Studying HCAHPS Scores and Patient Falls in the Context of Caring Science

Transcription

1 Studying HCAHPS Scores and Patient Falls in the Context of Caring Science STTI 26 th Research Congress: San Juan, Puerto Rico July 26, 2015 Presented by: Mary Ann Hozak, MA, RN, St. Joseph Health System Tara Nichols, MSN, RN, Henry Ford Medical Center John Nelson, PhD, MS, RN, Healthcare Environment

2 Agenda Work environment s impact on caring HCAHPS Patient Falls

3 Background A 15 country study (2012) available in Cochran Review revealed there has been no to little impact on decreasing falls in any of the countries studied (synthesis of 43 studies) Study revealed outcomes need to be examine in context of operations of care Source: Cameron, Gillespie, Murray, Hill, Robertson, Murray, et al., 2012

4 Background Robert Wood Johnson Foundation reports patients remain at risk, 10 years after Keeping Patients Safe 27% of hospitalized Medicaid patients are harmed by care they received during hospitalization Source: Published , accessed July 9, 2015

5 Background Robert Wood Johnson Foundation reports (continued) 44% of these events were preventable Frontline workers need more feedback of work process and involvement in process improvement Source: Published , accessed July 9, 2015

6 Background 60% of adverse events have been attributed to nursing care Fall rate by nursing care ward can vary by tenfold Professional models of nursing care decreased fall rate (p =.007) Source: D Amour, Dubois, Tchouaket, Clarke and Blais, 2014

7 Background

8 HCAHPS stands for Hospital Consumer Assessment of Health Providers and Systems HCAHPS survey is a standardized measure for patient s perception of their hospital experience Source: HCAHPS fact sheet, 2008 from 2014 HCAHPS training session

9 26 of 32 questions inquire about 7 dimensions: Communication with nurses Communication with doctors Responsiveness of hospital staff Pain management Communication about medicines Discharge information Care transition Source: HCAHPS training PowerPoint, 2014

10 Remaining Items inquire about: Cleanliness of hospital Quietness of hospital Overall rating of hospital Recommendation of hospital Source: HCAHPS training PowerPoint, 2014

11 Administered 48 hours to 6 weeks after discharge to random sample of patients Results reported publicly at Results influence payment for hospital care by CMS (government funded care) Source: HCAHPS training PowerPoint, 2014

12 As of September, 2013, 4,281 hospitals participated in HCAHPS Survey adapted for home health, health plans, clinician groups, nursing homes and ACOs Source: HCAHPS training PowerPoint, 2014

13 It was desired to understand how HCAHPS related to: Work environment Concepts of caring (care for self and others) Employee and organizational demographics Source: HCAHPS training PowerPoint, 2014

14 Methods CMS was contacted to request permission to use five HCAHPS questions while patients still in hospital IRB approved study

15 Methods Questions selected and amended for inhouse inquired about: Listening Pain control Pain management Discharge instruction Teaching possible side effect for new medication

16 Methods Questions presented at same time as 10 caring questions (Watson s theory) Correlations and regressions used to examine in relationship to other variables of interest

17 Results 223 patients responded to HCAHPS Factor analysis revealed 1 factor HCAHPS Item Loading Caregivers did everything possible to help me cope with my pain..900 Nurses listened carefully to me..845 During this hospital stay, my pain was well controlled..832 Caregivers talked to me about help I might need when leaving the hospital..774 Caregivers described possible side effects in a way I could understand..696

18 Results

19 Interview Methods Second study for HCAHPS used interview of nine patients who scored 8 instead of 9 or 10 on HCAHPS survey post discharge. Group comprised of 8 women and 1 man

20 Interview Methods Group interview lasted one hour and conducted by researcher trained in interview methods Interview resulted in 72 pages of transcript (appeared to be 12-font and double spaced)

21 Interview Methods Transcript was read and reread by Dr. John Nelson to establish understanding of interview content for the purpose of identifying themes Themes were selected and highlighted. Each theme has a different color to assist with review of themes

22 Interview Results Key Finding 1: A single act of inattentiveness prompted the low score Key Finding 2: Could not get staff to respond

