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Designing and Implementing a Patient Experience Bundle©
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April 3rd, 2019
Christina Mouradian, MSProgram Manager, Clinical Transformation
DISCLOSURE POLICY
Northwell Health adheres to the ACCME’s New Standards for Commercial Support. Any individuals in a position to control the content of a activity, including faculty, planners, reviewers or others are required to disclose all financial relationships with commercial interests. All relevant conflicts of interest will be resolved prior to the commencement of the activity.
The following Northwell employees have nothing to disclose:
Name RoleMartin Doerfler, MD Executive Sponsor
Nancy Riebling, MS AVP Improvement Science
Sherry Norouzzadeh, PhD Assistant Director Clinical Transformation
Christina Mouradian, MS Program Manager Improvement Science
George Reeder, RN Program Manager Improvement Science
Alison Hillier, BS Improvement Science Specialist
Ryan Cowan, PA-C, MBA Physician Assistant, Cardiology
Kendra Brereton, MS Improvement Science Specialist
1
Learning Objectives
• Understand how to use the bundle philosophy and process data to improve patient experience and “likelihood to recommend scores”
• Identification of key elements for a bundle approach to improving patient experience • Application of the Quick Start program to rapidly and successfully integrate meaningful
improvements using the Patient Experience Bundle© (PEB)
Overview
3
4
New York’s largest private employer and health care provider, with 23 hospitals and more than 700 outpatient facilities
Problem Background
• Six Sigma and Lean Projects at Northwell Health’s Emergency Departments (ED) to reduce the waiting time and number of holds (10/21 hospitals)
• 10% increase in patient volume
• Decreasing trend in patient satisfaction
Collaborative Work to Improve Patient Experience
Why use the Bundle Concept?
• Assists health care providers to more reliably deliver the best possible care to patients• Ties changes together into a package of associated interventions that must be
followed for every patient, every time• Bundle elements, when performed collectively and reliably, have been proven to
improve patient outcomes - Sepsis
• Incorporates the concept of roll throughput yield:
90% 90% 90% 90%
66%
0%
50%
100%
Element 1 Element 2 Element 3 Element 4 Overall
Overall Achievement with 90% Reliability
• When we operate in silos, 90% reliability at an individual process step would appear to be highly reliable
• However, when considered from a complete experience only 66% of patients receive the intended experience
Traditional Patient Satisfaction Approach
8
Exit
Do you know who your doctor is?
Do you know your plan of care?
Are your pain needs being managed?
How long did it take for your call bell needs to be met?
Are your food needs met?
Did you have a pillow/blanket when needed?
How long did it take for your bathroom needs to be met?
Was your personal privacy respected?
How was your experience?
Problems:1. Sample size2. Delayed feedback3. Too late to perform service recovery
Measured by 3rd
party survey vendors
Patient Experience Bundle© Approach
9
Exit
Do you know who your doctor is?
Do you know your plan of care?
Are your pain needs being managed?
How long did it take for your call bell needs to be met?
Are your food needs met?
Did you have a pillow/blanket when needed?
How long did it take for your bathroom needs to be met?
Was your personal privacy respected?
How was your experience?
