Hourly Visits to Patients Result in Higher Satisfaction

A couple of months ago my hospital initiated a new process to improve patient satisfaction and care.  It’s called “hourly rounding” and essentially requires a nurse or other caregiver (such as a CNA or PCT) to visit every patient once an hour in order to inquire about their needs.  Specifically the caregiver addresses the 5 P’s: pain, potty, position, periphery, and parting.  By inquiring about pain control, the nurse is able to give medicine to provide comfort before the pain becomes unbearable.  This is one the major concerns of patients in hospitals.  By asking about the need to visit the toilet, the caregiver may avoid a fall by a weak and unstable patient.  The position of the patient, especially someone who is immobile, must be altered routinely to prevent pressure sores; even a more ambulatory patient may need their pillow adjusted or their bed raised.  By assessing the patient’s periphery (the condition of their room, cleanliness, tidiness, accessibility to remotes and call buttons) they add another level of comfort.  The parting comments of the nurse always include a question about any other needs the patient may have, such as, “Is there anything else I can do for you?” 

It’s remarkable how this hourly rounding has impacted the HCAHPS scores of our patients in such a short time.  They have jumped up dramatically in all of the domains (example: pain control, quietness, nurse communication, etc.)  Even the scores for doctor communication increased even though the doctors do not participate in hourly rounding.  The increased score for doctors may be due to a perception of overall communication about physician instructions based on conversations with the nurses. 

Hourly rounding is promoted by the Studer Group and our hospital required training for all nurses.  The class included information about other hospitals’ results that use it as well as effective patient communication methods.  There’s been strong support for the program and our patients love it. 

Working in the lab, I have little patient contact.  Regardless, every employee in our hospital has a vested interest in making sure that our patient satisfaction scores are high.  In the past I have felt frustrated that I could not influence patient satisfaction directly.  Now that we are shown the effects of hourly rounding on the HCAHPS scores, I am thrilled that we have a program that really has tangible effects on our scores.  I’m so excited to see progress and grateful that our administrators put in the effort to bring the program to our hospital.

I’ve heard that the nurses like hourly rounding because they feel more connected to their patients, they have fewer patient falls, and less interruptions due to patient call bells.  I’ve seen patient interviews that show a patient explaining their gratefulness for the nurse who visited frequently to relieve her fears and provide comfort.  This is a new program at my hospital, but I think it will continue and will remain a vital part of our patient satisfaction responsiveness.  It’s a good thing for everyone.

Adverse Events: The Patient Matters Most

Last year my daughter became suddenly ill.  Really sick.  She was in a coma without a clue as to why.  After tons of tests the doctor said it was viral encephalitis; she was unresponsive for a couple of days.  While she was in the hospital I watched everything like a hawk.  I took notes about every medication she received and every conversation we had with the intensive care staff.  I wanted to be an advocate for her care.  It was a horrible, frightening time. Three days later we were blessed.  She awoke but became restless and unreasonable.  After long hours at her bedside, we went to the cafeteria for dinner while she rested in bed.  In her delirium, she got out of bed, ripped out her central IV line and her catheter, and decided she was going home.  She was irrational and didn’t know what she was doing, but could have really caused herself physical harm. The nurses caught her and put her back in bed and got control of the situation.  We were informed about all this when we got back from dinner; it had all happened in an hour.  I was glad we were told about the incident and that they rectified the situation quickly and appropriately.  We were accepting of the situation and grateful for her care even after we were told of all that had taken place.  It was scary, but we were glad she was okay.  The nursing team did the right thing by keeping us informed and explaining everything that occurred.  It actually helped us trust them more.  

Adverse events in a hospital are considered those injuries that affect a patient due to the medical intervention.  These events are not planned.  They aren’t supposed to happen.  They are errors.  The tricky part about medical adverse events is that the patient is often ignorant to the procedures and medications that are used to treat the condition.  The patient puts his entire trust in the hands of the caregivers, assuming that the right care will be given.  He is totally vulnerable.  

