SATISFACTION snapshot news, views & ideas from the leader in healthcare satisfaction measurement The Satisfaction Snapshot is a monthly electronic bulletin freely available to all those involved or interested in improving the patient/ client experience. Each month the Snapshot showcases issues and ideas which relate to improving patient satisfaction and customer service, improving workplace culture and improving the way we go about our work in the healthcare industry. The Satisfaction Snapshot features: «relevant articles from healthcare industry experts «case study success stories «tips and tools for quality improvement «patient satisfaction and other industry research findings «articles with ideas to help achieve success in your role If you would like your colleagues to receive the Satisfaction Snapshot please send us their names and email addresses. The Satisfaction Snapshot is published by Press Ganey Associates Pty Ltd. All material is copyright protected. Quotation is permitted with attribution. Subscribers are permitted and encouraged to distribute copies within their organisations. Subscription to the Satisfaction Snapshot is FREE! Please direct any comments, suggestions or article submissions to: Manager of Client Relations snapshot@pressganey.com.au Trust Your Staff But Check Validation The Key to Hardwiring Change Implementing quality improvement isn t just a matter of intellectually knowing what to do. Over the years haven t we been bombarded with all the latest tactics and process change initiatives that promise to save the world. We have all heard about them and attended the courses: TQM, CQI, process re-engineering, lean thinking and more recently specific tactics like hourly patient rounding. On a positive note, travelling around Australia and New Zealand and talking with hundreds of front line, passionate care givers, there are some fantastic outcomes being achieved with these tactics, there are also many frustrating failures. is the problem the tactic? - or is it the execution? Written by Terry Grundy - Managing Director Press Ganey Associates Australia and New Zealand Referencing "But we're already doing it!" Why Validation is the Key to Effective Hourly Rounds by Lyn Ketelsen, RN, MBA Press Ganey Associates t 07 5560 7400 f 07 5560 7490 snapshot@pressganey.com.au www.pressganey.com.au
Page 1 Introducing a change process is easy: research and profile the rationale, document a procedure, outline the steps, communicate the instructions, provide training and then TRUST that your staff will then implement. It would be nice if behaviour change was this easy, but it s not. Beyond teaching the right skills, let s look at some factors that cause people to change their behaviour. New behaviours take time to develop. When people are given a new tactic to implement, there must be a structured reinforcement process involving real world practice, reporting on progress, time lapse and accountability. We have found that the biggest factor in making change stick, (or hardwired), is validation that the staff are doing what they say they are doing. The best example is the concept of hourly patient rounding. All the research demonstrates that making regular, planned and expected patient contact on an hourly basis, (supported by key behaviours), reduces patient falls by 50%, reduces call bells by 38%, frees up staff time by 40 minutes a shift, increases patient satisfaction and improves the bottom line. In fact, the Institute for Healthcare Improvement described hourly rounding as one of the most powerful ways to redesign patient care, in addition to helping "restore sanity and joy to our workforce", (December 2007). Many clients are achieving and often exceeding these fantastic results, yet many quality managers so often report that the nursing units are doing the practice but they are getting limited outcomes. The same can be profiled for many other quality improvement activities, WHY? If we are not getting the always response we know that the tactic is only getting partial compliance. So why don't all organisations experience fantastic results from these tactics? First of all, some organisations have been known to deviate from the original formula set forth. For hourly patient rounding for example, it is critical to follow the eight behaviours which are profiled below: 1. Use opening non clinical words to gain trust and make a connection with the patient or family. 2. Accomplish any scheduled tasks, (e.g. medications or observations) 3. Address the "three patient risk factors" pain management, going to the toilet, positioning for pressure relief. 4. Address any additional comfort needs, (pillows, TV, reading material, phone). 5. Conduct an environmental assessment of the area, (is the patient in a safe environment can they reach everything). 6. Ask, "Is there anything else I can do for you? I have time." (giving permission to ask anything and not feel they are interrupting). 7. Tell each patient when you will be back, (stops risky behaviours and reduces call bell use) 8. Document the round. The main difference between those that are successful and those that are struggling to achieve results is validation or, said another way, lack of validation. If you want to drive the results described above, you have to Validate, Validate, Validate. "But we're already doing it!" Why Validation is the Key to Effective Quality Improvement We need to ask of our staff are you really doing it, fully focused on the outcomes, or are you just going through the motions? We need to do a quick test with our unit managers and staff. Ask yourself the question and then tick your response: Are the behaviours implemented consistently? Sometimes Usually Always Are the behaviours implemented correctly? Sometimes Usually Always
