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Quality Improvement Project
- 1. Improving Staff Responsiveness to Patient NeedsLourdes University College of Nursing BY: COURTNEY ARTHUR, COURTNEY GILLILAND, MARIA HOLUP, RACHAEL KILGUS, KRISTEN OXENDER, JILL SCZESNY, TAYLOR ZAPADKA
- 2. Problem o Wood County Hospital is scored at 72.3% in the category of responsiveness to patients when evaluated by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score compared with the 80.0% required by the Centers for Medicare and Medicaid Services (CMS).
- 3. HCAHPS Report Scores 64.0% 66.0% 68.0% 70.0% 72.0% 74.0% 76.0% 78.0% 80.0% 82.0% January February March April May June July August September October November SCORE MONTHS (2015) HCAHPS Report Where WCH Started Current WCH Score CMS Benchmark Linear (Current WCH Score) Medical-Cardiac Unit at an Acute Care Facility
- 4. Potential Problems oFall risk oPressure ulcers oHarm to patient oDecreased pain management oIncreased call light usage oDecreases other HCAHPS scores oDecrease reimbursement from CMS Call! Don't Fall! for Pediatric Patients. (2015). Retrieved November 18, 2015, from https://www.mskcc.org/cancer-care/patient-education/call-don-t-fall-peds
- 5. Root Cause Analysis o Why is this a problem? oScoring oWhy did this happen? oPatient satisfaction scores oHow to reduce this from happening again oUse evidence-based practice (2015.). Retrieved November 18, 2015, from http://www.becaudio.com/Shop/images/NHX-50M_small.jpg
- 6. Causes System oFunding of new technology oCall light system oPlacement oLack of answering stations People oLack of motivation oRole confusion oLack of knowledge Problem Resolution. (2015). Retrieved November 18, 2015, from http://www.statutorynuisancesolutions.co.uk/our-services/problem-resolution/
- 7. Suggestions oDifferent call light placement oIncrease number of call light answering stations oAlterative form of communication oWalkie talkies oBluetooth technology oNurse phones Lozze. (2015). Retrieved November 18, 2015, from http://lozzeisus.blogspot.com/p/suggestions-what-do-you-want-to-see.html
- 8. Data Collection Methods oCollected over 5 hours oResponse times measured oTime to answer call light at central answering station oTime to respond to the call light by entering the patients room oHourly rounding monitored for each patient
- 9. Staffing Ratio On the day of data collection: • Unit had a total of 28 patients • Floor staffing consisted of 6 Registered Nurses, 3 Aides, and a Secretary ◦ Assignments consisted of: ◦ 4 RNs had 5 patients [1:5] ◦ 2 RNs had 4 patients [1:4] ◦ 2 Aides had 9 patients [1:9] ◦ 1 Aide had 10 patients [1:10]
- 10. Who Answered Call Lights Medical-Cardiac Unit at an Acute Care Facility
- 11. Time to Answer Call Light 7:00-7:29 7:30-7:59 8:00-8:29 8:30-8:59 9:00-9:29 9:30-9:59 10:00- 10:29 10:30- 10:59 11:00- 11:29 11:30- 11:59 Total Average 9.8 16.8 25.1 15.6 18.3 26.3 34.5 21.5 10.1 9.1 18.7 Median 8 10 18 14 9 20 15 14.5 8 7.5 12.4 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 AnswerTime(s) Time Slot (AM) Medical-Cardiac Unit at an Acute Care Facility
- 12. Time for Staff to Enter Room 0.0 2.0 4.0 6.0 8.0 10.0 12.0 AVERAGEROOMENTRYTIME(MIN) TIME SLOT (AM) Room Entry Time Medical-Cardiac Unit at an Acute Care Facility
- 13. Hourly Rounding 64.3% 88.9% 85.7% 80.8% 92.3% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 7:00 8:00 9:00 10:00 11:00 PercentageofRoomsChecked Time (AM) Medical-Cardiac Unit at an Acute Care Facility
