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Zero to 50,000 — The 20th Anniversary of the Hospitalist

Robert M. Wachter, M.D., and Lee Goldman, M.D., M.P.H.

Twenty years ago, we described the emergence of a new type of specialist that we called hospitalista “hospitalist.”1 Since then, the number of hospitalists has grown from a few hundred to more than 50,000 (see graph) — making this new field substantially larger than any subspecialty of internal medicine (the largest of which is cardiology, with 22,000 physicians), about the same size as pediatrics (55,000), and in fact larger than any specialty except general internal medicine (109,000) and family medicine (107,000). Approximately 75% of U.S. hospitals, including all highly ranked academic health centers, now have hospitalists. The field’s rapid growth has both reflected and contributed to the evolution of clinical practice over the past two decades.

In the mid-1990s, the combination of managed care for privately insured patients and Medicare’s diagnosis-related-group–based payment system for inpatients pushed hospitals to manage care more efficiently without sacrificing quality or alienating patients. Hospitalists emerged as one potential solution. Within a few years, evidence showed that using hospitalists could result in reduced costs, shortened lengths of stay, and preserved or even enhanced quality of care and patient satisfaction2,3 — in essence improving the value of care. The field was off and running.

For hospital medicine to grow as quickly as it has, many stars had to align, including a viable financial framework, a pool of qualified physicians, and enough force to overcome resistance to change. Remarkably, those stars did align.

The first issue was economic. By the mid-1990s, elective medical admissions had all but disappeared, but emergency admissions were increasing. Acutely ill patients needed rapid attention on admission and often multiple daily visits during hospitalization, regardless of whether that disrupted the flow of physicians’ outpatient practices. Moreover, the remuneration for nonprocedural inpatient care, especially given its growing complexity, was not high enough to make physicians who had historically been responsible for such care (primary care physicians in community settings and specialist and researcher attendings in academia) feel strongly about retaining their hospital roles. So most such physicians willingly turned inpatient care over to hospitalists.

How could hospitalists, then, fashion careers out of a role that was economically unattractive to their colleagues? Once evidence of substantial cost savings had accumulated, health care organizations found it advantageous to have hospitalist programs, and most provided financial support to create appealing jobs with reasonable salaries. Thanks to the value proposition and new duty-hour limits for residents, hospitalists also increasingly became responsible for staffing nonteaching services in teaching hospitals.

The second facilitator of hospitalist growth was the very large pool of general internists in the United States, most of whom were trained predominantly in inpatient settings. Many internists, whether newly minted or experienced, found the hospitalist role attractive, particularly given growing dissatisfaction with primary care internal medicine. In contrast, the small reservoirs of general internists in countries such as Canada and Britain have hindered efforts to build inpatient programs staffed by generalists.

Third, the quality, patient-safety, and value movements and widespread implementation of electronic health records all emerged just as the hospitalist field came of age. Hospitalists’ early emphasis on improving systems of care4 bolstered the field’s credibility and fostered the development of a cadre of young physicians who would ultimately assume local and national leadership roles. For example, the U.S. Surgeon General and the chief medical officer of the Centers for Medicare and Medicaid Services are hospitalists — an impressive validation of such a young field.

As the specialty grew in size and stature, the model spawned variations on its central theme. One obvious extension was pediatric hospitalists, who now account for approximately 10% of hospitalists. More creative variations include “hyphenated hospitalists,” such as surgical hospitalists (also called acute care surgeons), neuro-hospitalists, and obstetrical hospitalists. Medical hospitalists also often comanage care with surgeons or medical subspecialists, thereby reducing costs and allowing those specialists to concentrate on procedural tasks.5 Finally, financial penalties for readmissions have led many hospitalists to staff post–acute care facilities to improve coordination with colleagues at acute care hospitals.

Despite the hospitalist field’s unprecedented growth, there have been challenges. The model is based on the premise that the benefits of inpatient specialization and full-time hospital presence outweigh the disadvantages of a purposeful discontinuity of care. Although hospitalists have been leaders in developing systems (e.g., handoff protocols and post-discharge phone calls to patients) to mitigate harm from discontinuity, it remains the model’s Achilles’ heel.

Many hospitalists have added value as local leaders in quality improvement, safety, and innovation, but some have functioned more as shift workers. For example, many community hospitalists have a 7-days-on, 7-days-off schedule that focuses mainly on high-volume clinical work and sends an unspoken but clear message that, at the end of an intensive clinical “on” stint, one is “off” and uninvolved. Our impression is that hospitalist programs provide more value when hospitalists’ inpatient assignments (clinical “systole”) are complemented by a systems-oriented “diastole,” during which clinical activity is limited but they contribute to key institutional programs. Productive diastole is more likely when hospitalists have strong leadership, a robust professional-development curriculum, and a mutual hospital–hospitalist commitment to adding value during specified and structured nonclinical time.

Another problematic, though not unanticipated, consequence of the use of hospitalists has been a diminished role for specialists and researchers on teaching services. Because specialists are far less likely than they once were to serve as inpatient attendings, trainees have less contact with them and less exposure to basic and translational science.

Finally, the few academic hospitalist groups that have developed substantial research programs generally emphasize the implementation of quality- and systems-related initiatives. Hospitalists have been slow to pursue substantial inquiry into discovery related to the common inpatient diseases they see or to lead multicenter trials of new diagnostic or therapeutic approaches. This deficiency limits hospitalists’ credibility in academia and the advancement of the field.

Although we continue to believe that the hospitalist model is the best guarantor of high-quality, efficient inpatient care, it’s clear that today’s pressures require innovative approaches around this core. In addition to following patients in post–acute care facilities, another modified approach is to have a subgroup of hospitalists function as “comprehensivist” physicians who care for a small panel of the highest-risk, most frequently admitted outpatients and remain involved when hospitalization is required. This model aims to blend the advantages of the hospitalist model for the vast majority (>95%) of inpatients with the potential advantages of continuity for a small group of patients who are admitted repeatedly.