Page 2 The most often heard excuse from staff regarding hourly rounds is, "We are already in the room that much anyway," or "I am already doing those things." Certainly this is the perception that many staff have; however, it is often not the reality. If it were, we would not hear so many patient complaints like, "I don't see my nurse enough," or "The staff seem so busy." The key Opportunities for Validation There are 7 key opportunities in validating if processes and behaviours are being implemented consistently: 1. Validation through documentary evidence. 2. Validation by the unit leaders (check with patients). 3. Validation by regularly assessing and discussing the outcomes on the unit. 4. Validation by external leaders (DON, quality manager or equivalent - check with patients). 5. Validation with the patient after discharge (through a discharge phone call). 6. Validate by turning the required behaviour into an annual competency, like other skill areas. 7. Follow-through when behaviour does not meet the requirements, take action. 1. Validate through documentary evidence Face time is not enough. Staff must understand that a tactic like hourly rounding is not about getting in the room every hour. It is about doing the eight behaviours every hour which just happen to require us to be in the room to do them. The key? Rounding Logs. I have yet to see an organisation be successful in getting the level of results mentioned above without using them. It is not sufficient to have staff just tick a box to say they have conducted the round. A log is a memory jogger to keep staff focused on completing the required behaviours. The log itself should not be just a tick box form, it should also prompt the staff member to note any specifics about the tasks implemented or patient concerns or responses. This provides evidence that the contact and behaviours were done. For many organisations the log is a paper-based document, some simply make a notation on a chart or whiteboard, while others like a client in Melbourne have produced in-house software to track and record the behaviours and outcomes, (example follows): 2. Validation by the unit leaders (check with patients) Nurse leaders, it's your job to validate. It's the nurse leader's task to validate that the behaviours are being implemented with enough consistency to achieve results. There are three steps in this validation: 1) Nurse leaders need to check that the logs are being completed consistently and correctly. 2) Nurse leaders need to round individually on patients on the unit to ensure that the staff initials on the log truly represent that all behaviours were accomplished, and 3) Nurse leaders need to check if effective communication has taken place for patient understanding. A few examples of key questions for a Nurse leader to ask a patient follow: Can you tell me the names of your nurses? (validating that staff are introducing themselves) What is your pain like now and when is your next pain medication? (validating that the staff cover pain management) Did the staff ask you if you needed to go to the toilet? (validating that staff cover toilet needs) Did the staff make sure that you could reach everything that you need before leaving? (validating that environmental assessments are conducted) Can you tell me when your nurse will be back for the next round with you? (validating that staff communicate when they will be back)
Page 3 Does nurse leader rounding work? Absolutely. Two clients, Salem and Arizona Hospitals in the US conducted an assessment of their patient satisfaction, differentiating whether they had rounding from a nurse unit manager during their stay in hospital. As the graph clearly shows, there was a massive difference between patients who were rounded on by the nurse unit manager and those that did not. Number of call bells for the week, the month, (trended with previous numbers) Total amount of time, (in minutes) spent responding to call bells, (trended with previous numbers) Number of falls for the week, the month, (trended with previous numbers) Number of pressure sores for the week, the month, (trended with previous numbers) Percentage of logs completed correctly, (trended with previous numbers) Patient satisfaction outcomes for the week, the month, (trended with previous numbers) Below is an example of data presented at hourly rounding meetings at an Australian facility: 3. Validation by regularly assessing and discussing the outcomes on the unit No quality improvement activity should continue without the regular assessment of the outcomes. The activity needs to be a standing agenda item for unit meetings and even change of shift handovers. This is where data plays an important role. Healthcare workers, through the very nature of their training, are always looking for evidence to justify a care path or treatment decision. Similarly healthcare workers need evidence to continue to support an initiative. With hourly patient rounding there are numerous indicators that prove that the tactic is having an impact. An example set of key indicators (data) that should be collated and presented at unit meetings follows: The discussions should then review the qualitative outcomes for the tactic. What is working well, what can be improved? What are the key issues for the patients and our staff? Who is doing the tactic well, who needs training or support? The final and not to be forgotten components of this phase are: 1. communicate the successes outside the unit, and 2. reward and recognise the staff that are consistently conducting the behaviours.