23 Interview Results Key Finding 3: Poor empathy/caring of staff Key finding 4: Communication Key finding 5: Clean bathroom

24 Secondary Analysis, Methods HCAHPS data from ,263 HCAHPS records

25 Secondary Analysis, Methods Items looked at: Nurses listen Help with pain Medication side effects explained Discharge instructions

26 Secondary Analysis, Methods Independent variables examined Patient age Zip code Length of stay Overall health Mental health Admit through ED

27 Secondary Analysis, Methods Independent variables examined Highest education Race Gender Service line Payor Language at home

28 Secondary Analysis, Results Listening Regression equations revealed: Overall health predicted 2.0% of perception of listening (p = <.001). Education had a negative impact on listening and increased explained variance to 2.4% of (p = <.001)

29 Secondary Analysis, Results Listening Cross tabs revealed the following profile was most likely to report never when asked if they were listed to carefully: From zip code 7424 Gender 1 (versus code 2) Service line 2 Having any college education at all (some college through more than 4 year college) Race, including Black and Indian

30 Secondary Analysis, Results Pain Control Regression equations revealed: Overall health had a positive relationship, predicted 1.8% of listening score (p = <.001). Mental health had a positive relationship and increased overall explained variance to 2.8% (p = <.001)

31 Secondary Analysis, Results Pain Control Regression equations revealed: Education had a negative impact on pain and increased explained variance to 3.2% (p = <.001) Feeling listened had a positive impact on pain score and increased explained variance to 23.2% (p = <.001)

32 Secondary Analysis, Results Pain Control Cross tabs did not reveal a profile for those who reported never

33 Secondary Analysis, Results Medication Education Regression equations revealed: Overall health had a positive relationship, predicted 1.4% of medication education score (p = <.001). Age had a negative impact on medication education score, increasing explained variance to 1.9% (p = <.001)

34 Secondary Analysis, Results Medication Education Regression equations revealed: White race had a negative impact on medication education score, increasing explained variance to 2.4% (p = <.001).

35 Secondary Analysis, Results Medication Education Cross tabs revealed the following profile: Payor group 1 was most likely to report never and this finding was statistically significant using contingency coeffecient

36 Secondary Analysis, Results Discharge Instructions Regression equations revealed: Race (Latino) reported high scores for satisfaction with discharge instruction and explained 0.6% of the variance (p = <.001) Age negatively related to discharge instruction score, increasing explained variance to 1.0% (p = <.001)

37 Secondary Analysis, Results Discharge Instructions Regression equations revealed: Race (Asian) negatively related the discharge score and increased the explained variance to 1.4% (p = <.001)

38 Secondary Analysis, Results Discharge Instructions Cross tabs revealed the following profile for those who reported never Race (White) Payor group 1

39 Key points of secondary analysis: Careful listening had a positive impact on pain control scores Higher education had a negative impact on listening and pain scores

40 Key points of secondary analysis: Overall health positively impacted scores for listening, pain control and medication education Payor group 1 had a negative impact on scores for medication education and discharge instructions

41 Key points of secondary analysis: Race, negatively impacted: listened to scores (being Indian or Black), medication education (White) and discharge instruction scores ( White or Asian) Race, positively impacted: discharge instructions (Latino)

42 Key points of secondary analysis: Age negatively impacted scores for medication education and discharge instructions

43 Patient Falls Background Falls have been shown to be one of the most common adverse event that are deemed to be influenced by nursing care Source: D Amour, Dubois, Tchouaket, Clarke and Blais, 2014 One study found 5.9% of all adverse events were from falls Source: D Amour et al, 2014

44 Patient Falls Background Decreasing falls is important as falls have been shown to increase length of stay in the hospital Source: Dubois, D Amour, Tchouaket, Clarke, Rivard, and Blais; 2013; Dunne, Gaboury, and Ashe, 2013

45 Patient Falls Background Patients who experience a fall while in the hospital have been shown to have higher comorbidity, more complications, and higher mortality Source: Memtsoudis, Danninger, Rasul, Poeran, Gerner, Stundner, et al., 2014

46 Patient Falls Background Despite understanding what relates to falls, there has been no to little impact on decreasing the adverse impact of falls Sources: Cameron, Gillespie, Murray, Hill, Robertson, Murray, et al., 2012; Chassin, 2014 Examination of literature in falls revealed limited to no use of theory in the investigation of falls

