nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 1

Phelps Memorial Hospital Center 5 South Bernadette Hogan, RN, Nurse Manager, Telemetry Mariel Consagra, RN, Anne Moss, RN Blessy Jacob, Pharm D, Clinical Pharmacy Coordinator Demographics 283 acute care community hospital 1,750 employees Set on 69 acres in Westchester County New York Built in 1956 Affiliated with North Shore-LIJ 1/2015 The NYMC Phelps Family Medicine Residency Program, is the first such program to be established in New York State in over 20 years Organizational Accomplishments Phelps Stroke Center Receives - Gold Plus Award from - American Heart/ American - Stroke Associations Cardiology accredited in echocardiography by the Intersocietal Accreditation Commission (IAC) nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 1

Organizational Accomplishments NICHE Exemplar Status ACR Designation- Radiology Screening Center of Excellence - Lung Cancer Alliance HealthStream s Excellence Through Innovation Award for Patient Experience Background 5 South is the Telemetry Unit at Phelps Memorial Hospital Center 5 South has historically had the lowest top box scores in the domain Communication about Medications in comparison to the other inpatient units. Our journey to improve our medication education scores began in November 2014 after being in the one percentile the previous 2 months for the Communication about Medication domain. Prior to this we had implemented many changes to our delivery of care, including hourly rounding, 15 min safety rounds, highlighting side effects on med sheets, using RELATE communication and words that work as well as narrating our care. As a result, many of our patient satisfaction results improved, but we did not see an improvement in the medication communication scores. Background 5 South is one of the busiest units at Phelps Hospital and has continuous activity and movement 24 hours a day. 5 South patients are for the most part, chronically, critically ill. We knew something had to be implemented to improve patient understanding of medications upon discharge. We also knew that it would be difficult due to the low health care literacy of patients in the United States Discharge phone call feedback, PG results and readmission rates confirmed this nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 2

OUR Goal Achieve the 60 th percentile or greater on the domain Communication about Medication in the ALL PG DATABASE with a stretch goal of 70 th percentile By 4 th Quarter 2015 HCAHPS Matters Clinically HCAHPS Dimensions HCAHPS Questions Communication with Nurses * Communication with Doctors Responsiveness of Hospital Staff * Pain Management * Communication About Medicines * Communication About Medications * Hospital Environment Discharge Information * Overall Hospital Ratings Nurse Courteous and Respectful Nurse Listens Carefully Nurse Explains Things Doctor Courteous and Respectful Doctor Listens Carefully Doctor Explains Things Assistance to Bathroom Response to Call Button Pain Well Controlled Help With Pain Explain new New medications Medications Explain new New medication Medication side Side effects Effects Cleanliness of room Cleanliness of bathroom Discharge Help Discharge Symptoms Overall Hospital Ratings Willingness to Recommend * Designates Patient Care Dimensions related to the Magnet Sources of Evidence nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 3

HCAHPS Primary Rating Scale Always Usually Sometimes Never Always is the only score that counts! Communication about Medications 15. During this hospital stay, were you given any medicine that you had not taken before? Screening Question. 1 Yes 2 No If No, Go to Question 18 16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? 1 Never 2 Sometimes 3 Usually 4 Always 17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? 1 Never 2 Sometimes 3 Usually 4 Always WE NEED TO KNOW WHAT PATIENTS DON T KNOW communication discrepancies between physicians and hospitalized patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 57% 77% 18% 67% Patient Correctly Identified Physician Thought Patient Knew 10% 0% Diagnosis Name of Physician Source: Olson DP and Windish DM, Communication Discrepancies Between Physicians and Hospitalized Patients Arch Intern Med 2010; 170 (15): 1302-1307 nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 4

Unit Education for RN s on medication administration with return demo Morning Rounds (Manager, RN Coordinator, Case Manager) to include medication discussion Daily Medication Education by our Pharmacist, Blessy Jacob Medication Education Brochure (by drug indication) Medication Communication Board (information same as brochure) Patient Friendly Medication Education Sheets (what medication is for and possible side effects) Medication Hotline Patient Get Well Cards STRATEGIES Pre Discharge Visit from TO RN ACHIEVE Coordinator OUR GOAL Discharge Phone Calls (added medication focus) New Discharge Checklist Unit Education Unit Education Safe medication administration practices were reviewed with all RN s on the unit We had each nurse complete a return demonstration of how they would administer medications The nurses were instructed to ALWAYS tell the patient what the medication is for and to let them know at least one possible side effect We also reviewed Teach Back method to ensure the patient has a good understanding of each of their medications We role played and performed random observation to ensure compliance Morning Rounds The manager, Case Manager and RN Coordinator implemented morning rounds During these rounds we discuss all aspects of care We discuss the patients current medications and answer any questions they may have We ask if they have been educated on the medications and side effects They are also asked if they can tell us about their medications nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 5