Page 4 4. Validation by external leaders (DON, quality manager or equivalent check with patients) To support the nurse unit leaders, and ensure that any facility initiative is on track and working, a key tactic is to have a qualified individual independently undertake validation on the unit. There are a number of reasons for this external validation: Nurse leaders who have been resistant to implementing the tactic may often report that their team is conducting the practice, however, the external data does not show the outcomes anticipated. Often, high performing leaders do not communicate the success they are having, nor get the recognition they deserve. Regular contact by a senior nurse leader such as the Director of Nursing provides this connection. The post discharge call is also an excellent opportunity to validate the behaviour of staff in quality improvement activities. Key questions that could be incorporated into the call could be: Did we check on you hourly during the day to assure you received very good care? Did we introduce ourselves and explain the course of your care to you and your family? Did we keep you informed about wait times when you were in the reception area? The outcomes from these discharge call validation questions then need to be fed back into the accountability practices of the organisation, often via the Quality Manager for appropriate follow up. As with nurse leader rounding, external validation requires discussions with patients. Similar questions can be asked as profiled above but the Director of Nursing or Quality Manger can add value to the process by including more whole of facility questions such as: Can you tell me what home care options were discussed with you when you go home? (validating that staff are discussing post discharge care) What is your understanding of the process if you have a concern or complaint? (validating that the staff cover complaint management) 5. Validation with the patient after discharge (through a discharge phone call) Conducting a post discharge phone call is a must do activity. Unfortunately research highlights that 1 in 5 patients experience an adverse event at home after leaving hospital, (66% of these events relate to medication issues). Adverse Events After Discharge from Hospital, Annals of Internal Medicine, February 2003. While post discharge calls have been routinely conducted for day surgery patients to check on their recovery, many facilities are now recognising that ALL patients benefit from the facility making contact after their hospital experience. 6. Validate by turning the required behaviour into an annual competency, like other skill areas Incorporating the required behaviours as a component of an annual competency assessment will add credibility to the skill and make it as important as all the other skills we validate annually. 7. Follow through when behaviour does not meet the requirements, take action Senior leadership must drive the process of accountability with their active involvement. Every manager and supervisor must be held accountable to understand, support, model and coach the behaviours required. When data arrives providing evidence of performance, and it is obvious that some units are doing well and others not, what happens in your organisation? If we set an expectation and do not follow through when data shows variation in outcomes we are telling the high performers that they are not valued and telling the low performers that we are not serious about the tactic.
Page 5 This is particularly the case when we let clinical skill, override our requirement for leadership performance. A number of years ago I was presenting Emergency Department patient satisfaction results to a team at a large metropolitan hospital. The Manager of the ED was widely regarded as the best trauma physician in the State. Before I presented the results his statement to his staff in the room was: our job is to fix people, not make them happy ok Terry, start your presentation. I later met with the Quality Manager of this hospital and asked about the performance of the ED. After getting a huge sigh, I was told it was the worst performing ED in the State for adverse events, the worst performing ED in the State for budget control, the worst performing ED in the State for patient satisfaction and it currently had a staff turnover rate of 30%. For many years this ED Manager was presented with these outcomes but never confronted or held to account. The reason: we can t afford to lose his skill from the ED. What does this story tell you about leadership accountability and follow through when we let the perception of skill override holding leaders accountable for their leadership role. Conclusion Sometimes nurse leaders invest the time in doing the validation but use too soft of an approach to get the real value. For instance: "Sara, I appreciate being able to shadow you and validate your hourly rounding skills. I think you did a great job. The only thing I didn't see you do was a scan of the environment to check for safety and things within reach. I'll go ahead and sign off but please be sure to do them next time." In this case, we have left open the door for Sara to continue to forget to use one of the eight behaviours of hourly rounds. Most clinicians are very accustomed to the approach taken for achieving certifications. That is, you need to be 100 percent correct to pass certification. You would never be certified and have them say, "You were pretty close on that dose of medication; just be sure to check closer next time." If you are validating skills, take the certification approach and give specific and immediate feedback on each behaviour. This way the staff will know what they are doing well and what they need to do differently. With diligence in validating skills, a tighter discipline to get all behaviours done well, and verification that they are actually occurring with every patient...the results will come. Yes, validation takes time but it's worth it. If the validation is so critical why do we have such a hard time doing it? The most obvious answer is time. Validating skills, particularly directly by observation, is certainly an investment in time, but those organisations that bite the bullet and get it done will tell you the results they get far outweigh the time spent. Trust Your Staff, but Check. Many nurse leaders will tell you, "When I verify that these processes are taking place, the staff feel like I don't trust them. They think I am checking up on them." Well...that's because you are but it's the right thing to do. After all, we trust that a doctor will do a history and physical assessment on every patient, but we still verify that he has done it. And we trust that a pilot will do his pre flight checklist, but, again, we verify. As a leader on your unit, you have the ultimate responsibility for the competency of your staff. For critical skills a "trust but check" approach is necessary.
Page 6 Final Checklist to Hardwire Quality Improvement Through Validation Review your current validation processes in your own organisation using the following checklist: Are documents like rounding logs consistently completed and checked? Sometimes Usually Always Are the unit managers rounding with patients consistently? Are unit managers regularly assessing and discussing the outcomes on the unit? Are external leaders rounding with patients? (DON, quality manager) Are patients receiving discharge calls that contain validation questions? Have the behavioural tactics been incorporated as annual competencies, like other skill areas? When behaviour does not meet the requirements is action taken? Now ask yourself, if I answered any of these statements with anything less than Always, that means I am receiving average performance at best from my leaders, then how can I ever expect to get anything better than average results from my quality improvement initiatives?