AIM statement: “By February 2007, 100% of the patients served by ABC-RHA will report they received the food they chose for each meal served.” PLAN Objective: To have all patients on surgical ward #100 report they re- What is the objective of this improvement cycle? ceived the food they chose from the menu for each meal within two Who is involved? weeks of initiating the changes. What? When? Where? Why? Plan: Ensure all patients to be admitted to ward #100 have the opportu- What do we predict will happen? nity to choose which foods they would prefer to eat at each meal while What additional information will we need to take in the hospital. action? Specifics: Have all patients to be admitted to ward #100 complete a food preferences sheet when they come to the hospital for their pread- mission information session. Completed patient food preference sheets will be entered directly into the electronic record, and be sent to the kitchen when the patient is admitted. Predictions: Following 1 week of patients completing food preference sheets all patients admitted to the surgical ward #100 will receive the correct food on their trays for each meal. Measures: Food services staff will ask each patient on surgical ward #100 during tray pick-up (after each meal) if they received the correct food choices on their tray. DO All patients admitted to the surgical ward #100 completed a food prefer- Was the test carried out as planned? ence sheet. Patient food choices were sent to the kitchen upon the pa- What did we observe that was not part of the tient’s admission. plan? STUDY 100% of patients received the food they ordered for both lunch and din- How did or didn’t the results agree with the ner, but only 80% of patients received the correct food for breakfast. predictions we made earlier? Some morning kitchen staff forgot to check patient choices prior to mak- What new knowledge was gained through this ing up trays. cycle? ACT Several ideas for future PDSA cycles were developed from this PDSA Now what? cycle: Do we abandon? Adjust? Adopt? • Incorporate reminders into the kitchen morning routine to Are there forces in our organization that will help ensure all staff check patient food preferences prior to dis- or hinder these changes? tributing breakfast trays. Objective of next PDSA? • Use food preference sheets for all surgical ward patients. • If surgical ward patients are satisfied with the use of food preference sheets institute a process whereby all newly admitted patients complete a food preference sheet. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—61 Health Quality Council 2006

Resources TARGET AREA or SPECIFIC TOOLS AND RESOURCES GROUP Provider • Penn State Hershey Medical Center. Example of a caregiver’s guide to using food Resources services to please patients, including descriptions of different therapeutic diets. http:// www.hmc.psu.edu/foodservices/patient/eatthis.pdf • Hospital Caterers Association. ⇒ Draft of a protected mealtimes policy. http://www.hospitalcaterers.org/pages/library/ protmealpol.html ⇒ Checklist designed to assist with implementing protected mealtimes. http://195.92.246.148/nhsestates/better_hospital_food/bhf_downloads/ HCA_Protected_Mealtime_Checklist.doc • NHS Better Hospital Food Programme. Website containing best practice guidance, resources, and background information to support the delivery of food for all food service professionals, healthcare staff and patients. http://195.92.246.148/nhsestates/ better_hospital_food/bhf_content/introduction/home.asp • Hospital Food Project. Website containing information about using sustainable resources in hospital food preparation in order to improve the quality of food served. http://www.sustainweb.org/hospital_index.asp • Picker Institute Europe. Best practices newsletter providing suggestions for improving the patient experience of hospital food services. http://www.pickereurope.org/Filestore/ News/foodnewsletterdec02.pdf • Success with Prepared Foods. A guide designed to improve the understanding of the use of prepared foods among professionals involved in providing food for people in institutionalized care. http://www.dietitians.ca/resources/success_contents.pdf • NHS Quality Improvement Scotland. Clinical standards for food, fluid, and nutritional care designed to assess performance in the provision of food, fluid and nutritional care in hospitals. http://www.nhshealthquality.org/nhsqis/qis_display_findings.jsp? pContentID=1015&p_applic=CCC&p_service=Content.show& • HCI Global E-library. Healthcare Caterers International library of electronic references for hospital caterers.http://www.hciglobal.org/library Special • Potential Hospital Menu Changes. Link to a news story summarizing different ways Populations to ensure that hospital food meets the needs of some special populations. http:// www.banderasnews.com/0603/hb-hospitalmenus.htm Quality • National Health Service. NHS Catering Satisfaction Survey: a tool for gathering Measurement specific information from patients regarding food service received while in hospital http://195.92.246.148/nhsestates/better_hospital_food/bhf_downloads/ patient_catering_satisfaction/NHSCateringSurvey.doc Improving the Acute Care Hospital Experience: Quality Improvement Guide E—62 Health Quality Council 2006

