HCAHPS Hospital Environment Domain: Promoting a Healing … · 2014-06-26 · TIPS for PATIENTS: Your room smells clean and is clutter -free – because it is cleaned every day. You

1 2013 Health Systems and Facility Summit

HCAHPS Hospital Environment Domain: Promoting a Healing Atmosphere Philip Loos, MBA Patient Experience Advisor Press Ganey Associates

2013 Health Systems and Facility Summit

We will be discussing…

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HCAHPS and Value-based Purchasing (VBP): The Fundamentals

Environment Domain: Promoting A Healing Atmosphere. Matching Patient Expectations to Performance

Strategies that Work! Best Practices for creating and maintaining a healing

environment.

2013 Health Systems and Facility Summit 3

HCAHPS and Value-based Purchasing (VBP)


HCAHPS

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• Hospital

• Consumer

• Assessment of

• Healthcare

• Providers and

• Systems

Who is Eligible? - All payer types. - 18 years or older. - At least one overnight stay in the hospital. - Non-psychiatric/rehab diagnosis. - Alive at the time of discharge.

“HCAHPS is a tool to be used for public reporting of major areas of hospital performance to support

consumer choice” - CMS


CAHPS Family of Surveys

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• Hospital (inpatient) CAHPS

• Home Health Care CAHPS

• CG-CAHPS (Clinician and Group)

• Outpatient Dialysis Centers

• Hospice

• Rehabilitation Facilities

• Emergency Department

• Pediatric CAHPS • Outpatient Surgical

Experience • Ambulatory Surgery

Surgical Experience


It is no longer just inpatients…

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Why is CAHPS important?

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Value-Based Purchasing

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Future Dollars at Risk

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HCAHPS Domains

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• Nurse Communication • Doctor Communication • Hospital Environment • Responsiveness of Hospital Staff • Pain Management • Communication about Medications • Discharge Information • Overall Rating • Care Transition Questions


HCAHPS Environmental Questions

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• “During this hospital stay, how often was the area around your room quiet at night?” Never Sometimes Usually Always

• “During this hospital stay, how often were your room and bathroom kept clean?” Never Sometimes Usually Always


Understanding HCAHPS Top Box

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67% 67%

20%

10% 10%

20%

3% 3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Hospital 1 Hospital 2

Always

Usuall

Sometimes

Never

Usually


Press Ganey survey questions

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HCAHPS only vs. Integrated

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2013 Health Systems and Facility Summit 15


Measuring Quality…

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There’s more though…

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We ALL can play a part by… Reducing Fear – Fear of the unknown, their condition, what will happen to them, their outcome, etc. Reducing Anxiety – Anxiety stems from the unknown (what comes next, who will interact with them, what will they say, what questions should be asked, will I retain the information, will my family members be able to all visit with me, will the noise disrupt my sleep, etc.)


Patient Expectations

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• Patient expectations are predetermined beliefs about a care experience that serve as a reference against which that care experience is judged.

• Patient expectations do not reflect what a patient “predicts” will occur. Rather, they reflect what a patient believes “should” occur.

• Patients view their expectations as realistic and attainable.

In today’s presentation, we are focusing on patient and family expectations of the Environment of Care.


Defining a Quiet Environment

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The EPA recommended guideline for continuous background noise is no more than 40 dB during the day and a max of 35 dB at night in patient rooms.


Why is a Quiet Environment Important?

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• Since 1960, hospital sound levels have risen from an average of 57 dB during the day to 72 dB and from 42 to 60 dB at night

• Sound levels 50< dB can • negatively impact healing and recovery • contribute to an increased LOS • disturb sleep • increase morbidity levels • decrease a patient’s ability to fight infections • Increase staff stress levels • Increase potential for of medical errors • Contributes to low patient satisfaction scores


Why are hospitals so noisy?

Typical hospital environment = hard, reflective surfaces that are easily cleaned but that reflect noise

Loud, irritating equipment Few effective behavioral protocols in place to increase staff

awareness Large number of caregivers Caregivers become accustomed to the noise levels that

surround them and unconsciously elevate the volume of their own voices to be heard

Overhead pagers Construction

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What Does a Clean Room Look Like to Patients?