- 14. Agency for Healthcare Research and Quality (AHRQ) oRecommendations for improvement: oTreat all call lights as emergent oProvide patient with correct number to call oCreate empathy from nurses oBe proactive oInclude family oStandardized white boards Dave, A., Schulke, D., & Brady, C. (2013, February 13). Responsiveness. Retrieved November 18, 2015, from https://cahps.ahrq.gov/surveys-guidance/hospital/hcahps_slide_sets/responsiveness/responsivenesssl.html Promise Hospital of Salt Lake » Promise Hospital of Salt Lake’s Interdisciplinary Patient Care Initiative Generates a Boost in Patient Satisfaction Scores. (2015). Retrieved November 18, 2015, from http://www.promise-saltlake.com/?page_id=206
- 15. Recommendations for Improvement oIndividual nurse communication devices ◦ Cell phones, walkie talkies, Bluetooth ◦ Improves communication between staff and patients oDirect communication from patient to nurse via individualized number: oNoise reduced oPatient call light being answered quickly oDecrease cost oDecrease unnecessary work hours oCon: Cell phones/walkie talkies are bulky Deamon et al., 2012, Digby, Bloomer, & Howard, 2011
- 16. Recommendations for Improvement oEasily accessible placement of call light receivers oProvides safety and reassurance to patients oHelps with monitoring alerts from rooms oInconveniently placed call lights can result in poor performance oNurse call systems are a legal requirement and there are legislations to help cover installation and use Dewsbury & Ballard, 2014
- 17. Recommendations for Improvement oIncreased involvement from nurse managers oEvidence-based practice leadership oOrganize activities based on the issue oModify the infrastructure to align with objectives oActively intervene oMonitor the work environment oProvide teaching & coaching regarding objectives oCommunicate about progress of meeting objectives with staff (2015). Retrieved November 18, 2015, from http://www.ionl.org/resource/resmgr/Images/Kellogg_pic.jpgStetler, Ritchie, Rycroft-Malone, & Charns, (2014)
- 18. Recommendations for Improvement 4 P’s Rounding Method: Pain, Potty, Position, Periphery (every 1-2 hours) oIncrease in patient satisfaction scores oDecrease in patient call light use oIncrease in urgency/seriousness when call light activated o“Patient complaints citing staff rudeness decreased 43%” (Blakley, Kroth, & Gregson, 2011) Support Station. (2015). Retrieved November 18, 2015, from http://www.rifton.com/products/bathing-and-toileting-systems/support-station?tab=features
- 19. Recommendations for Improvement oIncrease awareness of call light answer times oDiscuss call light response times at every opportunity (i.e. team meetings, handoff report) oPost informative information accessible to staff oRaise staff awareness to improve the response to patient calls o“Increase of 5.21% of call lights answered in less than 5 minutes” oDecrease in patient falls Digby, Bloomer, & Howard (2011)
- 20. Change Theory oTranstheoretical Model oBehavior focuses on personal change and incorporates key aspects of learning and behavioral change theories oRecommended change: oPersonal communication devices Change. (2015, April 15). Retrieved November 18, 2015, from http://thisisagoodsign.com/change/
- 21. Change Theory Stage One (Pre-contemplation) oThose involved are unaware change is needed Stage Two (Contemplation) oStaff is aware the problem exists and thinks about making a change, but does not take action Stage Three (Preparation) oPrepares for change in order to take action in the future oPreparation includes: oResearch on the best devices o Nurse input on the design of the device o Current budgeting to purchase devices o Research grants to cover costs o Design a training program before implementation
