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HCAHPS: Global Domain for Discharge
The Finley Hospital
Describe “best practice” methodologies associated with patient perception of readiness for discharge
Examine areas of “excellence” that potentially strengthen and/or tie into patient perception of readiness for discharge
Discuss individual roles of the interdisciplinary team that impact patient perception of care/readiness for discharge
Describe three interventions that you can trial in your facility to improve HCAHPs discharge scores
Objectives
Finley Hospital Discharge Domain scores have been consistently above the 90th percentile
The scores are in the top 10% nationwide
IHS Affinity groups such as the Patient Experience Team and the Case Management Team started asking us about what we do.
How did we get here?
FinleyIHS
We know that people are really interested in what we are doing
We cannot name just one or two things that we have worked on that make are scores what they are
We have many things that we are doing that are working well
What we know today
The discharge domain has two questions in the domain scoring◦ During this hospital stay, did doctors, nurses or
other hospital staff talk with you about whether you would have the help you needed when you left the hospital?
◦ During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
Discharge Domain Questions
Both questions are Yes or No◦ In other words: Pass/Fail
There is no way for the person to rate the quality of the discussion or the written instructions.
Discharge Domain continued
Press Ganey Solution Starters
For standard questions the solution starter gives the question definition and improvement solutions.
Best Practice & Areas of Excellence
Some of the ideas on the Solution Starters include:
Include the right people with the patient for both the discussion on the help needed at home and the review of the written discharge instructions
Address questions and concerns they have about the plan and the instructions before they leave
Press Ganey Solution Starter Ideas
Use white boards, note pads for questions and take-home packets for communication during the stay
Discharge instructions need to be simple and easy to read – health literate
Use the discharge phone calls to answer questions and reinforce information
Let them know who to call if they have questions
More Solution Starter ideas
Project RED (Re-Engineered Discharge)◦ Developed by researchers at Boston University
Medical Center (BUMC)◦ The Agency for Healthcare Research and Quality
(AHRQ) funded the development of the Project RED tool kit Effective at reducing readmissions and post-hospital
emergency visits
Best Practice & Areas of Excellence
Eleven activities that should be completed for every patient
Medication Reconciliation The plan matches with national guidelines
◦ Doing the right thing at the right time Follow-up appointments are set Communicate outstanding tests Arrange post-discharge services
Project RED Checklist
Written discharge instructions What to do if problems arise Patient education throughout stay Assess patient understanding Discharge summary sent to PCP Telephone reinforcement
Project RED Checklist continued
Improving Discharge Satisfaction May Also Improve
ReadmissionsCommunication Among
Staff and Providers
Communication with Patient/Family
Throughput
Patient Experience
We know that improvement has been consistent over the past three years
We have reduced variation in scoring, so we are more consistent in maintaining a narrower range of scores
What Do We Know About Our Improvement?
Finley Discharge Global Score by Year 2009-2011
Mean 87.83
Mean 92.87 Mean 95.38
Significant reduction in variation and increase in mean score per year demonstrated over 3 years
Comparing Data to Improvements
2009 and Prior
Right people at the interdisciplinary team meetings for communication
Focus on patient satisfaction ◦ Scripting for case managers
and social workers Focus on reducing length
of stay
Comparing Data to Improvements
2010 Move to new med-surg units Focus on updating new
custom white boards◦ Goals◦ Anticipated DC date◦ Anticipated DC plan
Focus on CM leading daily care conference
Focus on CM seeing patients daily
Discharge phone calls – Fall 2010
Comparing Data to Improvements Focus on preventing re-admissions
by:◦ Daily readmission report to Case
Managers◦ Readmission data collection on specific
data elements◦ Communication to Physician Champion
of any readmission from primary admitting physician
◦ Special Case Management /Social Work process trialed with one “Frequent flyer” patient to see if we can better meet needs including Reviewed patient admission history and
costs in multi-disciplinary care committee
Assigned physician (did not have primary care at first)
Assigned unit to be admitted to Assigned Case Manager and Social Work
Professional to see patient whenever readmitted
2011 and Forward Focus
1/5/2010 8/1/2011
4/1/2010 7/1/2010 10/1/2010 1/1/2011 4/1/2011 7/1/2011
1/5/2010Opened 4MS and 5MS
1/5/2010 - 4/2/2010Focus on updating
white board with patient goal daily
4/2/2010 - 10/2/2010Focus on Case Manager driving interdisciplinary patient team meetings
6/30/2010 - 10/2/2010Case Manager sees every patient
daily to discuss readiness for discharge
10/1/2010 - 6/30/2011Case Managers focus on
collaborative improvement in Core Measure Compliance
1/1/2011 - 8/8/2011Focus on readmission population
COPD/CHF/Pneumonia and begin to look at chronic disease management
Case Management Timeline for Change
5MS HCAHPs Global Nursing, Physician and Discharge Questions
Both Nursing and Physician global scores have risen annually along with information on symptoms/problems to report to the physician
90
85
80
75
70
65
60
Month
Individual V
alue
_X=80.25
UCL=87.34
LCL=73.16
1 2 3 4
I Chart of Global Rating of Nurses 5MS by Quarter 2009-2011
90
85
80
75
70
65
Month
Individual V
alue
_X=80.25
UCL=90.89
LCL=69.61
1 2 3 4
I Chart of Global Rating of Physicians 5MS by Quarter 2009-2011
100
95
90
85
80
Month
Individual V
alue
_X=87.75
UCL=97.50
LCL=78.00
1 2 3 4
I Chart of Staff Discuss Help 5MS Quarter 2009-2011
105
100
95
90
85
80
75
70
Month
Individual V
alue
_X=90.75
UCL=98.73
LCL=82.77
1 2 3 4
I Chart of Info on Sypmtoms/ Problems 5MS by Quarter 2009-2011
OB HCAHPs Global Nursing, Physician and Discharge Questions
OB scores are holding consistent and fairly high across all three years.