Hospitalist programs are innovating in other ways as well. Many are developing early-warning protocols in which electronic health record data are used to identify patients who are at risk for problems such as sepsis or falls. Others are implementing bedside ultrasonography for procedures and diagnosis, pioneering methods of making rounds more patient- and family-centric, implementing unit-based leadership teams, or applying process-improvement approaches such as the Toyota Production System to inpatient care.

Many academic programs are also experimenting with new ways of reconnecting specialists and scientists with trainees. Some have begun offering focused basic-science training to hospitalists, others have developed molecular medicine consult services, and still others have instituted dual attending programs, with a consultative teaching specialist joining a more hands-on teaching hospitalist. Such innovations are welcome and should be studied. In fact, the field’s greatest risk may well be complacency — failing to embrace the kinds of transformation and disruption that led to its birth, or being slow to address the inevitable side effects of even the best innovation.

When we described the hospitalist concept 20 years ago, we argued that it would become an important part of the health care landscape. Yet we couldn’t have predicted the growth and influence it has achieved. Today, hospital medicine is a respected field whose greatest legacies may be improvement of care and efficiency, injection of systems thinking into physician practice, and the vivid demonstration of our health care system’s capacity for massive change under the right conditions.

Latest Snapshot: Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)

carona 2

Building A Culture of Nurse Excellence to Drive Patient Satisfaction

Driving nurse excellence and engagement will be essential to delivering on patient satisfaction and experience.

  By Sara Heath

– When it comes to nurse engagement, efforts must go a lot further than just driving good job satisfaction. In fact, nurse excellence isn’t entirely about the nurses at all, although they are important. Instead, nurse engagement is an essential means to yield an overall positive patient experience, connecting all of the key elements of healthcare into one cohesive picture.

The call for good patient experiences is not something new. Healthcare has long valued the patient, striving for excellent bedside manner and good clinical quality outcomes. But in an age where healthcare consumerism reigns supreme and CMS reimbursements hinge on good satisfaction scores, driving that positive hospital experience has become even more crucial.

But building that experience is extremely nuanced, most industry experts can appreciate. A good patient experience requires a balance of certain hospitality elements, patient safety, and meaningful interactions between patients and staff.

And that’s hard, experts say. Hospitals only have so many resources to dedicate to facility amenities and clinicians are strapped for time, seriously hindering their ability to connect with patients on a personal level. Patient safety, although essential to clinical quality outcomes, can falter to human error in the most unfortunate cases, despite best efforts. Communicating those lapses then present a whole new challenge.

But those challenges aren’t insurmountable, especially when nurses are engaged. These clinicians are on the frontlines of everything ranging from patient interactions to medical care. So, when nurses thrive, everything else thrives, too, according to Christy Dempsey, DNP, MSN, MBA, CNOR, CENP, FAAN, the chief nursing officer at healthcare consulting firm, Press Ganey.

READ MORE: Pushing for Nurse Engagement to Drive Better Patient Experience

“A culture of nursing excellence really does impact everything,” Dempsey said in a recent interview with PatientEngagementHIT. “If you have a good culture of nursing excellence, then you’re more likely to have better physician engagement. You’re more likely to see that patient experience of their physicians, not just of the nurses, is better. Clinical quality is better. It’s the rising tide that lifts all boats in healthcare.”

As noted above, nursing excellence looks like a lot more than just good job perks and satisfaction, although those factors can be important. Instead, nursing excellence is about developing and advancing strong nurse leaders, who are then able to advocate for their patients and nurse peers.

“Nursing excellence requires a structure within the organization that supports shared governance so that nurses at every level are helping and involved in making decisions, measuring transparency of data, and establishing performance benchmarks and promoting autonomy for nurses inside that shared governance framework,” Dempsey explained.

Nurturing a culture of provider teamwork and implementing care frameworks that emphasize not just clinical quality, but safety and patient experience as well, is another key hallmark of nursing excellence.

But although the industry has a good model of what nursing excellence is – strong team-based care that gives all stakeholders the tools to succeed – it isn’t always happening.

READ MORE: Supporting Nurses to Address the Social Determinants of Health

“We are in an environment that is constantly changing. It’s complex in terms of the patients and the venues, the continuum of care,” Dempsey said. “There are a lot of pressures within healthcare today.”

But it’s those very factors that hamper efforts for nurse excellence that nurse engagement and empowerment can solve. When nurses are empowered, Dempsey maintained, the patient can thrive because the team can thrive.

“Even in today’s complex, constantly changing healthcare environment, that culture of nursing excellence can be fostered, promoted, and then impact everything else that happens in healthcare,” Dempsey asserted.

Healthcare organizations on a journey to nurse excellence need to start where they are today. Understanding their current competency in patient safety, nurse experience, and clinical quality and experience will be important for understanding the root causes of any underperformance they see in their facility, Dempsey instructed.

From there, organizations can design a path forward.

READ MORE: Nurse-Led Education Program Boosts Older Patient Experience

“Define what the nursing professional practice model in your practice is,” Dempsey said. “Once you have determined that, you’ve got to make sure that you have CEO and board support for that model and that the chief nursing officers and nursing leadership are involved in executive level decision making at the C suite and the board level.”

A nursing shared governance that included nurse managers and engages bedside nurses will help organizations build their accountability structure, leading nurses and other stakeholders to take ownership of the process. Stakeholders should also play a hand in writing out job descriptions, performance reviews, and standards for clinical practice.

After that, teams must scale that plan organization-wide.

“You need to establish a communication plan so that you are able to disseminate information and initiatives that help you drive towards nursing excellence,” Dempsey said. “You must have an organizational strategy for data transparency in how you talk about the data. You can’t just post it on the wall. How do you talk about the data and wrap stories around that data to make it come to life? Then, look at the specific work unit information and communication strategies.”

All of this must lead to an optimized work environment, Dempsey continued. Work environment, or the factors that make a job doable and even enjoyable, is even more important that staffing levels, Dempsey reported.

“Optimizing that nursing work environment is so important,” she said. “That includes the leadership development plan, how you are engaging nurses and fostering their development, and how you are providing incentives for professional development.”