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American Society for Healthcare Environmental Services TIPS for PATIENTS:

Your room smells clean and is clutter-free – because it is cleaned every day.

You see every staff member wash his hands or use sanitizer every time he/she enters the room. Visitors are reminded to wash too.

You have your own sanitizer at your bedside. When housekeeping cleans your room –

Fresh gloves every time. All high-touch areas washed – every time.

Your bedside tray is wiped down before and after every meal. Your trashcan is next to your bed and emptied frequently. You are given a fresh pillow if yours falls on the floor. You have a name and number to call if your room is not cleaned to your

satisfaction.


Patient Perception = Reality

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• Patients have varying perceptions of room cleanliness and why it’s important to them

• Some patients may wan to watch the room be cleaned. Others may prefer to return to a clean room after returning or after waking up

• Patients view cleanliness as a marker of safety and quality. • Most patients are not clinical, they look for things that make

them feel as though they are safe and the quality of care is good.

• Dirty = at risk • Infection rates


Identify Your Goal

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Maximize Value-Based Incentive Payments by Improving Performance in

the HCAHPS Environment Domain.


Challenges and Barriers

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Awareness is the Key

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Identify Causes

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Data

Comments

Observations

Cause-Solution

Root Cause Analysis

Consider creating individual HCAHPS Domain Teams –

establish Domain Leaders who are committed to examining

these steps and implementing improvement initiatives.


Identify Causes

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Some common root causes: People are not aware of the issue – its importance or the

impact of their own behavior. Resources and/or equipment need improvement. Positive staff and physician behaviors are not: Defined Promoted Supported

Infrastructure for sustaining environmental improvement initiatives is inadequate


Assess the Big Picture of Your Strategy

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Assess the Big Picture of Your Strategy

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Observation Tools

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A Full Menu of Best Practices

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Key Points: Infrastructure and

communication need to be part of EVERY plan.

Select one best practice for Noise Reduction and one for Cleanliness.

Link your choices back to your root cause(s).

Engage the staff! Focus on recognition.


Recommend Solutions: A Framework for Change

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Increase Awareness

Improve the Environment

and Work Processes

Promote Positive

Physician and Staff

Behaviors

Create Infrastructure

to Sustain Improvement


Common Equipment Upgrades

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Adapt Existing Equipment A Healing Environment sounds quiet . . .

Reduce volume of alarms/ring tones/elevator bells.

Use foam padding to minimize noise of pneumatic tube systems, sound of trash can lids closing.

Oil hinges on doors.

Replace existing cart wheels with rubber wheels.

Install variable volume controls on cardiac monitors, pumps, etc.

Install carpet where appropriate.


Common Environmental Upgrades

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Upgrade Your Environment A Healing Environment is uncluttered and visually pleasing . . . Take advantage of natural light whenever possible.

Use decorative touches on window itself if view is not optimal.

Insert home-like touches – framed pictures of staff, work of local artists. You may also want to invite patients to bring in their own pictures for their rooms.

Evaluate your color scheme (sage and gold have been deemed “patient-friendly” colors); increase frequency of touch-ups.

“Spring cleaning” and “Fall” cleaning with staff.

Minimize clutter.


Common Process Improvements

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Adapt processes to promote quiet and cleanliness:

Stop or minimize the use of intercoms and overhead paging.

Increase the frequency of trash removal, particularly before and after visiting hours and meals.

Stagger EVS and facilities staffing patterns to be more in alignment with peak patient and visitor volume.

Prioritize patient placement in single rooms whenever possible.

Ensure that staff and other meetings are held behind closed doors.

Schedule equipment delivery, cleaning at patient-friendly times.

Preventative maintenance and beautification programs.


Best Practices - EVS Staff Interaction

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• Be mindful and respectful that the room is now their space • Knock • Ask for permission to enter • Greet patient and family members in room • Introduce yourself • Say what you’re there for

• Make sure that patients regularly see ES staff clean the high-touch areas • Verbalize value (say what it is you’re cleaning) • If patient not present during cleaning, leave a table tent card, or business

card, sharing that the ES staff had cleaned the room • Ask patient if room was cleaned to their preference and if anything else can

be done • Pay close attention to hand hygiene

• To patients, frequent hand washing = clean hospital • Provide hand sanitizers on the patient’s bed table or by sink • Make sure patients see that you washed your hands


Communication Challenges

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For staff members who have English as a second language, effective communication with patients may a challenge.