47 Patient Falls Methods Similar to the HCAHPS question, it was hypothesized falls related to the work environment and concepts of caring Five hospitals were interested and collaborated, including the USA hospitals represented in this research presentation

48 Patient Falls Methods Constructal theory It was proposed there is a flow of falling, based on clinical setting and policy Falls have common risks for falling Clinical specialty has specific risks for falling Policy creates or inhibits risks for falling

49 Patient Falls Methods Literature searched for variables commonly proposed as predictors of falls Current hospital surveys used were evaluated Final list of 35 independent variables proposed important to measure, derived from literature and surveys

50 Patient Falls Methods Variables Measured Facility Unit / Ward Year Month Day of month Shift Time of day Sex Age Was fall assessment done on admission?

51 Patient Falls Methods Variables Measured (continued) Was fall assisted? Was patient identified at risk for fall? Were fall precautions implemented? If fall precautions were implemented, did plan of care address fall risk? Did patient have prior fall this month? (Galway hx of falls) Time since last fall risk assessment. Outcomes (did an injury occur?) Were restraints in use? Was fall assessment done every shift? Bed height Bed/Chair alarm indicated?

52 Patient Falls Methods Variables Measured (continued) Bed/Chair sensor implemented? Was the fall witnessed? Medication prior to fall? Event Type (bed, chair, walking, etc.) If yes to medication, what type of medication? Call light status (on or off) Floor condition (wet or dry) Appropriate footwear Toileting programme

53 Patient Falls Methods Variables Measured (continued) Location of fall Altered mental state/confusion Patient education prior to fall Purple armband Purple dot on white board Admit with urinary problem or symptom

54 Patient Falls Results (dependent variable - falls) Combining all datasets revealed 1,558 falls 1,340 falls reported if there was an injury 356 had an injury (26.6%) 984 (73.4%) with no apparent injury

55 Patient Falls Results There were 5 of 35 independent variables that had adequate data from 4 of 5 hospitals Due to no independent variable having adequate data in all hospitals, a combined analysis of all hospitals was not possible

56 Patient Falls Variable Hosp 1 missing data Hosp 2 missing data Hosp 3 missing data Hosp 4 Missing Data Hosp 5 Missing Data Number of facilities with adequate data Facility Unit / Ward 3 (.6%) (16.6%) Year

57 Patient Falls Variable Hosp 1 missing data Hosp 2 missing data Hosp 3 missing data Hosp 4 Missing Data Hosp 5 Missing Data Adeq. Month (.5%) (27%) 4 Day of month (18%) 48 (13%) 100 (27%) 4 Shift Time of day 3 (.6%) 1 (.7%) 90 (52%) Sex 0-2 (1%) 5 (1.3%) - 3 Age (.5%) 2 (.5%) - 3 Fall assessment 14 (2.8%) 5 (3.5%) 38 (22%) on admission? Fall assisted? 14 (2.8%) (91%) - 0

58 Patient Falls Variable Hosp 1 missing data Fall precautions implemented? Plan of care address fall risk? Hosp 2 missing data Hosp 3 missing data Hosp 4 Missin g Data Hosp 5 Missing Data Adeq. 169 (34%) (32.5%) 269 (55%) Prior fall this month? 14 (3%) - 36 (21%) Time since last fall assessment. 14 (3%) Did an injury occur? 7 (1%) 5 (4%) 0 3 (.8%) 136 (37%) 4 Were restraints in use? 14 (23%) 5 (4%) Was fall assessment done every shift? 192 (40%) 61 (42%)

59 Patient Falls Results Data was adequate for: Facility Ward Year Month Day of Month Due to extensive data missing, an analysis including all facilities was not possible

60 Patient Falls Results

61 Patient Falls Results

62 Patient Falls Next steps Henry Ford doing secondary analysis on complete data set extracted from EMR St. Joseph using Kindles and training in knowledge management to improve data and analysis

63 Discussion

64 Contact Information: John W. Nelson 888 West County Road D., #300 New Brighton, MN (office phone)

65 Thank you for listening!