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Associate Forums
November 2012
We are the Patient Experience
http://www.youtube.com/watch?v=tuwZKswcBUE&feature=player_embedded
Patient Satisfaction
Presented to:
St. Mary-Corwin Leadership Team
October 17, 2012
Ever feel like you’re stuck?
Our Roadmap to Increased Patient Satisfaction
• What did it take?
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Teamwork
Training & Resources
Operations
Communication
Associate Satisfaction
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Teamwork
• Departments broke down barriers and started working
collaboratively together, rather than in departmental silos
– Conduct annual departmental survey, associates rating departments
• Re-energized our Patient Satisfaction Committee
– comprised of directors from clinical and non-clinical areas, meets monthly
• Developed a Superstar Committee
– Tasked with brainstorming/carrying through on improvement items, that
stemmed from an internal survey on how we can improve patient sat.
– Comprised of associates from varying departments/levels, meets monthly
• Developed a Patient/Family Advisory Council
– Tasked with improving patient satisfaction from community perspective
– Comprised of patients, board members, community members, associates
• Physician Satisfaction & Involvement
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Training & Resources
• Implemented several StuderGroup initiatives
– AIDET
– Nursing leaders reviewed HCAHPS book together
– Thank you cards to associate homes
• Courageous Conversations, mandatory for all associates
• Customer Service training, mandatory for all associates,
facilitated by Laurie Kennedy, then STMH representatives
– Direction to line staff
– Added to orientation for all new associates
• Service Recovery
– Developed new policy and tool kit for any associate to use
– Rolled out this initiative at associate forums
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Operations
• Accountability and ownership at all levels
– Commitment to Excellence poster
• Patient Representative position added
• Radiology
– added a transport position
• ED
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Added a clinical position for front window, EMTs front and back
Front desk renovation, eliminated window for improved access
Improved triage process
Significantly reduced wait times with ‘pull to full’ process
Pain management process improvement team
April calls LWBS and AMA patients, next day or as soon as possible
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Operations, cont.
• OR
– Expanded AIC, all private rooms, TVs donated by Foundation
– Added a volunteer to provide family updates
– Added a private consultation family room
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Implemented bed side reporting in Med/Surg
Started a nursing Wound Care program
Started a Coumadin clinic
Started a cardiovascular clinic
Now providing ‘comfort things’ identified by various committees,
such as a blanket in radiology, courtesy snack cart from Dietary
• Attention to physical plant details from Superstar Committee
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Communication
• Post discharge phone calls across key departments
• Admin, Director and Supervisor patient rounding
• Patient sat. updates provided at quarterly associate forums and
department staff meetings
• SDS/Ortho
– Created a ‘What to expect’ information guide for ortho patients
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Communication, cont.
• ED
– Posted wait times online, stmhospital.org, included in marketing campaign
• Radiology/Cardiopulmonary/Neurodiagnostics
– Provides continuous updates to patients on wait times, delays
– Gives every patient a thank you card with pertinent testing/follow up info
• ICU/ED
– Created new pain management handout for patients
• Marketing & Communications
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Patient letters/Share cards included in Impact associate e-newsletter
Department patient sat. action plans featured in Impact
Added patient rep. and hospitalist education to patient guide
Feature article/video in Centura Connections associate e-newsletter
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Communication, cont.
• Nursing fully utilizes white boards: plan of the day, RN name
• Formalized department action plans, detailed with goals/timeline
– Presented all at management council, keep top of mind
– Plans and updates included in Impact associate e-newsletter
• Value Based Purchasing
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Training provided at associate forums and staff meetings
Communicating to associates the importance of high patient sat.
Shows quality scores side-by-side with patient satisfaction
Added to new hire orientation over a year ago
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Associate Satisfaction
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Direct correlation between associate and patient sat
As patient sat increased, so did associate sat/Press Ganey
Visibility of admin on units increased, is appreciated
Management performs associate rounding
– One-on-one time with their director
• Nursing engagement is key, most impact on patient experience
• Thank you notes to associate homes
• Associate engagement activities
– Employee of the Month, picnics, in-person recognition by admin
• EVS - white boards w/ housekeeping pager #, patient sat.
• Maintenance focus on temperature control using log
• Dietary survey cards on all patient trays, supervisor rounding
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Our Thoughts
• “We all may have been part of the problem, but are all now part
of the solution.”
– Dianne Bush, Imaging Director
• “A patient recently told me, ‘You can tell that your staff loves
what they do, it’s not just a job.’”
– Becky Vodopich, Patient Representative
• A key philosophy we put into action is that everyone is
responsible for patient satisfaction, and we need to hold each
other accountable
– Marcia DePriest, Chief Nursing Officer
• “Happy associate, happy patient.”
– Eric Harris, Director, EVS, Security and Support Services
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Pain Team
• The team has developed goals around:
– Education (staff, physicians, and patients)
– Alternative modalities for pain management
– IT (order entry processes) and Meditech flow
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Pain Team
• So far we have:
– Investigated current equipment for heating/cooling and a new product has
been ordered
– Physician education opportunities
– Trialed some positioning items for improving comfort, ordering 1-2 sets to
trial with our patients
– Developed a process flow out of the PACU to the floor for patients requiring
an RCA for pain medications
– Pain brochure developed in the ED; revised for hospital-wide use to include
alternative modalities (draft)
– Developed a slogan and plan for our hospital-wide campaign
o “Experience More Comfort”
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Pain Team
• Still to come:
– Updates to the Patient Guide for improving comfort
– Improvements with documentation flow with focus on status boards for last
dose and pain goal
– Consistent approach to white board use for improving communication about
pain management with our patients
– Options for music therapy
– Clarity and training for positioning aid use and breathing techniques
– Evaluation of all of the chairs in the patient care areas
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Pain Team
Goal is to have rolled out our Comfort Campaign to all staff,
physicians, and patients by the end of the year.