As a hospital leader I consider patient safety one of the most important aspects of my job.  My work requires me to review all errors that are reported by staff members in my department.  There are about 300 per month.  Some are really minor: a word spelled wrong in a report with no impact on the meaning, a wrong sample collection time recorded in the computer that gets corrected within the shift, or a biopsy sent through the tube system instead of by courier.  These represent a deviation from our standard operating procedure and are recorded so that we can track and trend the problem and address those that float to the top.  Other errors are more serious.  They are an adverse event.  When I am informed of these serious errors they make my heart sink.  I worry for the patient and I investigate the issue inside and out.  One thing that really bothers me is mislabeled samples.  I fear that the wrong results will be reported on a patient just because a sample had the wrong label.  The treatment provided may really belong to someone else.  There’s a big potential for harm.  I worry and I struggle to prevent it again. 

This leads to the question about whose perspective is the most important when determining whether an adverse event has occurred.  It would be easy to say that I, the healthcare provider, am the most important because of the broad and deep knowledge required to even understand that an error in treatment has occurred.  Some would argue that the view of the doctor, nurse, administrator or risk manager will matter the most since they know best about optimal medical interventions. Others will contend that regulators, judges, or lawyers are the ones that matter most since they will be the ones to take legal action against the offender.

I disagree.  If I, as a patient, am ignorant to the details of my medical care, I won’t know whether my treatment is appropriate or whether it is totally off-base.  I won’t know that my sample was mislabeled until it’s too late.  Even if the patient is not a healthcare professional, and his understanding of medical treatment protocols is negligible, his perspective is most important.  It may be that the patient discovers the error himself and informs his caregiver of the problem (such as wrong medicines or wrong operations).  This would certainly validate that his perspective is most important.  It could be that the hospital staff must reveal the adverse event to the patient (as when our daughter jumped out of bed and ripped out the lines).  When this is exposed, the patient’s response becomes most important.  If the patient is not understanding and forgiving, he may decide to take legal action, therefore, managing the conversation and the patient’s reaction is vital to reducing the risk of litigation.  The reason for admitting the error is not only for regulatory reasons or for mitigating legal action, but also because it is the right thing to do.  The patient will decide whether the event is tolerable (and forgivable) or whether restitution is more acceptable.  The patient has the most important point of view when considering adverse events.  It’s the healthcare provider’s obligation to review the facts, address the problem, and compensate the patient properly.

Will Pay-for-Performance Improve Quality?

In October 2012 Medicare’s Value-Based Purchasing program will begin.  Institutions will be paid based on their scores for the patient satisfaction HCAHPS survey and the core measures for clinical care in certain DRG’s.  This method of payment is meant to positively influence healthcare quality and service levels.  It is a critical phase in our healthcare reform journey.  The impact of this reimbursement method is causing a lot of angst among the healthcare financial community. 

The interesting thing is that there is no proven model to obtain optimum scores.  Everyone is scurrying to figure out the best way to achieve success in each of the HCAHPS subcategories and all of the core measures.  A couple of studies have shown that incentive programs have nominal impact on quality.  A pay for performance project in California showed no improvement in the quality measures after three years.  The CMS demonstration project had some early success with half of the hospitals showing improved quality measures with the incentive program, but it fell apart by the five-year mark.  The hospitals had all reverted back to their original levels.  This shows that there was early enthusiasm for the program, but the gains could not be sustained.  These disappointing results make healthcare administrators skeptical about their own prospects for success with the pay for performance program. 

There are many studies that describe the influence that monetary incentives have on employee performance.  It can be a strong motivator for change, but for large institutions like hospitals this concept gets lost.  There doesn’t seem to be a correlation between the amount of the financial incentive and the amount of attributable improvements.  Small incentives yield the same performance improvements as larger ones. 