Measured by 3rd
party survey vendors
Communication
Logistics
Basic Needs/ Comfort
Environment
Measure Patient Experience Bundle© Compliance in real time
for targeted service recovery
Patient Experience Bundle©
Comparing Approaches
• Post-discharge survey which only assesses outcome metric to represent level of patient satisfaction- Very satisfied or dissatisfied - Approximately 30% return rate
• Not real time and not specifically tied to process
• Service recovery approach for patient satisfaction
• Silo-ed tactic to address a connected experience
• Daily survey of all patients • Metric is real time, process driven
measure• Pro-active approach to improve patient
satisfaction• Cohesive approach to a unified patient
experience- Reinforces the interactions of
processes to collectively drive a single outcome
Traditional Patient Satisfaction Approach
Patient Experience Bundle©
Approach
A new approach to improving patient care was needed. The team took an innovative look at a more proactive and real-time approach to increase patient satisfaction across units in the Organization
Patient Experience Bundle©
Development
11
Patient Experience Bundle© Development
• Assemble and collate PGLTR scores and comments
• Conduct a literature review to establish benchmark
• Collect ED Holds information in Six Sigma methodology
• Update PGLTR scores and comments
• Collect ED Holds information in Six Sigma methodology
• Collect Floor Holds information in Six Sigma methodology
• Update PGLTR scores and comments
• Collect ED Holds information in Quick Start
• Collect Floor Holds information in Quick Start
12
Building the Model Validating the Model Expanding the Model
Criti
cal C
ompo
nent
sPa
rtici
patin
g Lo
catio
ns
• LHH• LIJMC• NSUH• SSH• SIUH
• HH• CCMC• PMHC• MMC• PBMC
QS 1• SH• PH• MMC• LIJFH
QS 2• GC• PBMC• LIJVS• SSH
QS 3• LIJFH• SIUH• LIJVS• SSH• MMH
Six Sigma Round 1
• Voice of Customer (VOC) to Critical to Quality (CTQ) Criticisms from patients were compiled, analyzed, and categorized to understand the drivers of dissatisfaction
LHH
SSH
LIJ
NSUH
SIUH
Summary of Common Themes
Defects Per Patient Service
Bundle
Communication
Environment
Basic Needs/Comfort
Logistics
Privacy
Toileting Needs
POC (MD to RN acknowledgement)
Rounding
Proper/Timely Med Administration
Dietary (hunger/Thirst)
Comfort Items
Response to calls/Request
TAT(request to tray delivery)
# times tray requested but not delivered
How long did it take to have your needs acknowledged? (<5 <15,<30,<60,>60,never)
Where were you located? (Holding Room, Main ED, Hallway)
What was your request? (Entertainment, Food, Bathroom, Other)
TAT (MD admit orders to RN acknowledgement)
# of MD pt rounds/shift
# of RN pt rounds/shift
Pain assessment level/RN rounds TAT ( STAT med order to administration time)
Did pt have requested number of pillow/sheets/blankets? (If no what were they missing Pillow/Sheet/Blanket)
TAT (laundry notification to linen delivery)
# times privacy curtain requested but not provided
# privacy curtains available
# times your toileting needs were not met/shift
# times dx/meds/results were explained to you per shift? (1,2,3,4,never)
# time refreshments/snacks offered/shift
“The Patient Experience Bundle©”
Sample Manual Surveys
• Each team designed a survey which at least included 8 questions related to bundle compliance
• Manual Data collection (patients surveys) • Daily bundle compliance calculated based on survey responses
Outcomes and Results
Bundle compliance improved from a range of 42%-67% to a range of 71%-88% and correlated with an increase in “likelihood to recommend”
80
81
82
83
84
85
86
87
0102030405060708090
Baseline
Post Im
prove
Control
Sustainabilit
y
PG S
core
(Lik
elih
ood
to
Reco
mm
end)
Bund
le C
ompl
ianc
e (A
vg, S
td) Hospital A
8585.58686.58787.58888.58989.590
0102030405060708090
Baseline
Post Im
prove
Control
Sustainabilit
y
PG S
core
(Lik
elih
ood
to
Reco
mm
end)
Bund
le C
ompl
ianc
e (A
vg, S
td) Hospital B
70727476788082848688
01020304050607080
Baseline
Post Im
prove
Control
Sustainabilit
y
PG S
core
(Lik
elih
ood
to
Reco
mm
end)
Bund
le C
ompl
ianc
e (A
vg, S
td) Hospital C
81.5
82
82.5
83
83.5
84
0102030405060708090
Baseline
Post Im
prove
Control
Sustainabilit
y
PG S
core
(Lik
elih
ood
to
Reco
mm
end)
Bund
le C
ompl
ianc
e (A
vg, S
td) Hospital D
767880828486889092
0102030405060708090
100
Baseline
Post Im
prove