• Make eye contact • Smile • Show interest in the patient • Have some limited scripting ready for use • Leave patient with a table tent card/business card with the staff members

name


The Role of the ES Management Staff

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• Round daily to solicit patient feedback (collect data when possible) • Have clear standards for staff and hold them to it • Look frequently at the organization’s score on room cleanliness and noise levels • Look frequently at unit level scores • Create dashboards that show staff how they are doing overall, what the scores

were last week, last month, etc. • Include Press Ganey and HCAHPS scores • Include your own metrics that you collect on your own (e.g. % compliance

for various key behaviors) • Use as way to share progress with upper management

• Review and share comments, both negative and positive, with staff

• Successful organizations believe that cleanliness is every hospital employee’s responsibility!


Best Practices: Construction Noise

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• Do not fill patient rooms above or below the construction area since the noise is likely to be disruptive.

• Provide patients with complimentary ear plugs accompanied by a note of apology for the excessive noise. These should be offered to patients upon admission to the area, so that the patients are well informed.

• Provide CD players with headphones for patients near the affected areas. Music is very soothing and offers a distraction from the noise.

• Post signs in hallways apologizing for the inconvenience. Make sure the signs include an invitation for patients to let hospital officials know if the noise is too burdensome.

• Keep a select number of beds open to relocate patients who complain about excessive noise.

• Provide a contact number for nursing units to call if noise or other construction disturbances are causing issues for patients.


Staff Members Influence During Construction

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Staff members often have the greatest influence on patient’s perceptions of the inconvenience of construction. While it is important to acknowledge the patient’s feelings and frustrations, personal feelings of frustrations by the staff members should remain private. • Remind staff members that negative comments about the construction will only hurt the

patient’s opinion of the hospital. • Provide staff members with scripts on how to respond to patient concerns with

construction. • Keep staff informed about the construction progress. Help build excitement about the

new or renovated area(s). Service Recovery: • Distribute special amenity bags or small gift baskets – include non-food items like

notepads, pens, magnets, etc. and an “I’m sorry for all the noise” note • Invite patients who were greatly inconvenienced by the construction back for a special

ceremony when the new area is opened • Make sure that service recovery tools are in place and accessible to all


Best Practice: Quiet Time

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Cleveland Clinic: “Help Us Support Healing” (HUSH) Protocol •Designated Quiet Time between 9 PM and 7 AM:

− Lights are dimmed. − Doors of alert patients are closed. − Overhead paging is eliminated. − All phones and pagers on vibrate. − Patients are offered eye masks and ear plugs. − All wear headphones to watch TV after 9pm. − Scheduling of ancillary services adapted to best meet patient needs.

Other Hospitals with Quiet Times: •Stanford Hospitals and Clinics. •Johns Hopkins. •Massachusetts General. •New York-Presbyterian. •And many more.


Best Practice Highlight: Noise Audits

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Cleveland Clinic “Employee Scorecards” Each Environmental Services employee receives hospital

cleanliness scores. Managers perform rounds on specific units and scorecards are

completed to gauge cleanliness- this information is routed back to Environmental Services for “real time” feedback.

Montefiore Medical Center Sound readings (decibels) over time on selected units.

Press Ganey Tools: Noise Source Observation Sheet. Guidelines for Noise Observation.


Best Practice: Rush University Medical Center

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What has been done? Wireless phones for nurses: reduced overhead pages 90%. Increased awareness “locally” by unit directors. Publicized how to order earplugs from warehouse. Found free noise meter apps for phones (iPhone and Android). Next on the plan: Eye shades. Longer-range: New hospital building:

Carpeted hallways. Dimmed lights. Quieter HVAC. Sound-absorbing artwork.


Best Practice Highlight: Noise Champion

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NewYork-Presbyterian Hospital

Nursing director improvement “owner” for noise identified.

Analyzes data and keeps leaders

informed via email blasts. Enhances transparency and promotes accountability.

Works with nursing clinical leads to ensure night staff are informed and educated.

Recognizes areas of success and turns leaders’ focus to areas in need of improvement and additional support.

