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