References 1. DeLuco, D., & Cremer, M. Consumers’ perceptions of hospital food and dietary services. Journal of the American Dietetic Association, 1990; 90: 1711-15. 2. NHS Quality Improvement Scotland. Clinical Standards – Food, Fluid, and Nutritional Care in Hospi- tals. 2003; http://www.nhshealthquality.org/nhsqis/qis_display_findings.jsp? pContentID=1015&p_applic=CCC&p_service=Content.show&, Accessed April 20, 2006. 3. Wohlgemuth, N., Chan, BTB., Koru-Sengul, T., Teare, G. Research Report: Improving the Acute Care Hospital Experience: A Survey of Saskatchewan In-Patients. Saskatoon: Health Quality Council. De- cember 2005. 4. Bélanger, M., & Dubé, L. The emotional experience of hospitalization: its moderators and its role in patient satisfaction with food services. Journal of the American Dietetic Association. 1996; 96(4): 354- 360. 5. Mason, M., Wenberg, B. G., & Welsh, P. K. The Dynamics of Clinical Dietitians. 2nd Ed. New York: John Wiley and Sons. 1982. As cited in Trudeau, E., & Dubé, L. Moderators and determinants of satisfaction with diet counseling for patients consuming a therapeutic diet. Journal of the American Dietetic Association. 1995; 95(1): 34-9. 6. Trudeau, E., & Dubé, L. Moderators and determinants of satisfaction with diet counseling for patients consuming a therapeutic diet. Journal of the American Dietetic Association. 1995; 95(1): 34-9. 7. Stanga, Z., Zurflüh, Y., Roselli, M., Sterchi, A. B., Tanner, B., & Knecht, G. Hospital food: a survey of patients’ perceptions. Clinical Nutrition. 2003; 23(3): 241-6. 8. Audit Scotland. Catering for patients. 2003. http://www.audit-scotland.gov.uk/publications/ pdf/2003/03pf12ag.pdf 9. National Health Service. Better Hospital Foods, http://195.92.246.148/nhsestates/ better_hospital_food/bhf_content/flexi_menu/overview.asp, accessed April 20, 2006. 10. Pietersma, P., Follet-Bick, S., Wilkonson, B., Guebert, N., & Pereira, J. A bedside cart as an alternate food service for acute and palliative oncological patients. Canadian Journal of Dietetic Practice and Re- search. 2003; 64(2): S100. 11. McLymont, V., Cox, S., and Stell, F. Improving patient meal satisfaction with room service meal delivery, Journal of Nursing Care Quality. 2003; 18(1): 27-37. 12. Caithamer, S. White glove foodservice - new approaches treat patients as customers. Today's Dieti- tian. 2004; 6(6): 22. http://www.todaysdietitian.com/archives/td_0604p22.shtml, Accessed April 20, 2006. 13. Anonymous. Food service from a patient’s point of view. Canadian Journal of Dietetic Practice and Re- search. 2000; 61(3): S4. 14. Picker Institute Europe. Food for thought: Bringing about improvements in catering services. Improving Patients’ Experience Sharing Good Practice. 2002; http://www.pickereurope.org/Filestore/News/ foodnewsletterdec02.pdf, accessed April 21, 2006. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—63 Health Quality Council 2006

References 15. Dubé, L., Trudeau, E., & Bélanger, M. Determining the complexity of patient satisfaction with food services. Journal of the American Dietetic Association. 1994; 94 (4): 394-9 16. National Health Service. Better Hospital Foods, http://195.92.246.148/nhsestates/better_hospital_food/ bhf_content/protected_mealtimes/overview.asp, accessed April 20, 2006 17. Watters, C. A., Sorenson, J., Fiala, A., & Wismer, W. Exploring patient satisfaction with foodservice through focus groups and meal rounds. Journal of the American Dietetic Association. 2003; 103(10): 1347-9. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—64 Health Quality Council 2006