Control
Sustainabilit
y
PG S
core
(Lik
elih
ood
to
Reco
mm
end)
Bund
le C
ompl
ianc
e (A
vg, S
td) Hospital E
Data is Collected: March 2015- April 2016
Patient Experience Bundle© Development
• Assemble and collate PGLTR scores and comments
• Conduct a literature review to establish benchmark
• Collect ED Holds information in Six Sigma methodology
• Update PGLTR scores and comments
• Collect ED Holds information in Six Sigma methodology
• Collect Floor Holds information in Six Sigma methodology
• Update PGLTR scores and comments
• Collect ED Holds information in Quick Start
• Collect Floor Holds information in Quick Start
17
Building the Model Validating the Model Expanding the Model
Criti
cal C
ompo
nent
sPa
rtici
patin
g Lo
catio
ns
• LHH• LIJMC• NSUH• SSH• SIUH
• HH• CCMC• PMHC• MMC• PBMC
QS 1• SH• PH• MMC• LIJFH
QS 2• GC• PBMC• LIJVS• SSH
QS 3• LIJFH• SIUH• LIJVS• SSH• MMH
Six Sigma Round 2
Huntington
MMC
CCMC
PBMCPMHC
ED
Inpatients
Summary of Common Themes
Defects Per Patient Service
Bundle
Communication
Environment
Basic Needs/Comfort
Logistics
Privacy
Toileting Needs
POC (MD to RN acknowledgement)
Rounding
Proper/Timely Med Administration
Dietary (hunger/Thirst)
Comfort Items
Response to calls/Request
TAT(request to tray delivery)
# times tray requested but not delivered
How long did it take to have your needs acknowledged? (<5 <15,<30,<60,>60,never)
Where were you located? (Holding Room, Main ED, Hallway)
What was your request? (Entertainment, Food, Bathroom, Other)
TAT (MD admit orders to RN acknowledgement)
# of MD pt rounds/shift
# of RN pt rounds/shift
Pain assessment level/RN rounds TAT ( STAT med order to administration time)
Did pt have requested number of pillow/sheets/blankets? (If no what were they missing Pillow/Sheet/Blanket)
TAT (laundry notification to linen delivery)
# times privacy curtain requested but not provided
# privacy curtains available
# times your toileting needs were not met/shift
# times dx/meds/results were explained to you per shift? (1,2,3,4,never)
# time refreshments/snacks offered/shift
“The Patient Experience Bundle©”
Outcome and Results
• Taking a closer look demonstrates congruent movement between PEB© compliance and PG Likelihood to Recommend scores
• Using the daily PEB© compliance score from the 2,758 patient surveys, the variation index, and standard deviation, the PEB © compliance score is predicting the PG LTR score
0102030405060708090
100
Apr2
017
Jul2
017
Oct
2017
Mar
2017
Jun2
017
Sep2
017
Jun2
017
Sep2
017
Jun2
015
Sep2
015
Jan2
016
May
2016
Aug2
016
Jan2
017
Apr2
017
Jul2
017
Oct
2017
Jul2
017
Oct
2017
Sep2
016
Dec2
016
Mar
2017
Jun2
017
Sep2
017
Oct
2016
Jan2
017
Apr2
017
Mar
2017
Sep2
017
A B C E G H I1 I2
%ile
Ran
king
Facilities and their participation duration
PG LTR vs. PEB Compliance Score
PG LTR
PEB
Expanding to Quick Start Program
21
Patient Experience Bundle© Development
• Assemble and collate PGLTR scores and comments
• Conduct a literature review to establish benchmark
• Collect ED Holds information in Six Sigma methodology
• Update PGLTR scores and comments
• Collect ED Holds information in Six Sigma methodology
• Collect Floor Holds information in Six Sigma methodology
• Update PGLTR scores and comments
• Collect ED Holds information in Quick Start
• Collect Floor Holds information in Quick Start
22
Building the Model Validating the Model Expanding the Model
Criti
cal C
ompo
nent
sPa
rtici
patin
g Lo
catio
ns
• LHH• LIJMC• NSUH• SSH• SIUH
• HH• CCMC• PMHC• MMC• PBMC
QS 1• SH• PH• MMC• LIJFH
QS 2• GC• PBMC• LIJVS• SSH
QS 3• LIJFH• SIUH• LIJVS• SSH• MMH
Book of Solutions
• The collective work from all teams was compiled and distilled into a collection of best practices
• Each bundle element has detailed examples of implemented solutions and contact information from the implementing site(s)
Quick Start Program Timeline
24
Survey data collection is continuous throughout timeline
Electronic Surveys
• Moving to electronic survey data collection will improve sustainability of the processes• Electronic data collection will feed to a graphical dashboard, supporting front line
clinical staff change efforts
Dashboard
26
Sustainability
“Pulse Checks”• Quarterly reports submitted by each
team and distributed to the Chief Operation Officer of Northwell Health
“Bring Back Day” • All participating teams brought back for
an in person presentation to senior leadership