Organizations must also assess how they are assuring they have the appropriate resources – both human and material – and emotional support for nurses. This will allow nurses to continue efforts for patient-centered care.

“Make sure that you’re optimizing staffing so that you have the right people taking care of the right patients in the right place at the right time,” Dempsey stated.

“Then, finally, track integrated metrics, so reducing silos both in terms of operations, but also in terms of the way we look at data,” she continued. “Integrate that data so that you can see things and how things move together — or don’t. This will help you draw insights from that integrated data and then build improvement plans, and accountability and ownership plans based on that integrated data.”

All of this will hinge on a culture of team-based care. The organizations that Dempsey sees fully committed to a culture of excellence are already deploying strong team-based care strategies, fostering collaboration, communication, and support across the team. This is a symbiotic relationship, she said, because the culture of excellence also draws on the whole hospital team.

And at the end of the day, that is what will help organizations push to the next level in value-based and patient-centered care.

“Driving nursing excellence is not just a good idea, it makes good fiscal sense,” Dempsey concluded. “It makes good sense to recruit and retain the best and the brightest. It is the rising tide that will help health care. We need to really promote that.”

Case Study: Surmounting Staff Scheduling at Valley Baptist Health System

By Carolyn Pexton and Blake Hubbard

Case Study: Surmounting Staff Scheduling at Valley Baptist Health System

Located in Harlingen, Texas, Valley Baptist Health System is a full-service, not-for-profit community health network ably serving the population of south Texas and beyond. The system is comprised of multiple organizations including Valley Baptist Medical Center, a 611-bed acute care hospital providing the number one rated orthopedics service in Texas, a state of the art children’s center and a lead level III trauma facility. The organization also serves as a teaching facility for The University of Texas Health Science Center.

In 2002, Valley Baptist Health System began to implement GE’s Six Sigma approach as a rigorous methodology for process improvement and a philosophy for organizational transformation. The adoption of Six Sigma at Valley Baptist fostered a revitalized culture that embraces the voice of the customer, breaks down barriers to change and raises the bar on performance expectations. Through this initiative, the team at Valley Baptist began to examine the most critical opportunities for improvement and select projects that would align with strategic objectives and produce measurable results.

As with most healthcare providers today, maintaining appropriate staffing levels and improving productivity are among the top concerns at Valley Baptist. During the initial wave of Six Sigma training projects, the team at Valley Baptist launched an effort to review and improve the staff scheduling process for one nursing unit in orthopedics. Within this particular unit, there had been a history of overtime and use of agency hours that did not seem to correlate with changes in patient volume. Patient census would fluctuate while staffing levels remained the same, and the higher hourly wage for overtime and agencies had begun to strain the overall labor budget.

The primary focus for this project was to improve the unit’s ability to responsibly meet staffing targets while protecting the quality of patient care. It is a challenge to reach that optimal level – avoiding overstaffing yet appropriately meeting daily needs. Paramount in this effort was the notion that targets would be met without adversely impacting customers. Patient satisfaction scores had to remain constant or increase, and this mandate was built into the project and measured through the use of upper and lower specification limits.

A cross functional project team was assembled including the chief nursing officer as sponsor, the assistant vice president from human resources, the nursing house supervisor, the nurse manager from the cardiac care unit, a representative from IT and a charge nurse. The introduction of any new change initiative can elicit skepticism, but since Six Sigma concentrates on fixing the process rather than assigning blame, once the approach was understood much of the skepticism subsided. Stakeholder analysis and other CAP (change acceleration process) tools helped to surface concerns and improve communication.

Also supporting this project were metrics to measure productivity for nurses and managers that had been introduced through the adoption of Six Sigma. The dual emphasis on productivity and quality provides a framework for offering cost effective care and aligns with the customer-centered mission at Valley Baptist.

Defining the Goal

During the Define phase of the project, the team concentrated on clearly identifying the problem and establishing goals. The nursing units in general had struggled to meet their staffing targets and were over budget on labor costs. For this project, the team decided to focus on one orthopedics nursing unit based on three criteria: the unit was not extremely specialized or unique so it offered the best representation of nursing as a whole; the manager was very supportive of the initiative; and this unit offered clear opportunity for improvement and results.

To understand the current scheduling process, the project team used the SIPOC tool to develop a high-level process map. SIPOC stands for suppliers, inputs, process, output and customers. Inputs are obtained from suppliers, value is added through your process, and an output is provided that meets or exceeds your customer’s requirements. SIPOC is extremely useful during process mapping.

Measuring and Analyzing the Issues

As they moved through the Measure and Analyze phases, the project team focused on data collection and the identification of the critical “Xs” that were impacting staff scheduling. Historical data was gathered from the payroll system to analyze regular time, overtime, agency use, sick time, vacation, jury, funeral leave and FMLA. They examined 24 pay periods for each data point. Fortunately, the team was able to extract the data they needed from existing systems and avoid manual data collection, which is more labor intensive and can increase the project timeline.

Given the availability of continuous data for the “Y” or effect and the potential Xs or causes, regression analysis was the tool chosen to help the team understand the relationship between variation from the staffing goals and vacation, FMLA, sick leave, overtime, agency nurse usage, and so on. Through regression analysis, they were able to determine that three critical Xs could explain 95 percent of the variation: agency use, overtime and census. The next step would be to understand underlying factors – data would point the team to interesting findings that disputed their original theories.

The Improve Phase

During the Improve phase, the team used many of the CAP and Work-out tools. Such acceptance-building techniques are key to success, since improvements introduce changes in process and human behavior. The team conducted a Work-out session to develop new standard operating procedures for better management of overtime and agency usage – critical drivers in staffing.

The chief nursing officer attended the sessions to underscore the importance of this initiative from a leadership perspective. The project team used the process map to indicate where they might have opportunities for improvement, and then conducted separate Work-outs on each area. They brought in nursing staff, house supervisors and other stakeholders to participate in the search for solutions.

This project translates to $460,000 in potential savings for one unit. Conservatively, if it were spread across the health system the savings could exceed $5 million.