Additional Information This section has information on the Model for Improvement, including templates for the Charter for Improvement and PDSA cycles. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—65 Health Quality Council 2006

The Model for Improvement This section was adapted from England’s National Primary Care Development Team and includes references from: Langley, G. J., et al. The Improvement Guide : A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass. 1996. Introduction Our environment is constantly changing. Some changes are imposed on us and we have to find a way to manage the impact. At other times, change is something we choose to make, motivated by the desire to make things better. It is obvious to say it, but while every improvement is certainly a change, every change is not always an improvement. Making changes to the way that we do things can be time-consuming and can sometimes feel risky. The Model for Improvement (Langley et al. 1996) is a tried and tested approach to achieving successful change. Use of the Model for Improvement offers the following benefits: • It is a simple approach that anyone can apply; • It reduces risk by starting small; • It can be used to help plan, develop and implement change; and, • It is highly effective. The Model for Improvement The Model for improvement was first published in 1996 by Langley et al. in The Improvement Guide: A Practical Approach to Enhancing Organisational Performance. The Model for Improve- ment provides a framework for developing, testing and implementing changes to the way that things are done that will lead to improvement. The Model for Improvement consists of two parts that are of equal importance. The first, the ‘thinking part’, consists of three fundamental questions that are essential for guiding improvement work. The second part, the ‘doing part’, is made up of Plan-Do-Study-Act (PDSA) cycles that will help you make rapid change. The three fundamental questions for achieving improvement A planned approach to improving things will give you a better chance of being successful. The three fundamental questions for achieving improvement are a useful way of framing your work. 1. What are we trying to accomplish? This question is intended to help you be clear about the improvements that you would like to make, what results you would like to get, and how you would like things to be different. Having a clear vision of your aims is crucial. 2. How will we know that a change is an improvement? Without measurement it is impossible to know whether you have improved. Think about how you Improving the Acute Care Hospital Experience: Quality Improvement Guide E—66 Health Quality Council 2006

The Model for Improvement want things to be different when you have implemented your change and agree what data you need to collect to measure it. You can focus your measurement on your results or how outcomes might be different, how the service that your patients receive will be better, or how your processes might change. 3. What changes can we make that will lead to an improvement? Finally, you need to decide what changes you will try in order to achieve the results you are looking for. What evidence do you have from elsewhere about what is most likely to work? What do you and your team think is a good idea? What have other people done that you could try? This is where you can adapt ideas or be completely creative. Remember that you know your own system best, so keep your objectives in mind and use your knowledge and experience to guide you. Gather together as many ideas as you can. These will form the basis for the next step – your PDSA cycles. The Model for Improvement W h a t a r e w e tr y in g to a c c o m p lis h ? H o w w ill w e k n o w th a t a c h a n g e is im p r o v e m e n t? ACT PLAN W hat changes can w e m a k e th a t w ill r e s u lt in im p r o v e m e n t? STUDY DO Adapted from the National Primary Care Development Team. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—67 Health Quality Council 2006

The Model for Improvement Change cycles Once you have decided exactly what you want to achieve, you can use change cycles, a series of Plan-Do-Study-Act rounds to test out your ideas developed from the third question, ‘What changes can we make that will lead to an improvement?’ The key to change cycles is to try out your change on a small scale to begin with and to rely on using many consecutive cycles to build up information about how effective your change is. This makes it easier to get started, gives results rapidly and reduces the risk of something going wrong and having a major impact. If what you try doesn’t work as well as you hoped, you can always go back to the way you did things before. When you have built up enough information to feel confident about your change, you can then implement it as part of your system. Think of a ‘small’ PDSA cycle in terms of the scope of your test. You might, for example, like to run your cycle over one day, with one person or in one clinic. You might wish to look at the last ten patients seen, the last twenty referrals made, or the next dozen reports. It helps to spend some time making your ‘Plan’ explicit and ensure that you are clear on the objective of the particular PDSA: what you are specifically trying to do, who will carry it out, and when and where. It is also crucial to voice your predictions because we often find what we are looking for (confirmation bias) and making our predictions explicit helps us to learn more when that prediction is confirmed or refuted. Finally, your plan should include the measures you are going to use to see if the change you are trying in this PDSA is an improvement. The ‘Do’ is simply that – try it out and document what you did as sometimes your plan and how it gets realized are somewhat different. The ‘Study’ part of the cycle gives you the opportunity to reflect on what happened, think about what you have learned, and to build your knowledge for further improvement. Finally, you can move on to your next steps – the ‘Act’ part of the cycle. Do you need to run the same cycle again, gathering more evidence or making some modifications based on what you learned? Or do you need to develop further cycles to move your work forward? Practicalities • Improvement is nearly always a team endeavour. Try to ensure that you involve the right people in your work. • People have a tendency to jump straight to solutions rather than really work out what the root of the problem is. If you use the three fundamental questions, it will help you be sure that you are dealing with the issue that really needs to be addressed. • When you plan your cycle, make sure you are clear about who is doing what, where, and when. Improving the Acute Care Hospital Experience: Quality Improvement Guide E—68 Health Quality Council 2006