Distributes unit specific signage monthly for PCD’s to post and discuss with staff.


Best Practice: Communication for Ongoing Awareness

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New-York Presbyterian Hospital

NY press article featuring “Quietness.”

Includes metrics about noise performance.

Features quotes from “Quietness Champions.”

Provides all staff with specific behaviors on how they can help promote quietness in patient care areas.

Source; NYPress, NewYork_Presbyterian Hospital publication


Monitor: Did Change Happen?

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•Behavioral Expectations •Leadership Role Models •Staff Resources •Quiet Hours •Adopt a Unit

•Shared Governance •Staff Champions •Standing Agendas •Integrated Best Practices •Recognition •Ongoing Assessment

•Frame Expectations •Upgrade equipment •Upgrade processes •Workflow •Environmental Upgrades

•Data and Comment Analysis •Noise and Cleanliness Audits •Patient Focus Groups •Staff Education •Barrier Analysis

Increase Awareness

Improve the Environment

and Work Processes

Promote Positive

Physician and Staff

Behaviors

Create Infrastructure

to Sustain Improvement


Thank you!

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Questions and Comments? Philip Loos Patient Experience Advisor [email protected] (855) 671-5158

mailto:[email protected]

1 © 2012 Press Ganey Associates, Inc.

Increase Awareness and Understanding

Tactics Steps Focus Review Your Data Patient Satisfaction data

Comments Discharge Calls

Identify areas of best practice Improvement Opportunities

Observe the Patient Experience

Staff Observations – all shifts Noise and Cleanliness Audits Leader Rounding Patient/Family Observations Noise meter apps for phones

Quick wins Workflow opportunities Equipment issues Facility issues

Discuss Findings Leadership Meetings Unit Practice Councils Town Hall Meetings Physician Meetings

Increase awareness Educate re: best practices Identify and explore barriers

Brainstorm Strategies Immediate Action Annual Long-term

Prioritized workplan


Improve: Environment and Work Processes Tactics Steps Focus Evaluate Current Processes

Equipment Facilities – internal and external Patient and Staff Traffic Patterns Staffing Construction/renovations

Quick wins Workflow opportunities Equipment issues Facility issues

Update Equipment Adapt Replace Improve existing maintenance processes Long-term budgeting

Immediate adaptations Longer-term planning for equipment replacement

Update Facilities Adapt Upgrade Improve existing maintenance processes Long-term budgeting

Immediate adaptations Longer-term planning for facilities upgrades

Improve Work Processes

Re-route staff to minimize use of nursing units as “shortcuts” Frequency of trash removal “Patient-friendly” equipment and supply delivery times Staggered shifts to accommodate needs on evening and night shifts

Patient-centered re-evaluation of process of care and workflow


Promote Positive Behaviors Tactics Steps Focus Frame Strategy in Positive Terms

Link HCAHPS Environment Domain to - Mission/Service Standards - Healing Environment

Minimize sense of “add on work”

Implement Role Guidelines 2-3 specific behaviors for each role Staff will know what is expected of them Staff hold each other accountable

Designate Quiet Hours Identify day, evening and night hours Noise reduction during strategic times

Provide Staff with Tools and Resources

Patient Relaxation Toolkits Key Words/Role Plays Literature Review Data updates to illustrate progress

Providing staff with something positive to offer patients and visitors during times of peak noise or anxiety will improve employee satisfaction and reinforce the positive

Implement “Adopt a Unit” program

Patient care areas are “adopted” by leaders and staff from non-clinical departments

Caregivers feel supported by ancillaries Nonclinical department engagement


Infrastructure to Sustain Improvement Tactics Steps Focus Shared Governance Engage Unit Practice Councils Staff ownership and engagement in

strategy

Manager/Staff Champions

Designate Healing Environment “champions” Accountability at all levels

Communication Plan - Standing agenda item at all meetings - Intranet - Success Stories - Orientation

Consistent communication re: goals, current status and strategy will sustain focus

Integrated Best Practices

Hourly Rounding Discharge Calls Service Recovery Key Words to frame patient expectations

Build tactics to increase awareness and to promote strategy into existing best practices at every opportunity to avoid fragmentation of effort

Recognition Highest HCAHPS Environment domain scores Most Improved Environment domain scores Achievement of Environmental goals/targets On-the-spot recognition options