All components of the Patient Experience Bundle© must be reliably in place to drive change in the outcomes
29
Breakout Activity
Communication
Logistics
Basic Needs/Comfort
Environment
Patient Experience Bundle© Survey Patient
Communication Logistics Basic Needs/ Comfort
Environment
123456789
10Total Sum
1 2 3 4 5 6 7 8 9 10
Patients to Survey
Survey the patients above by counting how many indicators, of each
color, a patient has. Tally the flags per patient in the table below:
Today’s date:
April 3rd, 2019CC C C C CC
LL L
L L
LL
L
BB
B
BB B
B
BB
EE EE E E EE E
C L B E
Communication
Logistics
Basic Needs/Comfort
Environment
Patient Experience Bundle© Survey Patient
Communication Logistics Basic Needs/ Comfort
Environment
1 1 1 12 1 1 13 1 1 14 1 1 1 15 1 1 16 1 1 1 17 1 1 18 1 1 19 1 1 1
10 1 1 1 1Total Sum 7 8 9 9
1 2 3 4 5 6 7 8 9 10
Patients to Survey
Today’s date:April 3rd, 2019
CC C C C CC
L L LL L
LL
LB
BB
BB BB
B B
EE EE E E EE E
C L B E
Survey the patients above by counting how many indicators, of each color, a patient has. Tally the flags per patient in the table below:
Patient Experience Bundle© Dashboard
43%
29%
14%
14%Communication
Logistics
Basic Needs/Comfort
Enviornment
Daily Bundle Compliance
Average PEB Score
0
20
40
60
80
4/2/20193/31/2019 4/1/2019 4/3/2019
%
% Defects by Bundle Element
64.5%
0
5
10
15
4/3/20193/31/2019 4/1/2019 4/2/2019
Count
Daily # of Surveys
Average Surveys per Day
10
Conclusion and Discussion
• Although it is routine to measure individual processes to improve patient experience, patients do not view these as separate events, but rather as a collection of encounters that determine the patient’s perception of his or her experience
• The Patient Experience Bundle© is built upon identification of common specific elements of care that impact patient satisfaction and detailed mathematical analysis of the relationship between factors
• Current patient satisfaction assessment results are delayed and selective making it difficult for hospitals to assess standings and evaluate process improvement initiatives real time
• Implementing the Patient Experience Bundle© will improve all facility scores, regardless of starting position:- Low-performing sites move to the middle of the distribution- Mid-tier sites are able to spring board to the upper tier- Top-tier achieve and sustain 90th percentile and higher ratings
References
1. Riebling, N. S. Norouzzadeh, C. Mouradian, G. Reeder, A. Hillier, and M.E. Doerfler. 2018. Quantifying Patient Satisfaction with Process Metrics using a Weighted Approach. BMJ Open Quality. (https://bmjopenquality.bmj.com/content/8/1/e000458).
2. S. Norouzzadeh, N. Riebling, C. Mouradian, G. Reeder, A. Hillier. Improving Patient Experience with High Reliability. CipherHealth'sPartners in Excellence Conference, San Diego CA, June 19-20, 2019. (Accepted)
3. Norouzzadeh, S., N. Riebling, C. Mouradian, G. Reeder, A. Hillier. Using Real-Time Surveys to Deliver Exceptional Patient Experience with High Reliability. The Beryl Institute call for case studies 2019. (Accepted)
4. Mouradian, C., N. Riebling, S. Norouzzadeh, G. Reeder, A. Hillier, and M.E. Doerfler. Designing & Implementing a Patient Experience Bundle. The Beryl Institute Patient Experience Conference, Dallas, Texas April 1-5, 2019. (Accepted)
5. Riebling, N. S. Norouzzadeh, C. Mouradian, G. Reeder, A. Hillier, and M.E. Doerfler. How to Measure and Improve Patient Comfort: Designing and Implementing a Patient Experience Bundle. BMJ & IHI Quality Forum: International Forum on Quality and Safety in Healthcare. Melbourne, Australia, September 10-12, 2018.
6. Norouzzadeh, S., R. Cowan, C. Mouradian, E. Chen, G. Reeder, and N. Riebling. Weighted Yield Bundle to Quantify Patient Experience in Hospitals. 2017 INFORMS Annual Meeting, Houston, Texas, October 22-25.
7. Riebling, N., S. Norouzzadeh, G. Reeder, C. Mouradian, E. Chen, M. Doerfler. Quantifying Patient Satisfaction with Process Metrics Using a Weighted Bundle Approach. Institute for Healthcare Improvement, 28th Annual National Forum on Quality Improvement in Healthcare, Orlando, Florida, December 4-7, 2016.
8. Norouzzadeh, S. and G. Reeder. Weighted Bundle to Quantify Patient Experience. 25th Annual Service Quality Conference, Chicago, IL, October 24-25, 2016.
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Thank you!