Never Assume

This project furnished a classic example as to how Six Sigma can be used to either corroborate or dispel original theories. Management at Valley Baptist had initially assumed they were over budget on labor costs due to sick leave, FMLA, vacation and people not showing up, which would have naturally necessitated the additional overtime and agency hours. The data and analysis proved those assumptions to be incorrect.

It turns out there were several factors contributing to the staff scheduling challenges. One illuminating aspect to come from the Work-outs was the realization that nurses didn’t like floating in and out of units – this came up in every session. There were also issues with the staffing matrix which attempted to set parameters based on volume. Compliance was not ideal, and the matrix itself was based on data that was not completely current. Another complication was that maintaining information in the matrix involved labor intensive, manual processes that were difficult to control.

The team discovered the use of overtime was not always need-based. Units would regularly schedule 48 hours for each nurse, with the extra eight hours of overtime built-in as “traditional” usage. This became an accepted practice and although in theory, adjustments are supposed to be made when the patient flow is lighter, this was not happening. On the form used to submit data the nurses would have to guess what hours they might actually work. The matrix might indicate compliance, but the payroll data actually showed them clocked in for 14-15 hours instead of 12.

Another critical issue is that the nursing unit lacked appropriate mechanisms for shift coordination and handoff. There were two fully independent teams between the day and night shifts, and there was not a smooth transition between them. Part of the problem stemmed from a lack of written guidelines governing the overtime between shifts. Nurses would finish their regular 12-hour shift and stay on overtime to complete tasks rather than pass them on to the next shift.

The central metric of this Six Sigma initiative was worked hours divided by equivalent patient days. Valley Baptist Health System defines worked hours as those hours during which an employee was actually working – including regular time and overtime, and excluding non-productive hours such as sick and vacation time. Equivalent patient days is the volume statistic utilized within the Orthopedics Unit. It is the typical patient days number adjusted to reflect short-term observation (STO) patient volume.

Results and the Control Phase

The development of new standard operating procedures has clearly had a positive impact on the organization. This gave staff a plan they can follow and established accountability. The unit began a process for transition meetings between shifts. The outgoing nurse now takes the incoming nurse to the patient’s room, introduces them and provides a report on the current status and whether there are outstanding orders. In addition to improving operations for the hospital, this change has also been well received by patients, as reflected in rising satisfaction scores during the pilot.

The project on staff scheduling has led to an overall reduction in the higher hourly cost of overtime and agency use, and has translated to $460 thousand in potential savings for this one unit. Conservatively, if this project were spread across the health system the savings could exceed $5 million. It is also important to note that this project started at the 0 sigma level and increased to Six Sigma for nine consecutive pay periods.

“At Valley Baptist, we continually seek opportunities to improve productivity,” said Jim Springfield, President and CEO. “This focus is critical for our future success and ability to meet patient needs.”

To ensure results are maintained, managers use control charts and trend reports with data from HR, time and attendance and payroll systems. This provides real time information on productivity, tracking worked hours versus patient days to show alignment with targets on an ongoing basis.

Organizational and Customer Impact

The bottom line is that nurses, management and patients are all happier as a result of this project. With the pilot in the Control phase, Valley Baptist has held Work-outs to determine how they might broaden the SOPs and implement this approach across the system in all nursing units.

“Staff has become much more flexible. We initially encountered some resistance, but using the CAP tools and working through the process helped to create a shared need and vision.”

Leadership involvement and support turned out to be a significant factor in the overall success of the project. This initiative represented a major culture change from previous CQI and TQM approaches to quality improvement. All previous efforts had involved hard work and good intentions, but prior to Six Sigma, they lacked the framework and rigor to institute statistically valid long-term results.

The health system is moving toward autonomy through additional Green Belt and Black Belt training with projects, and through participation in a Master Black Belt course at GE’s Healthcare Institute in Waukesha, Wisconsin. This experience provides instruction and interaction that prepares the MBB to come back and teach within the organization.

“Coming from the HR side, it’s important for organizations to know it’s possible to change the way you’ve always done things, and that employees will adapt to a new approach. If you can overcome the stress surrounding change you can realize increased efficiency. This is a positive way to control staffing without employing slash and burn techniques.”

Irma Pye, senior vice president at Valley Baptist, attended a conference in Utah with other healthcare executives. When the issue of performance improvement and staffing came up, someone mentioned they’d attempted to do a project on this and it had failed because they couldn’t afford to alienate and potentially lose good employees. Irma spoke up and let them know that based on her own recent experience, you can indeed address this issue and it can work if it is approached in the right way using the right techniques.

“Usually, when you ask the department manager to trim labor costs they think it can’t be done because it will antagonize employees . . . they’ll either take a job somewhere else, or stay there with negative feelings which impacts morale. This approach was able to affect change, while avoiding issues of layoffs or pay cuts.”

Using Predictive Analytics to Help Seniors Maintain Their Independence

Evan McLaughlin 09 September, 2019

action-adult-care-339620-1

We might not be able to observe the progressive loss of cognitive and intellectual abilities someone with dementia is experiencing from the outside, but healthcare clinicians can detect it when they observe their ability to bathe, groom or dress themselves deteriorate. Minitab consultant  and Insights 2019 speaker David Patrishkoff is researching how to help with the aid of Minitab software.

Activities of Daily Living (ADLs)

The healthcare industry calls basic self-care tasks like one’s ability to properly feed themselves, move around or go to the bathroom “Activities of Daily Living,” or ADLs. Since the 1950s, healthcare professionals have scored ADLs with pre-set criteria (see this worksheet from the National Palliative Care Research Center for example).

After populating a worksheet like this, a healthcare professional can flag the functional capabilities of older adults and use the results to assess their ability to live independently.

What if symptoms could be caught earlier?
Enter Machine Learning and Predictive Analytics

David Patrishkoff

 

David Patrishkoff

There is evidence that deterioration of ADL scores are preventable. Screening can greatly help as the first step in the process too. For example, preventing elderly patients from falling has been shown to reduce the use of home healthcare, and the associated costs.

