Redesigning Care Together: Measuring and capturing the impact

Redesigning Care Together: Measuring and capturing the impact Sophie Baillargeon, Assistant to the Director of Nursing, McGill University Health Centre (MUHC) Maria Judd, Senior Director, Patient Engagement and Improvement, Canadian Foundation for Healthcare Improvement (CFHI) @CFHI_FCASS

Objectives 1. Clarify concepts related to patient- and family- centred care 2. Share experience supporting patient engagement projects and how captured and measured impacts 3. Highlight measurable improvements and organizational impacts made by patients and staff at the McGill University Hospital 3

3 inter-related concepts = an important lever for quality improvement i. Patient experience ii. Patient- and family-centred care iii. Patient engagement 5

Patient Experience One Heart Two Hands Patient & Family Centred Care: Improving quality outcomes by helping care providers engage effectively with patients at the point of care. Patient Engagement: Improving quality outcomes by helping people engage effectively together at the planning table. 6

ii. Patient Experience 7

iii. Patient Engagement Patient engagement is the involvement of patients and/or family members in decision making and active participation in a range of activities (e.g. planning, evaluation, care, research, training, and recruitment) starting from the expertise by experience of the person, in collaboration with, and as equal partners of professionals. Adapted from Tambuyzer A, Pieters G, Van Audenhove C, Patient involvement in mental health care: one size does not fit all, Health Expectations, (2011): 5. 8

In my organization Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree Patients and families are involved in quality improvement initiatives 5.4% (2) 18.9% (7) 16.2% (6) 40.5% (15) 18.9% (7) We measure the patient experience and set patient experience improvement goals 2.8% (1) 25% (9) 22.2% (8) 38.9% (14) 11.1% (4) Patients and families are involved in developing the questions and formats for tools that measure patient and family perceptions of the experience of care 8.1% (3) 35.1% (13) 21.6% (8) 27.0% (10) 8.1% (3) Patients and families assist in responding and finding solutions to information gathered through mechanisms that measure patient and family perceptions on the experience of care 5.4% (2) 27.0% (10) 24.3% (9) 40.5% (15) 2.7% (1) Our patients are meaningfully involved in decision-making regarding their own care across services 2.7% (1) 16 2% (6) 21.6% (8) 37.8% (14) 21.6% (8)

CFHI key questions How can we meaningfully engage patients in improving healthcare (design, delivery and evaluation)? What difference does their involvement make? How do we share what we re learning? 11

Patient Engagement Projects (PEP) Overall intent: Uncover and disseminate lessons learned and promising practices leading to care that is truly patient-centred. Key objectives: Support the development, implementation and evaluation of patient engagement interventions for health services whose goal is to improve the quality of patient- and family-centred care services Enhance organizations capacity to engage patients in the design, delivery and evaluation of healthcare Increase knowledge of promising patient engagement strategies that ensure patients are at the core of health services, and about how and why such strategies may be effective 12

Accompanying Research 1. Literature Review 3. Interviews with Experts Inform 2. Web 2.0 Engagement Strategies 4. Case Studies of Innovative Practices 5. Qualitative Analysis of the PEP Teams

PEP Outcomes Three types of outcomes: Improvements to engagement itself Improvements to the patient experience (via multiple dimensions of quality) Organizational impacts (changes in culture and practice)

Tambuyzer, Pieters and Van Audenhove (2011) Patient involvement in mental health care: one size does not fit all, Health Expectations 15

Patient Engagement Continuum 17 Anu MacIntosh-Murray, PEP Qualitative Analysis, 2010-2013

Reflection Question What would it take in my area of work to facilitate patient engagement in our improvement processes? 18

McGill University Health Centre: Co-designing Inpatient Care with Patients @CFHI_FCASS

The MUHC (2013) Montreal Children s Hospital (1912) Royal Victoria Hospital (1893) Montreal General Hospital (1955) Montreal Neurological Hospital (1934) Lachine Hospital & Camille-Lefebvre Pavilion (1913) Montreal Chest Institute (1931 & 1956) 20

MUHC Redevelopment: March 2015 The Glen Campus (RVH, MCI, MCH): Summer 2015 Mtl Neurological Montreal General Lachine

Transforming Care at the Bedside (TCAB) Developed in 2003 by the Institute for Healthcare Improvement (IHI), funded by Robert Wood Johnson Foundation to revitalize care on medical & surgical units and places care improvements in hands of the frontline staff 5 Pillars of TCAB Transformational Leadership Competencies Value-Added Care Processes Safe & Reliable Care Patient & Family Centered Care Teamwork & Vitality

Project Objectives Objective # 1 Objective # 2 Objective # 3 Understand the inpatient experience through the eyes of patients & families Deeply engage patients & families, along with staff, in reshaping care processes that respond to their real needs, thus improving: safety, access & work environment. Increase RN time in direct care

Implementation Plan (2010-2014) Wave 1: 5 units (3 sites): Medicine/Surgery New: Psychiatry Wave 2: 3 units (3 sites) Medicine New: Pediatrics Wave 3: 8 units (3 sites) Medicine/Surgery New: OR/HD/ER Teams consist of: 1 Nurse Manager 1 Asst. NM (CNS or NPDE) 2 Nurses 1 Patient Attendant 1 Unit Coordinator 2 Patient representatives Physicians Rehab therapists, social worker, dietician One day/wk staff & pt reps tested improvement ideas