Reinforcement of progress sustains motivation over time

The Importance of a Clean and Quiet Hospital Environment When the Center for Medicare and Medicaid Services (CMS) included questions to measure the patient perception of the hospital environment on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS®) questionnaire, it escalated the visibility and importance of cleanliness and quiet to patient satisfaction. Clinically speaking, there is already an established body of literature that documents the impact of noise and cleanliness on the healing process of patients (and to a lesser extent on caregivers). There are established functional and behavioral strategies for reducing noise, as well as guidelines for the construction of new healthcare settings. There are regulatory requirements for cleanliness of the hospital environment and the impact of cleanliness on infection rates and patient mortality is understood. Bringing patient satisfaction into this equation now requires hospitals to expand the focus of their improvement efforts beyond actual noise reduction and improving cleanliness to include understanding and then setting/managing patient perceptions. In other words, they must now be more transparent about what they are doing to promote a healing environment and what patients should expect as a result. (Note: It is beyond the scope of this workbook to provide a comprehensive review of the literature; however, there is a bibliography included at the end for your reference). Patient Experience Strategies to Promote a Healing Environment

Given the sheer size of our client base, Press Ganey has the benefit of seeing the true “big picture” of the impact of the HCAHPS survey on the patient experience strategies created and implemented by our partner organizations. For the HCAHPS Environment domain, these strategies now include the following elements: Best Practices and Strategies to Frame Patient Expectations. This requires a proactive approach to informing patients and visitors about the importance assigned to cleanliness and quiet and transparency about challenges that are not easily fixed (e.g. expected construction noise). Some highlights -

Summaries of Improvement efforts on Hospital public websites, with opportunities for patients to become involved or to give suggestions

Consistent talking points for use with patients and families upon admission or at transition points in the process of care.

Engagement of Patient/Family Advisory groups in the implementation of healing environment strategies.

Proactive service recovery in situations of anticipated noise or when expectations have not been met.

Engagement of patients/visitors in refinement of family-centered open visiting hour expectations and processes.

Best Practices and Strategies to Increase Staff Awareness and Engagement. For most organizations, this starts with diving into their data and patient comments to truly understand patient and family perceptions, and then sharing and validating this information with staff. Other potential strategy elements -

Internal and external marketing campaigns to increase awareness HCAHPS Environmental domain scores posted on hospital intranet page and covered as a

standing agenda item at all administrative and staff meetings. Leveraging shared governance committee infrastructure to engage staff in improvement planning Opportunities for leaders, staff and visitors to conduct real-time observations Individual and Team reward and recognition programs for best and improved HCAHPS

environment results

Focused Patient Satisfaction Best Practice Implementation or Modification of Existing Best Practices. It is not always necessary to reinvent the wheel! Successful organizations leverage the patient experience infrastructure and best practices already in place whenever possible to promote a healing environment. This approach minimizes rework and fragmentation of effort.

Quiet Hours Series of short daily discussion topics for use in daily “huddles” or meetings Hourly Rounding – expansion of scope to incorporate ancillary and support service staff. Leadership Rounding – expansion of scope to include questions re: the environment (in

adherence with CMS guidelines).

Short and Long-Term Planning to Eliminate Equipment and Facility Noise Sources. Unfortunately, most hospitals do not have the resources or space to start from scratch and construct new buildings that meet acoustic guidelines for healthcare facilities (see Solet, J. M., Buxton. O.M., Ellenbogen, J.M., Wang, W., and Carballiera, A. (2010). Evidence-based design meets evidence-based medicine: The sound sleep study. Concord, CA: The Center for Health Design)

Immediate repair/modification of existing equipment (wheel replacement on carts, oiling of squeaky door hinges, etc.)

Preventative equipment preventative maintenance programs Long-term plan and budget for substitution of existing work surfaces with sound-absorbent

replacements Long-term planning for nursing station placement and provision of “off stage” staff meeting areas

to minimize noise and disruption to patients and visitors Workflow and Process Redesign to Promote Cleanliness and Quiet. It is common to find work routines and standard operating procedures that were put in place to promote efficiency at the expense of the patient experience (one example of this is the practice of scheduling MRI and CT scans for inpatients at night in order to be able to accommodate high outpatient volumes during daytime hours). Several examples -

Re-evaluation of the timing and location of supply and equipment delivery and restocking Evaluation of Environmental Services staffing patterns against visitor volume and patient

admissions/discharges on the evening and night shifts Mechanisms to Ensure Manager and Staff Accountability for a Healing Environment. Successful organizations ensure that there are clearly defined expectations, as well as consequences for not meeting the standard.