Building off of related research, Minitab consultant David Patrishkoff set out to use Machine Learning to help detect ADL deterioration earlier in the process and address it accordingly.

In healthcare, interventions are activities or strategies (such as screenings or vaccinations) to assess, improve, maintain, promote or modify health of individuals or groups. David uses Minitab Statistical Software and Salford Predictive Modeler (SPM) to examine 1,200+ interventions and therapies that nurses and home care workers provide to people across the country, and select the best ones to maintain or improve their independence and their ADLs.

“I start in Minitab with data visualizations and clean up the data, then jump into SPM for the really heavy lifting of very complex data sets,” David said. “I have columns of data where I have one of any 83,000 prescriptions that are prescribed to people. There are 43,000 diagnosis codes too. The algorithms in SPM can deal with highly dimensional data.”

A Master Black Belt who began his career in the automotive industry, David has consulted in about 60 different industries worldwide and trained nearly 30,000 professionals in Lean Six Sigma and patient safety.

Applying Predictive Analytics to Problem-solving

David first began using TreeNet in SPM to enhance his research into causes of traffic accident injuries and deaths, and he is applying some of the same methods now to ADLs and home care.

There is a belief that you have to be a data scientist coding in Python and R to handle these kinds of problems, he notes, but that’s not necessarily true. David recommends learning to use predictive analytics software like SPM to see how you can do better root cause analysis.

David also credits the 64-bit version of Minitab 19 with helping him with larger data sets he was unable to work with in previous versions.

“It helped me tremendously,” he said. “I had old files that were too big and then with the 64-bit Minitab 19 it further helped my analysis.”

What’s Next?

David has been speaking at conferences about his research and how classic Six Sigma and operational excellence practitioners can build on their knowledge of statistical methods to take the next step into the data science revolution. He plans to present and publish further findings next year on how to provide home healthcare clinicians a stable methodology to improve patient outcomes.

Fewer X-Ray Errors Reduce Cancer Risk, Wait Time and Costs Evan McLaughlin 27

Evan McLaughlin 27 November, 2019

Clinicians examining a radiograph

In hospital and clinic settings, making the right decisions doesn’t just reduce costs from duplicative work and process inefficiencies — it results in better outcomes for patients. Think about needing to take an extra X-ray because the first captured the wrong foot. Even if it’s the right limb, what if they captured it from the wrong angle?

Over the 14 years he worked in healthcare quality improvement, Art Wheeler saw this and many other process improvement scenarios. Most recently, as decision support manager for quality improvement services at one of the country’s largest not-for-profit freestanding pediatric healthcare networks, he was the primary statistician, as well as a mentor and coach for Six Sigma Black Belts and Green Belts, program managers and project leaders for 8 1/2 years.

An expert in statistical quality control, one of his key responsibilities was ensuring data was collected in a way that was sound and ensured the best chances for detecting statistical significance of any reported improvements. He also developed the charts and writeups for the analysis sections of corresponding published articles and responded to reviewer questions or comments to help ensure acceptance.

Remember that extra X-ray scenario we mentioned earlier? Art served as a consultant on a duplicate X-ray study, which found each unnecessary scan cost facilities an extra $150 to $300 and overall patients were waiting longer. One study of 18 US pediatric emergency departments showed radiology errors are the third most common event in pediatric emergency research networks and human errors rather than equipment issues caused 87% of them.

Besides reducing errors, the team were also motivated to achieve their goal of zero errors at two clinics so they could also reduce lifetime radiation exposure for individuals, which in turn diminishes their risk of developing cancer. Efforts like this were part of the hospital’s “Zero Hero” program – they would measure the time period and the number of cases involved, aim to reduce incidents to zero and record how long they maintained zero incidents.

It wasn’t all black and white though. They needed to understand the context behind the duplicate X-rays to truly make improvements. With a retrospective review of a 14-month period at two facilities, they knew there were good and bad reasons behind the 170+ duplicate X-rays that were recorded, for a duplicate radiograph. Each duplicate radiograph was classified as …

  1. No error, where they intentionally studied from multiple views;
  2. Incorrect location, when the patient’s initial complaint did not match the initial radiograph (e.g. the aforementioned wrong foot);
  3. Incorrect laterality, when it’s the wrong side; or
  4. Unnecessary radiograph, a known issue when a clinical athletic trainer preordered multiple radiographs without physician evaluation and assessment.

The Pareto chart below shows the most common error during the 14-month period was incorrect location.

pareto-chart-radiograph-error-classification-resize

The quality improvement team took steps to meet their zero percent goal in both clinics, which included issuing surveys to patients and families during registration to help document where they needed to be X-rayed and if they had been X-rayed in the past.

The unnecessary radiograph was also a known issue when a clinical athletic trainer preordered multiple radiographs without physician evaluation and assessment. An intervention was made to fix this, making physicians responsible for putting their own radiograph orders in the Electronic Medical Record.

Overall these steps improved communication between physicians, clinical athletic trainers, radiology technologists, patients and families, and greatly contributed to better outcomes for everyone involved.

How Hospitals Can Raise Patient Satisfaction, CAHPS Scores

Sara Heath

Editor
sheath@xtelligentmedia.com

Improving patient satisfaction scores, such as CAHPS, is key for driving practice reputation and reimbursements.

Healthcare organizations with high patient satisfaction and CAHPS scores see a multitude of benefits. High patient satisfaction scores usually result in higher reimbursement payments from CMS, better patient retention rates, and the assurance for hospital staff that they fostered a positive experience for patients.

A May 2016 report from Vocera showed that patient satisfaction is the top-ranked priority at healthcare organizations. Due to the importance of ensuring favorable feedback from patients, the demand for patient experience officers and patient advocate executives is increasing, with these professionals pulling equal rank with other C-suite executives, the report said.

The primary measure for patient satisfaction is the Consumer Assessment of Healthcare Providers and Systems (CAHPS). The CAHPS survey is developed and funded by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS, and forms a component of some value-based reimbursement programs.