Tools and Measurements Modules/Interventions: Act # 1:PDSA + Quality Indicator Study Do # 2: 5S Sort, Set, Shine, Standardize, Sustain # 3: Pt Experience of care Whiteboards, Comfort Rounds & Therapeutic Questions # 4: Admission & Discharge process mapping Plan Measurements: Staff: RN Time in direct & value-add care using PDAs Vitality Survey, focus groups Teamwork, recognition, turnover, OT, absenteeism Patients Patient Narratives HCAHPS Survey: Hospital Consumer Assessment of Healthcare Providers and Systems Patient Activation Measure Measure of Processes of Care

TCAB/PEP Journey: The Patient and Staff Nurse Voices 26

Results

Module 1: PDSA Applying PDSA to test, measure, adjust & maintain new processes while engaging stakeholders Ex: Use of SBAR to Reduce Time of Report Pre : avg. 34 min Post : avg. 17 min * SBAR = situation, background, assessment, recommendation

PDSA: The Difference PRE POST Call bells 5 1 Time to respond 1 min 10 sec Right away Time 1 st RN rounds 7:50 7:30 Time last RN rounds 8:30 7:40 While doing a SPOT CHECK a nurse saw a patient laying on the bed who was unable to use the call bell, vomitting and needing help.

Reducing Non-Value Time: Equipment Relocation Time saved in a yr = 1,100 hours or 0.7 FTE No more tests or treatments cancelled because wheelchair could not be located

New Team Admission in Mental Health: Clinical Efficiency Serial interviews (4.3 hr) replaced by team interview with patient (1 hr) Pre Post 5 4 4.23 Hours 3 2 Time Saved: 300 adm/yr x 4.23 hrs = 0.7 FTE 1 0 1 hr

Module 2: Improving the Physical Environment Using 5S: Sort, Set, Shine, Standardize, Before Sustain After Storage room where equipment was inaccessible, getting damaged and creating a hazard for staff

5S-Measures: Dressing Cupboards Pre Post

5S:Patient Redesign of Family Visiting Room Pre Post Pre: - Visitors room and OR prep room -Sharps containers and cancer pamphlets on walls Post: Example of nothing about me without me approach to redesign

5S:Patient Redesign of Alcove

Module 3: Patient Experience of Care Implementing bundled interventions to improve patient experience of care, including use of whiteboards, comfort rounds and therapeutic questions Ex: whiteboard with basic and complex information, including: date, names of care team and phone number diagram of upcoming surgical procedure

Whiteboards: 2 way Communication Tool Whiteboards adopted by patients and their families to communicate with care team and to provide support and encouragement for each other

Patient Experience of Care 3 Therapeutic Questions: 1. What is your greatest concern right now? 2. What information do you need that would be the most helpful? 3. What do you need from me right now that would help you?

Improving Admissions & Discharges: Inter-professional Collaboration Multidisciplinary Team Process Mapping Creating process maps to identify waste and opportunities for standardization and improvement

Process Map Ex: Discharge Swim lane efore After

Process Map Ex: Discharge Swim lane BEFORE AFTER

Discharge Checklist: Developed by Patients for Patients While in hospital Ask your doctor for planned date of discharge. Remind healthcare team to enter planned date of discharge on whiteboard Done The date of discharge should be updated daily on the whiteboard. Communicate to the hc team your needs regarding discharge i.e.date, transport, clothes, help at home, caring for yourself after return home Ask the doctor for time off work letter, if needed. Get someone to drop off insurance papers at you doctor s office Day of discharge Make sure you have the prescriptions to prevent pain & constipation Ask about restarting medications you were taking before admission. Make sure you understand any changes in the medication you were taking before your admission (if applicable). Make sure you have follow-up appointments, if needed. Review discharge teaching sheet with the nurse.

Quality Indicator: Pain MUHC pain pamphlets are now routinely added to admission packages. This allows nurses to review the content of the pamphlet and pain scale with patients at the bedside.

Quality Indicator: Pain 120% 100% 80% 60% 40% 20% MNH- 3 South Documentation of Pain after Intervention % Noté apres l'intervention / % Documented after intervention Objective / Goal 0% Nov 20th 2012 Nov 27th 2012 Dec 11th 2012 Dec 18th 2012 Jan 29th 2013 Feb 26th 2013 Mar 19th 2013

Quality Indicator: Pain 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% MNH- 3 South % of Patients knowing to call a Nurse when Pain Reaches 3/10 or more Nov 20th 2012 Nov 27th 2012 Dec 11th 2012 Dec 18th 2012 Jan 29th 2013 Feb 26th 2013 Mar 19th 2013 % des patients / % of patients Objective / Goal

