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Hospitals Have Room to Grow for Surgery Patient Safety Measures

More hospitals are meeting the surgical volume threshold, a key patient safety measure, although there is still room for growth.

By Sara Heath

– Adherence to key patient safety protocol during high-risk surgery may be getting better, but steps lay ahead for organizations delivering a slate of certain medical procedures, according to a new report from the Leapfrog Group.

The report, Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey, looked at how hospitals adhere to certain patient safety protocol when delivering one of eight common but high-risk surgeries.

Specifically, the report investigated how many hospitals deliver certain surgeries and meet what the Leapfrog Group calls its surgical volume threshold for those procedures. The surgical volume threshold refers to the minimum and maximum amount of times an organization administers a surgery.

When a hospital meets the minimum volume threshold, it is doing the surgery frequently enough to have experience in the area. But perform the procedure too often, the hospital runs the risk of spreading resources too thin.

The Leapfrog Group research team looked at how many hospitals meet the recommended volume thresholds for eight surgeries: bariatric surgery for weight loss, carotid endarterectomy, esophageal resection for cancer, lung resection for cancer, open aortic procedures, mitral valve repair and replacement, pancreatic resection for cancer, and rectal cancer surgery.

READ MORE: Reflecting on To Err is Human: 20 Years of Patient Safety Work

A higher percentage of hospitals met the surgical volume standard in 2019 than did in 2018, save for esophageal resection for cancer. In 2018, 2.6 percent of organizations hit the volume standard compared to 2.5 percent of hospitals that did in 2019.

However, the overall number of hospitals performing high-risk surgeries and hitting the volume thresholds is still less than ideal. The surgery type with the highest rate of organizations hitting the volume threshold was for bariatric surgery for weight loss, and even then, only 48 percent hit the threshold in 2019.

Next up was carotid endarterectomy, but only about 22 percent hit the threshold.

“The good news is we are seeing progress on surgical safety,” Leah Binder, the president and CEO of the Leapfrog Group, said in a statement. “The bad news is the vast majority of hospitals performing these high-risk procedures are not meeting clear volume standards for safety. This is very disturbing, as a mountain of studies show us that patient risk of complications or death is dramatically higher in low-volume operating rooms.”

“It’s time for hospitals and health systems to upgrade their surgical volume policies,” she added. “It will save lives.”

READ MORE: Providers Lack Tools to Boost Patient Safety, Achieve Zero Harm

These figures differed slightly for rural hospitals, with rural hospitals being less likely to hit the volume threshold than urban ones. However, when viewed as a proportion of hospitals offering a high-risk procedure and hitting the volume threshold, rural facilities fared better.

“To the credit of rural hospitals, most choose not to perform elective procedures for which they have inadequate patient volume,” the researchers said. “Hospitals that cannot perform a safe volume of procedures should follow the lead of the vast majority of rural hospitals and refer patients to safer options.”

In other words, rural hospitals are aware of their low volume and make a judicious decision not to offer the procedure. The most common high-risk surgery a rural hospital will opt into is a rectal cancer surgery, and even then, 73.2 percent are opting not to offer that surgery and refer patients to safer options.

The report also looked at protocol to ensure organizations only conduct a certain surgery or procedure when it is absolutely necessary. For cancer surgeries, hospitals must convene a multidisciplinary group to review cases, or they must have national accreditation from the American College of Surgeons.

For other high-risk surgeries, organizations must report on hospital policy for reviewing surgical necessity and preventive measures geared at preventing surgery overuse.

READ MORE: Hospitals Fall Short in Mitigating Serious Patient Safety Events

Hospitals are very likely to have adequate procedures in place. Over 70 percent of hospitals had adequate appropriateness procedures in place for cancer surgeries.

Fewer had them in place for other high-risk surgeries. Only 32.1 percent of hospitals had appropriateness procedures in place for open aortic procedures, while 43.2 percent had them in place for Mitral valve repair and replacement. Up to about 60 percent had appropriateness procedures in place for bariatric surgery for weight loss.

When stratifying for hospitals that meet the volume standard, Leapfrog found that hospitals commonly had adequate appropriateness standards. The number of hospitals offering surgery for cancers with appropriateness standards reached up into the low 90 percent for various procedures. For other high-risk surgeries, those numbers crept up to between 55 and 70 percent, depending on the procedure.

“It is critical that hospitals do not perform surgery when the procedure is not appropriate for the patient,” said Binder. “In addition to the increased potential for harm to patients, unnecessary surgeries contribute to the burden of overuse and excess expense in the U.S. health care system.”

This information is key for patient decision-making, the researchers said.

“While progress has been made, far too many hospitals are performing surgeries too infrequently to be deemed safe for patients,” the research team wrote. “Abundant evidence suggests that for certain procedures, patients can save their lives by choosing a hospital and a surgeon with adequate, ongoing experience performing that surgery and as well as a hospital that protects against unnecessary surgery.”

Many hospitals do opt into sharing this kind of data with the Leapfrog Group, but currently there are not requirements for hospitals to do so. This means patients can miss out on important information that could help them make a care access decision based on safety.

“Hospitals should implement policies to ensure safe volumes,” the report authors concluded. “If they cannot achieve a minimum volume for safety, they should not electively perform that procedure. Physicians should be willing to have a conversation with their patients about facility or surgeon alternatives that will improve the patient’s odds of a better outcome.”

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.”

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.

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