CMS also uses CAHPS scores to inform its star ratings, which are publicly available ratings about the quality of healthcare facilities.

Several types of CAHPS surveys are utilized throughout the care continuum, ranging from hospitals to nursing homes to health plans. However, the Hospital CAHPS (HCAHPS) and Clinician and Group CAHPS (CGCAHPS) are the most prominent and commonly used surveys.

Both surveys measure many of the same factors, including nurse care, doctor care, and facility environment.

The HCAHPS survey also includes questions about experiences within the hospital, including pain management, and continuity of care experiences.

CGCAHPS surveys target their questions to the general practitioner, asking questions about ease of healthcare access and how often the patient has been visiting the office.

Because HCAHPS and CGCAHPS are used for both reimbursement and patient rating purposes, it is important for healthcare organizations to improve their scores. Healthcare organizations can improve their CAHPS scores by understanding what is important to patients, what the surveys measure, and how to meet patient needs.

Improving Patient-Provider Communication

Provider Picture

The first two sets of HCAHPS questions pertain to nurse and physician communications with patients. These questions ask whether nurses and physicians communicated clearly with patients, and whether patients understood their diagnoses, prognoses, and treatment options.

Clear communication about healthcare information is integral to a positive healthcare experience, experts say. Hospitalization is often a stressful and worrying time for patients, and made even worse when clinicians do not adequately communicate what is going on and how they will treat a patient’s ailments.

In addition to allaying patient worry, providing meaningful explanations of conditions and treatments will help the patient taken ownership of her own health.

“Patients have a need for information,” explained Deirdre Mylod, PhD, Executive Director of the Institute for Innovation and Senior Vice President of Research and Analytics at Press Ganey.

“It’s not just making consumers happy to meet that need, but it’s also providing the right care. When you give people the right information, they can engage in care, they can be active participants, they’re better prepared to care for themselves at home, they’re less likely to be readmitted.”

Clear communication will require collaboration between the different members of the care team, added Mylod.

“As a patient, when one team member tells me one thing and somebody else tells me another, now I’m afraid and I’m thinking you’re not working together. Now I’m more scared than I need to be in a hospital,” she pointed out.

HCAHPS also asks patients whether nurses and physicians treated them with respect and empathy. Clinicians must tap into their interpersonal skills to provide compassionate care to their patients, while being mindful of cultural norms and barriers.

The healthcare industry might be falling short in this respect. A January 2017 survey conducted by Oliver Wyman and the Altarum Institute found that 40 percent of low-income patients have walked away from appointments feeling disrespected.

The survey, funded by the Robert Wood Johnson Foundation, showed that in addition to reducing patient satisfaction, lacking compassion also lowered quality of care. Patients who felt disrespected were three times less likely to trust their clinicians, and two times less likely to adhere to treatments.

Healthcare organizations should support their clinicians in pursuit of being more empathic. Organizations can host cultural sensitivity seminars, work with patients to continue to develop their interpersonal skills, and educate clinicians on evidence-based best practices for enhancing patient-provider communication.

Improving the Physical Hospital Environment

Hospital Setting

Two HCAHPS questions pertain to the hospital environment: hospital cleanliness and hospital noise levels.

In order to maintain an appropriately clean and sanitary facility, organizations must support their custodial staff and reinforce the importance of a healthcare facility being clean.

The American Hospital Association has long advocated for improving the hospital setting for patient satisfaction. In a 2016 guide, AHA listed the ways in which organizations can create environments more suitable for patient rest and recovery.

To create a quiet and peaceful environment, AHA says hospitals should implement and enforce rules about quiet hours and lights-out times.

“It makes sense that patients rate hospitals poorly when they cannot get good sleep or rest and have the additional stress of noise added to the already stressful situation of being unwell,” AHA wrote. “Data shows that noise in hospitals is the factor that scores lowest on HCAHPS scores nationwide.”

Healthcare organizations can take it a step further than HCAHPS mandates. Many hospitals are turning to their patients to inform room design that will facilitate a more comfortable experience.

When designing its new facilities in Delaware and Orlando, leaders at Nemours Children’s Health consulted with its patient and family advisory board to decide which features would best suit pediatric patient rooms.

“The parents came in and tested all of the furniture that they might be sleeping on in the rooms. They provided input into what we actually purchased,” recalled Nemours Chief Information Officer Bernie Rice.

“The children came in as well and helped pick colors and room layouts as far as if the counter was too high,” he continued. “They were very valuable and heavily influenced our construction and design to make sure it was a very family- and patient-friendly environment.”

Being Attentive and Reducing Unnecessary Discomfort

Improving Patient Discomfort

One highly-debated part of patient experience surveys is pain management. Amidst a raging opioid abuse epidemic, many experts question whether pain management should be a part of patient satisfaction scores that result in provider reimbursements. By tying payments to pain management, some clinicians may feel compelled to prescribe opioids when there could be other potentially less-risky forms of pain management.

In November 2016, CMS removed the pain management questions from the HCAHPS survey. However, the agency maintained that pain management is an important part of patient care and experience.

“CMS continues to believe that pain control is an appropriate part of routine patient care that hospitals should manage, and is an important concern for patients, their families, and their caregivers,” CMS said in a public statement. “CMS is continuing the development and field testing of alternative questions related to provider communications and pain, and will solicit comment on these alternatives in future rulemaking.”

While the pain management portions of the HCAHPS survey are currently under construction, clinicians should still work to reduce unnecessary patient discomfort.

Press Ganey is adopting this approach when consulting on patient experience, Mylod said.

“The way that we approach improvement for patient experience measures is to reframe it,” she explained. “The exercise is not to make consumers happy. The exercise is to reduce patient suffering.”

To boost scores in this realm, Mylod suggests clinicians – especially nurses – become even more attentive. This means not only answering call buttons, but also making regular rounds to hospital beds to ensure they meet all patient needs.