- 22. Change Theory Stage Four (Action) oAction includes modifying behaviors to overcome the problem oPurchase devices oImplement training oTrial runs to put the plan into action Stage Five (Maintenance) oEstablish change through intentional work to prevent reversion and maintain gains oMaintenance is achieved
- 23. Change Theory Stage Six (Termination) oChange process is complete and no further work is needed to prevent reversion oTermination is complete when: oResponse time scores improve oPatient satisfaction scores improve oHCAHPS scores meet or exceed the national standard
- 24. Hypothetical Evaluation Modification POSITIVES: Decrease in response times to patient needs Decrease incidents of injury to patients Increase patient satisfaction scores Increase funding to the hospital NEGATIVES: Patient might feel like their care is being interrupted Patient safety issues resulting from system failure
- 25. Hypothetical Evaluation Continued: FINANCIAL: Cost of implementing new communication system(s) Purchasing of the cell phones at another institution had shown to save almost $125,000 a year in nursing work hours Within 1 month, 166 Hours of nursing care can be gained back MORBIDITY: Decrease in patient injuries o Reduces patient falls by as much as 50% o Reduces pressure ulcers by 14% o Reduces use of call light by 38%
- 26. In Conclusion oInterventions: oIndividualized communication devices oPurposeful hourly rounding oIncrease staff awareness oStaff education oProper placement of call light answering systems oResults: oImprove patient satisfaction scores oDecrease cost to the hospital and patient oDecrease risk of harm to the patient Evidence-based practice
- 27. Questions Questions - Google Search. (2015). Retrieved November 18, 2015, from https://www.google.com/search?q=questions&source=lnms&tbm=isch&sa=X&ved=0CAcQ_AUoAWoVChMI_cLxg86ayQIVQ3YeCh1brwT_&biw=1600&bih=736#imgrc=s36UoalyiHYH2M:
- 28. References oBlakley, D., Kroth, M., & Gregson, J. (2011). The impact of nurse rounding on patient satisfaction in a medical- surgical hospital unit. MEDSURG Nursing, 20(6), 327-332 6p. oCall! Don't Fall! for Pediatric Patients. (2015). Retrieved November 18, 2015, from https://www.mskcc.org/cancer-care/patient- education/call-don-t-fall- peds oDave, A., Schulke, D., & Brady, C. (2013, February 13). Responsiveness. Retrieved November 18, 2015, from https://cahps.ahrq.gov/surveys- guidance/hospital/hcahps_slide_sets/responsiveness/responsivenesssl.html oDearmon, V., Roussel, L., Buckner, E., Mulekar, M., Pomrenke, B., Salas, S.. Brown, A. (2012). Transforming care at the bedside (TCAB): Enhancing direct care and value-added care. Journal of Nursing Management, 21, 668-678. doi:10.1111/j.1365- 2834.2012.01412x oDewsbury, G., & Ballard, D. (2014). Nurse call systems: ensuring a fast response to emergencies. Nursing & Residential Care, 16(1), 32-34 3p o Digby, R., Bloomer, M., & Howard, T. (2011). Improving call bell response times. Nursing Older People, 23(6), 22-27. oDudkiewicz, P. B. (2014). Utilizing a caring-based nursing model in an interdepartmental setting to improve patient satisfaction. International Journal For Human Caring, 18(4), 30-33 4p. oHuey-Ming, T. (2010). Perspectives of staff nurses of the reasons for and the nature of patient-initiated call lights: An Exploratory survey study in four USA hospitals. BMC Health Services Research, 1052-64. doi:10.1186/1472-6963-10-52 oKrepper, R., Vallejo, B., Smith, C., Lindy, C., Fullmer, C., Messimer, S., Myers, K. (2014). Evaluation of a standardized hourly rounding process (SHaRP). Journal for Healthcare Quality, 36(2). oStetler, C. B., Ritchie, J. A., Rycroft-Malone, J., & Charns, M. P. (2014). Leadership for evidence-based practice: Strategic and functional behaviors for institutionalizing EBP. Worldviews On Evidence-Based Nursing, (4), 219.