Universal behavioral expectations to promote cleanliness and quiet Role-specific behavioral guidelines Process and tools for managers and staff to hold each other accountable to behavioral standards.

This generally requires setting an organizational “norm” for speaking up in situations where someone is doing a great job or is not meeting the behavioral standards.

Multi-Sensory Strategies to Promote a More Pleasing Environment Overall. It is perhaps natural that organizations initially focus on minimization of noise at night and on room cleanliness; however, some organizations are taking a broader and more multi-sensory approach to promoting a healing environment and overall experience.

Replacement of unpleasant environmental sounds with more positive sounds, such as soft music, waterfalls, or even white noise machines.

Aromatherapy for an enhanced sense of cleanliness (beyond the antiseptic) Providing patients with relaxation toolkits that include ear plugs, music, instructions for relaxation. Images of nature Window treatments, sky lights that allow for natural light Softer lighting Contracting with local artists to display their work – promotes a more homelike atmosphere that

patients and families may find relaxing

Noise Source Observations Observer Name ______________________________________________________________________ Observation Date ___________________________ Unit/Room Number _____________________ Start Time _________________________________ End Time _____________________________

Time

(e.g. 0700)

Noise Source

(e.g. Food Cart)

Details

(e.g. Food Cart rattled down the hall between room stops from 0700 to 0715)

Inpatient Unit Observation Log: Staff Behavior, Cleanliness and Noise Upon Arrival at the Inpatient Unit, staff at the nursing station:

Desired Behavior Yes No Comments

Smiled

Made eye contact within 10 seconds

Greeted you with welcoming words “Good morning! How are you? How may I help you?”

Wore ID badge If yes: Wore badge so you could read the name

Used a friendly tone

Displayed facial expressions of interest and care

Maintained appropriate eye contact with you

Assisted you promptly

Gave clear instructions for the next steps

Looked clean, neat and professional

Closed the encounter with a smile or pleasant comment

The environment on the inpatient unit

Desired Environment Yes No Comments

Unit Cleanliness

• Halls clutter-free? • Trash emptied? • Floors clean? • If carpeted – stain free? • Sharp boxes clear? • Nursing station free of dietary trays? Food

containers? • Purell stations fully stocked? • Odor-free environment? • Public restrooms on unit:

o Clean? o Fully-stocked? o Accessible?

Unit Maintenance

• Furniture in working order? • Appropriate temperature? • Signage in good repair? • Ceilings – stained areas? • Light fixtures working?

Selected Patient Rooms

• Call bell within reach of bed? • Bedside table within reach of bed? • Whiteboard – up to date? • Clutter free? • Linens appear fresh? • Floor clean?

Staff: General Observations

• Staff wearing ID badges? • ID badges easy to read from a distance? • Able to tell the difference between job roles? (E.g.

RN versus aid versus EVS worker, etc.) • Did you overhear staff engaged in private

conversations? (with each other or cell phones) • Were staff in the rooms with patients? • Did staff acknowledge your presence? • Did you observe staff making an effort to protect

patient privacy? (e.g. pulling curtains, closing doors, lowering voice during conversations)

• Staff wearing gloves?

Unit Noise Level

• Would you describe the unit as quiet? • Which of the following sounds did you hear?

o Equipment beeping o Patients calling out o Staff conversations o Carts (squeaky wheels, etc.) o Visitor conversations o Staff making rounds on patients o Call bell acknowledgements o Overhead announcements o Beepers going off o Music o Other (describe)

General Observations: Did you see –

• Patient satisfaction scores posted • Contact information for unit leadership • Complimentary letters from former patients

Documents

HCAHPS Hospital Environment Domain: Promoting a Healing … · 2014-06-26 · TIPS for PATIENTS: Your room smells clean and is clutter -free – because it is cleaned every day. You