During these rounds, nurses can ask if the patient needs assistance using the restroom or if they need an object, such as a television remote, handed to them. Paying attention to these seemingly inconsequential needs could reduce adverse safety events, Mylod explained. If a patient gets up to retrieve a book, for example, he could fall and hurt himself, affecting the patient experience, increasing length of stay, or requiring additional expenses related to an injury.

Streamlining discharge processStreamlining the Discharge and Follow-up Process

HCAHPS asks patients about how doctors and nurses managed continuous care and the discharge process. The survey asks whether clinicians checked in on post-discharge care plans, made it clear which provider will follow-up with ongoing needs, and whether that care will be adequate for the patient’s condition.

At patient advocacy group Planetree, leaders have developed a hospital discharge plan to ensure clinicians meet patient needs.

The plan includes identifying a family care partner that will help take care of the patient following hospital discharge, said Planetree’s Director of Research Jill Harrison, PhD.

From there, clinicians check in with the patient and appointed caregiver to determine which functions they will need to learn for optimal at-home care.

“Planetree has a program that allows people to say that they want help with wound changes, or help ambulate their loved one, or help check a tracheotomy if the patient has one,” Harrison said. “Caregivers go through a training program with the nursing staff and learn how to provide that care so that when patients get out of the hospital setting their family members are ready to take that all on.”

Other key healthcare players are advocating for a similar strategy. AARP has been sponsoring a law in state legislatures across the country to support family caregiver engagement. The organization says caregiver engagement will help support continuity of care.

Research confirms that family caregiver engagement can reduce hospital readmissions by up to 25 percent.

Hospitals that implement family caregiver engagement and discharge plans may see not only increases in HCAHPS scores, but in quality of healthcare, as well.

The importance of improving patient satisfaction and CAHPS scores is well-founded. These scores help inform CMS value-based reimbursements and hospital ratings published on the CMS website. Many healthcare organizations also use these scores to inform their own internal practice improvement processes.

However, when it comes to improving patient satisfaction, it is also important for practice leaders to look beyond the survey. Improving patient satisfaction means understanding the facility’s unique patient population and its needs. What will please one group of patients may not satisfy another, and hospital leaders must bear that in mind.

While supporting initiatives specifically geared toward improving CAHPS scores, healthcare organizations should also consider projects that will serve their unique population.

Issuing practice-specific patient input surveys or consulting with a patient advisory council will help healthcare organizations move beyond surface-level satisfaction and find solutions that will be truly meaningful for patients.

Patient Safety: Akron Children’s Hospital Uses Lean Six Sigma and Minitab in the NICU

Serious about Patient Safety: Akron Children’s Hospital Uses Lean Six Sigma and Minitab in the NICU

 Akron Children’s Hospital is serious about enhancing the patient experience, along with delivering quality healthcare in a timely, efficient manner. While the hospital formally established the Mark A. Watson Center for Operations Excellence in 2008, it has been performing quality improvement since its early beginnings 125 years ago. It’s no wonder the healthcare provider has consistently earned Best Children’s Hospitals rankings in 7 of the 10 specialties evaluated annually by U.S. News & World Report—including cancer, diabetes and endocrinology, pulmonology, neonatology, neurology and neurosurgery, and orthopedics.

The hospital encourages employees across all skill levels and departments to become involved in quality improvement, offering several levels of Lean Six Sigma training. As part of its green belt training and certification, employees learn to use Lean Six Sigma by leading and completing long-term projects with the guidance of experienced black belts.

One such green belt project, which began at the hospital’s Mahoning Valley, Ohio campus, had a goal to decrease one particular safety event—unplanned extubations in the hospital’s neonatal intensive care unit (NICU). To complete this project, the hospital improvement team relied on Lean Six Sigma tactics and the data analysis tools in Minitab Statistical Software.

The Challenge

Akron Children’s Hospital relies on Minitab Statistical Software to analyze their Lean Six Sigma project data. The hospital used Minitab to verify improvements made to the intubation process in the NICU.

An intubation is a medical procedure in which a breathing tube is placed into a patient’s trachea. This tube connects the patient to a machine called a ventilator, which helps the patient breathe. The procedure is common for both pediatric patients and adults in intensive care, but is most common for premature newborn babies residing in a hospital’s NICU. Babies born prematurely often have undeveloped lungs, which cause breathing problems and the need for the assistance of a ventilator.

Although this medical procedure is commonly performed, it is not without risk, and can cause trauma to or introduce an infection into the patient’s airway. Unplanned removal of the breathing tube, which is also known as an unplanned extubation, is a likely occurrence that can cause harm. Unplanned extubations are the fourth most common adverse event in NICUs across the U.S.

Akron Children’s Hospital’s Department of Respiratory Care had been collecting data on the rate of unplanned extubations in the Mahoning Valley NICU for well over a year, but had not had the capacity to investigate the occurrences further. Bonnie Powell, a Registered Respiratory Therapist and manager of respiratory services at Akron Children’s Hospital, was a green belt candidate during the time unplanned extubation data were collected. As part of her Lean Six Sigma training and certification, she set out to lead a project that would decrease the rate of unplanned extubations in the Mahoning Valley NICU.

“I knew this project was the perfect fit for me because as a respiratory therapist, I’ve been part of the frontline staff primarily responsible for intubating,” Powell says. “When you’re the one actually putting the tube into the patient, it just affects you more because you know the trauma that you could be causing to them.”

How Minitab Helped

While there’s not a true benchmark rate that NICUs should strive to stay below regarding unplanned extubations, the Vermont Oxford Network—a research collaboration of nearly 1,000 global NICUs including Akron Children’s—considers 2 in 100 intubated patient days to be the upper limit of acceptable. Previous data collected on the rate of unplanned extubations at the Mahoning Valley NICU revealed a rate of 3 in 100 intubated days.

“Any unplanned extubation has the potential to cause harm to the patient and negatively impact overall patient satisfaction,” says Powell. “We wanted to improve our performance on this metric.”

Powell’s Lean Six Sigma project team included a multidisciplinary group of nurses, respiratory therapists, a neonatal nurse practitioner, and a neonatologist.