Editor's Notes
- The score has been decreasing over the months Jan. 73.5% Feb. 72.3% March 72.9% April 75.3% May 74.7% June 71.9% July 72.4% Aug. 72.5% Sept. 72.3% Oct. 70.9% Nov. 69.7%
- Graph represents HCAPHS scores beginning from January 2015-November 2015 Displays 3 different Trend lines: -Where WCH Started -Current WCH Score (Trendline demonstrates that without improvements, scores will continue to decline) -CMS Benchmark **Not sure if this needs a citation! Information for graph came from the photocopies that Casey made for the binder
- Root Cause Analysis Determine what happened. Hospital was ranked at % and the benchmark is % in Responsiveness to staff Determine why it happened. Patients were given a survey of their experience while staying at the hospital and rated the staff low in this category Figure out what to do to reduce the likelihood that it will happen again. Staff will have a quicker response time to patients. Staff will reduce the time it takes to have patient needs meant. Cause: This problem is an organizational cause. It is not one person’s fault, it is a group as a whole. Staff includes the whole hospital team, not just one department. Suggestions for Improvement: Have a better way of communication needs of patients to staff. Suggestions include call light in different placement, or have another call light phone station in all three nursing station corners, each nurse could have their own personal communication device like a walkie talkie, phone, or clip that the nurse could talk directly into device to have direct communication to other staff members. Determine the two most likely problems: We determined that the two main issues include communication and placement of the call light. For example, if the call light goes off and a nurse or nurse aid is not the one side of the nurse station, he/she is not able to reach it in a timely manner. The call light is placed in busy area where people frequently pass through but are not situated there during times of charting. It was noted during data collection that staff members would answer the call light and tell the patient that he/she would tell their nurse, and the staff member would not notify the nurse. Often times the staff member would continue to do what they were previously doing.
- People may not know the importance of answering the call light Funding for new technology is expensive and there may not be enough money in the budget There is only one call light station for 3 different desk/counter areas, making it difficult to answer People are under the impression that someone else will answer the phone, so no one answers the phone
- Strengths and Weaknesses for each form of communication Walkie talkies: Strengths: real time communication, cohesive because everyone hears what is being said to each other, affordable, user friendly Weaknesses: Bulky, battery life, noise, patients can hear what is being said Blue-tooth technology: Strengths: small, easily portable, current technology, confidentiality, less bother some, appears professional, evidence based practice is stating that this form of technology is the best form of communication Weaknesses: cost, care of device, fragile, require training, dependent on technology to work,
- Students were stationed at the call light phone and in each hallway. The time it took to answer the call phone was measured, and the time it took for someone to enter the patient’s room to fulfill their needs was measured. Students also recorded for each room if a staff member entered into every patient room every hour.
- How long it took for call light to be answered (at call light answering station) *WHO answered call light
- How long it took to answer call light from answering station: *Average (mean) response time: includes all data times *Median: middle response time of collected data (another way to analyze response times; essentially, “outliers” are removed)
- Time it took from call-light being answered (i.e. hung up at central answering station) to someone entering the patients room *Average for each 30 min. increment *Trendline indicates that as the day continues, response times to enter the patient(s) room increases
- Uses number of active rooms (“off unit” not included for rounding) The hallways with rooms 10-19 had the least amount of rooms checked for hourly rounding. It had a pattern where 3 of the rooms were missed more than twice in the 5 hour data collection period.
- Emergent: Treat all lights as if it was a potential patient safety issue. You do not know why the patient is calling until you answer it. Call number: if the nurse was to have his/her own phone or phone line, allowing the patient to have direct access to the phone number or code to call the nurse allows for direct communication Empathy: During staff meetings have the staff sit on a bedpan or have a melting ice cube in their hand. This allows the nurse to feel what it is like to be a patient who is uncomfortable, which will create empathy. This can start to engage the staff in effective change theory. Proactive: Purposeful hourly rounding, tell the patient when you will return Including family: When including family members in the care of the patient, it can decrease call light usage and improve the family in caring for their loved one, which can improve care post-discharge Standardized whiteboards: This displays the healthcare team for the day, it can have what the goals are for the day, what drugs the patient is taking, why they are taking them and when the next dose is due. This reduces the amount of times the patient uses the call light.
- Day time hourly rounding is hourly, at night after 11 rounding should be every two hours (for stable, non-critical patients)
- Stage one: One example includes pre-HCAHPS scores. These scores bring awareness to the problem. Stage Two: They receive HCAHPS results and inform staff by posting them on their information boards and are available on the intranet. The floor focuses on one benchmark at a time. “Quiet Times” are the current focus on the medical-surgical floor.
- Stage Four: Staff leaders (and Super-Users) should be involved in the training program to provide support to other staff. Stage Five: Maintenance is achieved when nurses are properly utilizing equipment as part of their regular routine and they have accepted the change.