Results: Direct Time in Care (using PDAs) 60% Time in Direct Care Results and Trend - Summary 52.2% 53.4% 51.3% 8% 50% 44.0% 43.3% 46.1% 40% % of Time 30% 20% 10% 0% 15.4% 15.7% 13.8% 13.5% 16.6% 12.7% 12.2% 13.0% 14.7% 12.9% 12.6% 10.1% 6.6% 6.5% 6.6% 5.8% 6.4% 5.7% 1.7% 1.9% 1.9% 2.0% 2.1% 4.9% Aug. 2010 Dec. 2010 July 2011 Dec. 2011 Mar. 2012 Study Dates 50% Direct Care Activities Indirect Care Activities Waste Activities Administrative Documentation 46

HCAHPS Results: Responsiveness Q: During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? Q: How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? (never, sometimes, usually, always) % of patients selecting top score 120 100 80 60 40 20 Responsiveness (n=287) 20% improvement 0 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 Financial Periods US Benchmark Aggregate 5 units Agg excl. Psych

HCAHPS: Medication Communication Q. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Q. Before giving you any new medicine, how often did hospital staff describe side effects in a way you could understand? Medication Communication (n=245) % of patients selecting top score 100 80 60 40 20 0 9 10 11 12 13 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 Financial Periods US Benchmark Aggregate 5 Units Agg excl Psych 10% improvement

Progress Markers = Ladder of Change Love to See Like to See Expect to See Love to See Like to See Expect to See Truly transformative change More active engagement and learning Early response to basic activities 49

MUHC Progress Markers Love Love to to See See Truly transformative Change Pt. Reps help the teams to problem-solve challenges and generate new processes of care improvement Like to to See See Expect to to See More active engagement and learning Pt. Reps participate in discussions and provide new perspectives Pt. Reps are informed of the TCAB meeting dates The meeting room accomodates wheelchairs Pt. Reps understands the issues and ideas that are being discussed 50

Successful Partnerships in Co-Designing Care Thank you for giving us this project. We are discovering our strengths and we are working together. Who would have thought this would be possible? (Co-President, MUHC Patients Committee)

Elements of Success Extensive stakeholder engagement Protected release time & facilitator support critical Clear deliverables for each module & provide Coaching on how to conduct simple measurements that are meaningful to frontline staff Communicating the achievements at all levels Support of Senior Leadership

Lessons Learned: Patients Patient perspectives are often different. Codesigning processes together led to respect, better ideas, new partnerships. Many patients want to be engaged in their health care treatment plans TCAB has been a wonderful opportunity to not only engage the patient, but partner with them as well

Lessons Learned: Teams Real empowerment and obvious pride from TCAB teams to implement changes and to present their findings at the end of each module Learning new skills such as: Change Management Rapid cycles improvement and LEAN tools Resistance management and conflict negotiation Understanding of the experience of patient care (integration of patients in changes) Sustainability of newly acquired skills and knowledge

Thanks to Generous Donors & Supporters Canadian Foundation for Healthcare Improvement Max Bell Foundation Canadian Institutes for Health Research Newton Foundation, Mtl General Hospital Foundation Roasters Foundation, RVH Foundation MUHC: Executive, Many leaders, Patient Committees

Spreading change Improvement On Call: Patient Engagement Webinar Series Patient Engagement Impact Stories and Videos Patient Engagement Resource Hub Ingredients to successful patient engagement PEP I teams (2012) Ingredients to successful patient engagement, http://www.cfhi-fcass.ca/whatwedo/collaborations/patientengagement.aspx Patient Engagement Learning Collaborative (new!)

Reflection & Discussion Questions What would it take in my area of work to facilitate patient engagement in our improvement processes? What will I do next week to advance person- and family-centred care?

Thank you! www.cfhi-fcass.ca Contact: Maria Judd, CFHI Maria.Judd@cfhi-fcass.ca

Appendix (additional slides)

Patient-centred care Health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care. Institute of Medicine, Crossing the Quality Chasm, 2001 is about engaging the hearts and minds of those you work with and those you care for Planetree/Picker

i. Patient- and Family-Centred Care Respect and dignity. Listen to and honour patient and family perspectives. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated. Information Sharing. Communicate and share complete and unbiased information with patients and families in useful, affirming ways. Provide timely, complete, and accurate information to support effective participation. Participation. Patients and families are encouraged and supported in participating in care and decision-making at the level they choose. Collaboration. Collaborate with patients and families in policy and program development, implementation, and evaluation; in health care facility design; and in professional education, as well as in the delivery of care. Institute for Patient- and Family-Centered Care http://www.ipfcc.org 62

How Do We Capture the Impact? Progress Markers A graduated set of statements describing a progression of changed behaviours (actions and practices) in a boundary partner Moves from easier to more difficult to achieve changes in actions, activities and relationships leading to the ideal outcome Demonstrates visually the complexity of the change process 63

Outcome Documentation Form http://www.wish-qatar.org/forums/patientengagement/forum-members 65

Lessons Learned Create space and time for reflection Involve your quality improvement specialists Ensure provision of the necessary resources, knowledge and skills to address the challenges we face Patient engagement must be hard-wired into the everyday structure and culture of our organizations PEP I teams (2012) Ingredients to successful patient engagement, http://www.cfhi-fcass.ca/whatwedo/collaborations/patientengagement.aspx 66