The team began by using Lean Six Sigma tools to brainstorm reasons why unplanned extubations were occurring, as well as solutions for stopping them. “The fishbone diagram and cause maps were among the most helpful tools we used,” Powell says. “We looked at the highest impact solutions, as well as how easy they would be to implement, and prioritized solutions from there.

“This step helped us to organize and roll out our seven improvements into two phases,” she says.

Along with more frequent communication between nurses and respiratory therapists before, during, and after an intubation, as well as educational information distributed in meetings and via email, one improvement implemented was the “two to turn” rule. “Anytime an intubated patient is repositioned, one caregiver is turning the patient and another is holding the tube at the patient’s mouth,” Powell explains.

The team applied the improvements for several months, as collecting enough data to meet the required 100 intubated days for pre- and post-improvement comparison proved difficult for many reasons.

“There is a continuing trend in neonatal care to use devices such as masks and nasal prongs to connect the patient to the ventilator to help with breathing. When these devices are used, there is no need for a breathing tube, which reduces the number of intubated days and lengthened our post-improvement data collection period,” Powell says. “That, coupled with greater attention to our weaning protocol, which focused on shortening the time babies need ventilator support of their breathing, contributed to why we saw a reduced amount of intubated days.

“Of course, fewer intubated days was a good thing in this case, and supported the idea that our improvements were working,” adds Powell.

To compare unplanned extubations, pre- and post-improvement, the team visualized their data using control charts in Minitab Statistical Software.

Minitab graphs clearly reveal the impact of improvement efforts. This control chart displays the reduction in unplanned extubations after Lean Six Sigma improvements were implemented.

To verify their results statistically, the team ran a 2 proportions test in Minitab to see if their unplanned extubation rates decreased after improvements were put into place.

Hypothesis testing in Minitab makes it easy to determine if there is enough evidence in a sample of data to infer that a certain condition is true for an entire population.

The analysis showed the team that after improvements were implemented, the unplanned extubation rate had indeed decreased.

The team also used Minitab to perform process capability analysis both pre- and post-improvement. This tool provided another before-and-after comparison of unplanned extubation rates, and aided the project team in assessing whether the new process was capable and in statistical control.

“I have never taken a statistics course and have no background in this type of work,” Powell notes, “but Minitab, coupled with the instruction I received from the Center for Operations Excellence, made it easy for me to analyze and understand my data.”

Trauda Gilbert, deployment leader for the Center for Operations Excellence at Akron Children’s, echoes Powell. “To be able to use Minitab to visually demonstrate the before and after effect with a control chart, which you can then share with your team and champion is really valuable. Minitab also makes it easy for front-line staff to document that they have made a statistically significant difference. To be able to do that without having to interact with a biostatistician or one of the other very rarely found statistical resources in our organization, is very beneficial,” she notes.

“Healthcare quality is a little different than manufacturing because we can’t just run a DOE and tweak a process line,” says Gilbert. “Even though we’re different, Minitab still helps us out.”

Results

The data revealed a dramatic reduction in intubated days after the improvements were made, as well as a considerable reduction in the rate of unplanned extubations at the Mahoning Valley campus. The reductions brought their rates in line with the Vermont Oxford Network’s suggestion of 2 unplanned extubations in 100 intubated patient days.

“This project showed us that simple improvements can create real change,” says Powell. “The cultural change this project instilled in our team was exciting—the recognition that even they could make a difference is huge.”

Cost savings resulting from the reduction in supplies and staff time needed to care for unplanned extubations can be calculated, but the overall financial impacts are hard to quantify. “The larger costs of unplanned extubations—such as a longer NICU length of stay, ventilator-associated pneumonia, and other setbacks that the patient can experience from the event—can be difficult to tease out,” Powell says.

“Neonatal patients are some of our key customers here,” she continues. “Due to the fact that they were born early, they come back to our institution for care frequently, especially initially. Making sure they have a safe experience early is critical, because the results of good care at this stage can have exponential benefits for patients in the future.”

In addition to improving the patient experience, the project helped Powell obtain her Lean Six Sigma belt certification. “I did get my green belt as a result, and we’ve also rolled out selected improvements to the NICU at our Akron campus,” she says. “We’re in the process of collecting data there as well, so this project didn’t just stop in Mahoning Valley.”

Powell’s project is just one example of an estimated 300 documented projects that have been completed throughout the Akron Children’s organization. The total financial savings of the hospital’s operations excellence program is estimated to be more than $25 million since its official beginnings in 2008.

Learn more about lean six sigma in healthcare :  Six Sigma Master Class – Improving Healthcare Processes

Mapping the Healthcare Value Stream

Congratulations Vicki Chernoff on becoming Masters Certified in Continuous Healthcare Improvement!

1/07/2016 For Immediate Release – Phoenix, Arizona * United States

TPMG would like to congratulate Vicki Chernoff for successfully completing the Masters Certification for Continuous Healthcare Improvement program and earning her MCHI Certification!  Vicki successfully completed a rigorous 10 unit – 45 lesson online Masters Certification in Continuous Healthcare Improvement workshop by passing the certification examination with distinction.  This accomplishment acknowledges she has fulfilled the requirements for the MCHI program of study and, from this day forward, is certified as a MCHI professional.  By completing this distinctive course, she is qualified and authorized to implement Continuous Improvement and Performance Management systems.  Congratulations Vicki!

Vicki Chernoff is a Senior Clinical Data Analyst Mission Hospital.   She holds a BSN from Saddleback College, a Bachelor of Arts in Psychology from Concordia University Irvine, and a Masters Of Arts Degree in Research Psychology from San Fransisco State University.

The Performance Management Group’s Masters Certification for Continuous Healthcare Improvement program is specifically designed for professionals who work for healthcare clinics, hospitals and systems. TPMG has been certifying continuous improvement professionals for more than 15 years. The company provides training and certification on-site, online, and on-campus (at the University of Phoenix) nationwide. For more information regarding lean six sigma training, certification and consulting – contact TPMG llc at 623.643.9837 or logon to www.helpingmakeithappen.com.

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