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Baseline # of
Surveys
Performance # of
Surveys
HCAHPS Performance Standard
HCAHPS - Survey Dimensions
April 2010 - Dec July 2012 - Sept
2010
2012
Floor
(Minimum)
Benchmark
Threshold
Achievement Improvement
Points
Communication with Nurses (% Always)
79.10%
79.70%
42.84%
84.99%
75.79%
4
1
4
Communication with Doctors (% Always)
81.40%
80.00%
55.49%
88.45%
79.57%
1
0
1
Responsiveness of Hospital Staff (%
Always)
65.50%
69.30%
32.15%
78.08%
62.21%
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3
5
Pain Management (% Always)
74.00%
71.30%
40.79%
77.92%
68.99%
3
0
3
Communication About Medications (%
Always)
66.90%
53.90%
36.01%
71.54%
59.85%
0
0
0
Cleanliness and Quietness (% Always)
66.60%
65.70%
38.52%
78.10%
63.54%
2
0
2
Discharge Information (% Yes)
89.10%
80.40%
54.73%
89.24%
82.72%
0
0
0
Overall Rating of Hospital (% 9 to 10)
61.80%
61.90%
30.91%
82.55%
67.33%
0
0
0
Your VBP HCAHPS Base Earned Point (max 80 points)
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Your VBP HCAHPS Consistency Points (max 20 points)
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Your VBP HCAHPS Domain Score =(Your HCAHPS Earned Points + Your HCAHPS Consistency Score)/100
(15 + 15)/100
= 30.00%
Physician Satisfaction
Survey & Action Plan
Key Indicators
Percent
Very
Satisfied
Overall, how
satisfied are
you with this
hospital?
Overall, how
satisfied are
you with nursing
care?
Would you
recommend this
hospital to your
family or friends
if they needed
hospital care
Percent
Satisfied
Percentile for
Very
Satisfied
2009 Survey
22%/11%
1st percentile
25%
61%
32nd
percentile
33%
67%
50th
73rd
Definitely
would
48%
Probably
Would
41%
30th
N/A
Presentation Title – Date (month #, ####)
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• Action plan – focus on communication from
and with physicians
Joint Commission/Mock Survey
Survey Findings - highlights
Crash Carts not checked daily
Refrigerator logs not completed daily
Outdated Supplies and Drugs in multiple
locations
Incomplete Restraint Documentation
Pain Reassessments not completed within 1 hour
time frame
Scopes not stored properly
Foley catheter care and documentation and
timely discontinuation of Foley catheters
Inappropriate waste disposal
Lack of use of Universal Protocol for procedures
in all areas of the hospital
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Action Plan – Directors, managers and
supervisors responsible for areas with
findings will be putting together an action
plan to address each finding. You will be
hearing more from the leadership team
about this soon.
We are expecting The Joint Commission
Survey to occur this winter, potentially as
early as the beginning of February
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Associate Wellness
Update on Strive Classes
• Great participation in both the Healthy Life Weight and Coping
with Stress Class
•Between all 23 participants in the Healthy Life Weight classes
there has been weight loss of 96 pounds.
•New Years is just around the corner! Sign up for the Healthy Life
Weight Classes starting this January
•There will be two sessions running:
Healthy Weight Jan 8- Mar 12th Tue 5:00-6:00pm
Community Room
Healthy Weight Jan 10- Mar 14th Thu
Noon-1pm
Community
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Update on Wellness Events
•Freeze Your Weight Challenge! There are “eat this, burn off that”
posters located on the communication boards.
Sign your name off on the foods you burn
off in preparation for that big
Thanksgiving meal
• Relaxation Retreat coming up in December, look for sign up in the
Impact!
•System-wide biometric Screenings scheduled for February 20 &
21st 6:00am-10:00am. Sign ups will be online, look for more
promotion early January!
Associate Satisfaction
St. Thomas More Hospital Associate Partnership
Storyboard
Action Planning Update
Progress to Date
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Areas to Focus
Results communicated, action items identified
Entity results shared with all associates
Listening sessions completed
Entity areas of focus identified
Associate Action Planning Team members identified
Direct manager dashboard results reviewed and actions
identified
• Department leaders shared and discussed results with
their associates
• Progress updated with all associates
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Action Areas
1.
Excellent Performance is recognized
here
2.
I have opportunities to influence
policies and decisions that affect my
work
3.
My work group is asked for opinions
before decisions are made.
Recommended Next Steps
Create Associate Satisfaction Team
Who’s
Responsible
Timing
Stan Miller
Re-survey staff for recognition – Excellent Performance
Survey Monkey
Assoc Sat Team
November
Explanation of policies/decisions that come from Corp or
regulatory that can’t be touched
Discussion at Management Team
Administration/
Department Dir.
Monthly
Standardized agenda developed for dept. meetings
Discussion at Mgmt. Team /
Agenda Developed
Admin/Dept. Dir
November
Implement Relationship Based Care
Administration final Education
Administration
TBD
STM Updates
• Centura Health at Home
• Rocky Mountain Children’s Hospital
• New Directors
• Maureen McKasy-Donlin, Manager of Mission & Ministry
• Anita Berk, Director, Pharmacy
• Dawn McWilliams, Supervisor, Professional Development
• Medical Staff Services – Sonny Apodaca
• OB Remodel/Projects
• Financial Update
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Questions?
Thank you!