The changes needed to impact the scores will take time, but the deadline is approaching.  Large hospitals have had trouble translating the necessity for improved quality measures into processes that actually deliver.  Hospital leaders and staff are aware of the connection between quality scores and the amount of financial incentive, but the steps and workflow changes that must be implemented to improve the scores is mired in bureaucracy and the complexity of the care process.  Smaller hospitals will probably have less difficulty with the change process; large integrated networks will struggle.  Hospitals that already have quality improvement programs embedded in their culture will be able to adjust more quickly.  In hospitals with weak process improvement programs, this will be difficult.  At my hospital we have invested a lot of effort into improving the patient satisfaction HCAHPS scores.  It has been more of a struggle than improving the clinical measures that had already been an integral part of the quality assurance program.  The important point is that we are taking action before the pay for performance program is fully implemented so that we can make improvements ahead of the implementation.

Quality...

Quality is a nebulous concept.  What it means to me may mean something different to someone else.  In my own experiences I can identify high quality in well-made clothing, good restaurants, and nice cars.  I know that I often pay more for higher quality because I know the product will be better than others.  It will be excellent.  Superior.  The same every time.  Without defects.  I know when I’m treated right that I feel good leaving an encounter.  That’s quality customer service!  But quality can be hidden sometimes.  When I purchase a product for the first time, I may not know its quality level until after I use it.  Because of this, I love Consumer Reports.  It helps me find tested, quality products without the trial and error. 

 

I reflect on all these aspects as I think about healthcare quality.  How is it defined?  I think high quality is related to a superior patient experience, best clinical outcomes, lowest error rates, and a pleasant environment.  I work in the laboratory of a large hospital.  We have a constant focus on quality results.  This means that we provide accurate results in a timely fashion.  We strive to keep errors to a minimum and get the results to the nurse and doctor quickly.  A bad lab result can kill a patient, so there’s no room for error.  Our lab has many certifications, licenses, and accreditations.  These are distinctions that prove our quality, but we are constantly reviewing our metrics and scorecard to continually improve.  In my job I will never concede to lower quality.  It always comes first.

Hospitals that are Baldridge winners and ISO 9001 certified automatically are perceived as being higher quality institutions.  We’re striving for the same at my hospital.  The public may not know what these awards mean, but we do.  I think publicly reported measures are a great way for the public to understand the quality level of a hospital.  Just like Consumer Reports, these reports can provide quick guidance on the best place to get healthcare.  Patient satisfaction scores are now listed on the internet.  When we first saw the low HCAHPS scores from our hospital, we were horrified.  Then reality set in.  We are not meeting the expectations of our patients and we need to change.  If we are to achieve the highest quality, we need to impress our patients and exceed their expectations--- just like a fine hotel strives to go above and beyond in order to get repeat business.

I’ve been a patient in the hospital too.  It’s interesting being on the other side.  I noticed that I didn’t want to speak up to correct my nurse who was not using the best process or to ask a doctor to explain again the medications.  I hesitated because I didn’t want retaliation or to be perceived as a complainer.  I think many patients feel like this.  I think this needs to change.  As a patient, we should decrease tolerance for improper technique or attitudes.  We should speak up.  As a hospital staff member, we should keep the lines of communication with the patient and the family open and transparent.  We should encourage patients to tell us their concerns, so that we can overcome any bad impressions and move forward.  I think clinical quality has been easier to achieve than patient satisfaction.  We have a lot to learn about customizing our care.

 I have found that good quality often correlates to higher price.  I want to find a good deal just like the next guy, but, in general I find that I must pay a higher price to get the higher quality item.  Like my Coach purse or my Lexus SUV.  I’m not being pretentious.  I’m being sensible.  I know my purse and my car will last a long, long time because of their quality.  When I was first married we couldn’t afford good furniture, so we bought lower-end furniture.  It was crap and fell apart in a couple of years.  The fabric was not durable.  After growing in our careers and making more money, we bought nicer, higher quality furniture and paid more for it.  We’ve had that furniture for over ten years and it still looks great!  

Although I admit to paying more for higher quality products at home, I’m not convinced that higher cost correlates to higher quality in healthcare.  Previously, I listed several criteria that I think relate to healthcare quality.  Price wasn't one of them.  It is clear that the U.S. pays more per capita on healthcare, yet does not have the best outcomes to match.  This is where American healthcare needs to improve.  We need to be more efficient, promote preventive medicine, manage chronic diseases better, and provide universal access.  This will make progress in creating value for our healthcare dollars.