Daily Rounds on the Unit by Pharmacist Blessy, our pharmacist, comes to 5 South daily and has a discussion with each nurse regarding their patients Nurses identify patients that have been started on new medications Blessy meets with patients one on one, and family members, if possible, to educate them stressing what the medication is for and possible side effects Blessy gives patient and/or family an opportunity to ask questions Studies have consistently shown that Pharmacists can increase medication compliance and decrease readmission rates by counseling patients about the purpose, use, most common side effects and management of side effects for their medications [1] Medication education by pharmacists can help prevent medication errors after discharge 1. Griffith NL, Schommer JC, Wirsching RG (1998) Survey of inpatient counseling by hospital pharmacists. Am J Health Syst Pharm 55: 1127-1133. Medication Education Brochure Quick Reference guide to medications and their side effects This reference guide was shared with us by HVHC (Hudson Valley Hospital Center) The guide is a quick reference to medications and their side effects It is divided into 3 sections * indication for medication * medication names (generic and trade names) * most common side effects nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 6

Medication Education Board The board is located in the center of the 5 South hallway across from the nursing station This board was designed to look like the medication brochure It contains the same information as the brochure Patients and families are instructed to stop and read it when ambulating in the hall The purpose of the board was to reinforce the brochure and promote conversation/questions about medications The patients and families refer to the board frequently Medication Education Board 5 South Banner located above the Medication Board nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 7

Patient Friendly Medication Education Sheets 5 South patients are chronically, critically ill These sheets were designed to simplify information on medications Patients are handed patient care notes or lexicomp information on medications which are too lengthy and frequently overwhelm the typical 5 South patient These are 1 page sheets with drug name, use, and possible side effects Drug Name: Azithromycin injection, suspension and tablet (Zithromax) What is this medication used for: This medication is a macrolide antibiotic Treatment of a variety of bacterial infections Possible Side Effects: Skin rash Nausea, vomiting, diarrhea, upset stomach, stomach pain Local inflammation, pain at injection site (IV administration) Disclaimer: The information above lists some of the more common indications and possible side effects of the medication. It is not intended to be an all-inclusive listing. For a detailed description please refer to the prescribing information supplied or check with your Doctor or Pharmacist. Drug Name: Metformin Glucophage, Glucophage XR) What is this medication used for: This medication is used for the treatment of Type 2 Diabetes Mellitus (to lower blood sugar) Possible Side Effects: Diarrhea, nausea/vomiting, flatulence, stomach pain/discomfort Headache, dizziness, lightheadedness, weakness Metallic taste in the mouth Disclaimer: The information above lists some of the more common indications and possible side effects of the medication. It is not intended to be an all-inclusive listing. For a detailed description please refer to the prescribing information supplied or check with your Doctor or Pharmacist. nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 8

Get well cards Get Well Cards Made to distribute to patients during hospitalization Lets the patient know that they can ask questions about medications and their side effects Contains business cards for Bernadette and Blessy Also contains the Medication Hotline for questions they may have after discharge nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 9

Pre-Discharge Visit from the RN Coordinator Arlene, the RN Coordinator visits each patient prior to discharge During this visit she introduces herself She discusses discharge medications She makes the patient aware that she will be calling within 1-2 days to see how they are doing She also lets them know she will be asking about their medications and side effects Discharge Phone Calls 1-2 days post discharge, Arlene calls the patient and discusses their hospital stay, their perception of the quality of care, and inquires if there is anything we could have done better She asks if there is anyone that should be recognized for exceptional care We added medication questions to the discharge phone call script * Were you able to fill your prescriptions? * Can you tell me what new medications you are taking and their side effects? * Do you have any questions about your medications? Discharge Checklist The discharge checklist was revised to include an area for patients or family members to write any questions they may have for RN, Pharmacist or Physician The new checklist lets the patient know that they are an important part of their healthcare team The checklist also includes words that work and the medication hotline number nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 10