The Model for Improvement Your results are dependent on how good your plan is. • Discuss what you think will happen when you try out your change. What is your hunch? When you have carried out the cycle, compare your expectations with what actually happened. You may learn something interesting about how things work. • Record your PDSA as you go along: the plan, the results, what you learned, and what you are going to do next. Not only is it very motivating to see the results of what you have tried, it is also a great way of accumulating information about your systems and a good way of sharing your learning with other people. • Use PDSAs consecutively to build up the information about your change and then use them to implement it systematically into your daily work. PDSA cycles generally do not operate in isolation – you should expect to have a series of them leading towards your goal. And finally…. • PDSAs cannot be too small • One PDSA will almost always lead to one or more others • You can achieve rapid results • They help you to be thorough and systematic • They help you learn from your work • Anyone can use them in any area Improving the Acute Care Hospital Experience: Quality Improvement Guide E—69 Health Quality Council 2006

Quality Improvement Charter Worksheet Health Region Team (e.g., HR, LTC, Rehab Team) Key Contact (name, email, phone number) Improvement Aim (What are we trying to accomplish?) Measures Outcome (How will we know if a change is an improvement?) Process Balancing Team Members Team Sponsor Project Boundaries (Constraints, financial limitations, guidelines, procedures) What changes can we make that may result in an improvement? Health Quality Council

Plan-Do-Study-Act Cycle Planning Sheet Cycle 1 Cycle 2 PLAN What is the object of this improvement cycle? Who is involved? What? When? Where? Why? What do we predict will happen? What additional information will we need to take action? DO Was the test carried out as planned? What did we observe that was not part of the plan? STUDY How did or didn’t the results agree with the predictions we made earlier? What new knowledge was gained through this cycle? ACT Now what? Do we abandon? adjust? adopt? Are there forces in our organization that will help or hinder these changes? Objective of next cycle? Health Quality Council TLQIT (Teams and Leaders in Quality Improvement Training)

Patient Experience of Acute Care Quality Improvement Guide Evaluation Form To help us determine the usefulness of HQC products such as the ‘Patient Experience of Acute Care Quality Improvement Guide’, we ask that you complete this brief evaluation form. Please answer all the questions that apply to you, and e-mail, fax or mail this form to the address at the end of the survey. Thank you for your time. 1. Which sections of the QI Guide did you 3. Do you have any suggestions for use? (Please check all that apply) improvement for any of the sections of ❒ Section 1 – Planning the QI Guide? ❒ Section 2 – Reflecting Section 1 – Planning ❒ Section 3 – Executing (please specify) ❒ Pain management Section 2 – Reflecting ❒ Provider-patient communications ❒ Discharge planning Section 3 – Executing ❒ Food 2. What did you find most useful about each section that you used? 4. What organisation do you work for? Section 1 – Planning 5. What is your main role in the above Section 2 – Reflecting organisation? ❒ Senior leader Section 3 – Executing ❒ Middle management ❒ Front-line staff ❒ Other (please specify) Do you have any other comments? Thank you for your time. Please return completed forms to Nicole Wohlgemuth, Researcher: E-mail: nwohlgemuth@hqc.sk.ca Fax: (306) 668-8820 Mail: Health Quality Council Atrium Building, Innovation Place 241 - 111 Research Drive Saskatoon SK S7N 3R2

Quality Improvement Project Guide

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