Obstacles Low (n) number of responses to patient satisfaction survey Skewed results due to patients transferring off the unit right before discharge Confused patients Families answering the survey Sick Calls Vacations Language Barriers Time it is taking to implement all strategies Educating all staff and ensuring adherence to plan Ability to have side effect added to EMAR HCAHPS Quarterly Comparison Top Box Percentile rank 5 south Quarter 1-2015 Top Box Percentile All PG Data Base Quarter 2-2015 Top Box Percentile All PG Data Base Quarter 3-2015 Top Box Percentile All PG Data Base Communicat ion about Meds Tell you what medicine was for Staff describe medicine side effects 35 77 72 WE REACHED OUR GOAL! 66 80 71 18 73 71 HCAHPS Quarterly Comparison Top Box Percentile 5 south Quarter 1 2014 Top Box % PMHC Peer Quarter 1 2015 Top Box % PMHC Peer Quarter 1 2014 Top Box Percentage Quarter 1 2015 Top Box Percentage Communicat ion about Meds 1 38 40.2% 56.7% Tell you what medicine was for 1 40 50.0% 73.3% Staff HCAhPS Quarterly Comparison describe medicine side effects 1 26 30.4% 40.0% N=24 N=15 nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 11

Press Ganey HCAHPS Summary Report Results Medication Communication July Sept 2015 Heading in the right direction Press Ganey HCAHPS Summary Report Results Nurse Communication July Sept 2015 Our improved Medication Communication has helped improve our Nurse Communication scores! Overall Inpatient Results Feb 2016 After rolling medication education tools to inpatient units Medication Education has helped improve top box scores and rankings in multiple domains nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 12

All DB N = 1897 NY Peer Group N = 124 NSLIJ Custom N = 12 PMHC Peer N = 7 Your Top Box Score Domains and Questions n Previous % Aug- Oct Current % Nov-Jan Percentile Percentile Percentile Percentile Rate hospital 0-10 224 66.1% 74.6% 60 86 91 83 Recommend the hospital 222 74.2% 78.4% 69 87 82 83 Comm w/ Nurses 225 77.2% 81.4% 62 85 91 83 Nurses treat with courtesy/respect 224 85.2% 89.3% 73 89 91 83 Nurses listen carefully to you 225 72.5% 74.7% 32 59 55 33 Nurses expl in way you understand 224 73.9% 80.4% 79 93 91 83 Response of Hosp Staff 200 62.7% 66.2% 47 76 91 67 Call button help soon as wanted it 187 63.1% 67.4% 63 82 91 83 Help toileting soon as you wanted 126 62.4% 65.1% 30 63 73 50 Pain Management 138 73.7% 77.8% 89 94 91 99 Pain well controlled 138 69.8% 75.4% 96 97 91 99 Staff do everything help with pain 137 77.6% 80.3% 59 87 91 99 Comm About Medicines 129 66.0% 67.0% 69 90 99 83 Tell you what new medicine was for 129 82.1% 78.3% 53 74 73 67 Staff describe medicine side effect 124 50.0% 55.6% 76 91 99 83 Discharge Information 192 88.7% 83.9% 17 49 82 67 Staff talk about help when you left 188 87.5% 80.9% 22 47 82 67 Info re symptoms/prob to look for 191 89.8% 86.9% 19 47 64 67 Feb 2016 Top Box Scores all inpatient units Our Next Steps Include hospitalists and residents in our morning rounds Addressing medication questions patients may have during rounding with hospitalists and residents TEAM up with hospitalists and residents to make sure patient knows the Physicians name, their diagnosis and any new meds ordered Initiate Discharge Checklist, Get Well Cards & Med Hotline Present at Patient Education Council Roll out on other units Be more diligent with patient focused rounding in order to gain insight into how our initiatives are working HCAHPS: Hospital CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS & Systems HCAHPS Can Also Mean nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 13

Going forward. Follow our scores on Press Ganey Survey Open to any suggestions from staff Encourage Senior Leaders that are rounding on the nursing units to please ask staff about our Med Ed initiatives Communicate results at all levels of the organization Connect the Dots for all staff Celebrate and share our successes The real voyage of discovery consists not in seeking new landscapes, but in having new eyes. Marcel Proust 41 Questions? nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 14