110
105
100
95
90
Month
Individual V
alue
_X=98.5
UCL=103.82
LCL=93.18
1 2 3 4
I Chart of Info on Sypmtoms/ Problems OB by Quarter 2009-2011
130
120
110
100
90
80
70
60
50
Month
Individual V
alue
_X=92.75
UCL=111.37
LCL=74.13
1 2 3 4
I Chart of Staff Discuss Help by Quarter 2009-2011
120
110
100
90
80
70
60
Month
Individual V
alue
_X=88
UCL=103.07
LCL=72.93
1 2 3 4
I Chart of Global Rating of Physicians OB by Quarter 2009-2011
110
100
90
80
70
60
Month
Individual V
alue
_X=86.75
UCL=101.82
LCL=71.68
1 2 3 4
I Chart of Global Rating of Nurses OB by Quarter 2009-2011
Discharge Domain Percentile Rank by Unit
OB Overflow Unit
4MS 5MS ICU50
60
70
80
90
100
% = unit survey response/overall response
Percent of Overall HCAHPS Surveys Returned by Unit
4MS 5MS OB ICU Overflow Unit0
5
10
15
20
25
30
35
40
What is Working• Case Managers (RNs) Round on All Inpatients
• Daily rounding by Case Managers• Scripting for Case Managers:
• What can we do to help you get ready for discharge?
• What are your goals for discharge?• What problems do you anticipate may occur at
discharge?
What is Working• Social Workers are assigned to patients
based on need.• Examples: Over 65 years, Major surgery,
Nursing Home Placement, Need for Home IV Therapy
• Social Work Scripting: How do you feel about going home? Any concerns or worries?
Communication Between Disciplines Case Managers and Social Workers are
assigned to units and work well together Case Managers and Social Workers report to
same Director Daily Care Conference on Med Surg units
that includes: Charge Nurse, Case Manager, Social Worker, Pharmacy, Physical Therapy and other disciplines when requested◦ Targeted conversations on re-admitted patients
What is Working
It Takes a Village….Daily Care Conferences
Large white boards in prominent place in Med-Surg areas
Include names of nurse, tech, case manager and social worker
Include anticipated discharge date and plan for discharge such as home or nursing home
Patients and Families may write questions and notes on the white board
Communication
White Board Example
Disease management education is primarily a nursing function, but also provided as needed by case management, when appropriate ex therapy, dietary
A case manager is one of the presenters at the Joint Camp a class for patients preparing for their new joint replacement◦ Joint Camp presentation includes typical plan for
discharge
Education
Written discharge instructions are a mix between home grown mainly for surgical patients and Micromedex instructions
Booklets for specific groups such as the total joint population and the new moms/parents
Education
Core Measure patients are identified on admission or as soon as possible after admission
Core Measure patients (CHF, Pneumonia and AMI) receive specially made folders that include several types of patient education material as soon as they are identified as having a core measure diagnosis.
Core Measures
Core Measure Folder
When possible they are made prior to discharge Staff check with patient regarding what time
of day is best for the patient for follow up appointment
Appointment is made by unit secretary Return appointment is written on an
appointment card with specific instructions if lab or x-ray is needed prior
Orders for lab or x-rays are faxed to the office where the tests are to be performed
Follow-up appointments
If patient is discharged with home-care or to a nursing facility information is faxed prior to discharge to agency
Nursing staff call nurse to nurse report to home care agency or the nursing facility
Medication list and copy of discharge instructions are faxed to My Nurse for follow up phone calls.
Hand-off communication
Medication list reviewed with patient and family
New medications or changes in medication dosages are reviewed in detail
Prescriptions are faxed to pharmacy of patient’s choice if requested
Home medications
Equipment needed for ambulation is ordered and delivered to room by physical therapy
Home supplies such as commode, hospital bed, or any other large item is ordered by social worker and delivered to the patient’s home prior to discharge if possible
Home Equipment
After instructed by nurse, patient or family will do a return demonstration of care such as dressing changes, trach cares, catheter cares, emptying drains, etc.
Nurse will assess readiness or re-educate if needed
Teach Back
Home care instructions specific to diagnosis are reviewed with patient and family member.
Medication list reviewed
Follow up appointment reviewed
Nurse or nursing tech take patient to the hospital exit and assist into vehicle
Ready to Go
Med- Surg patients receive a phone call from My Nurse within 48 hours of going home
My Nurse reviews medications and discharge instructions prior to making the phone call
Scripted questions are asked to patient (teach-back)
Patient has opportunity to ask nurse questions
At Home Follow-Up
Suite Beginnings
◦ All new mothers and babies have a one time home visit by an obstetric nurse
OB Follow up Visit
Work on reducing readmissions
Monthly reporting/posting of patient satisfaction data
Affiliated with The Studor Group◦ Leader rounding on patients◦ Leader rounding on staff◦ Hardwiring intentional rounding◦ Thank-you notes to staff◦ Monthly meeting model◦ Employee selection◦ WOW orientation ideas◦ Next up – hardwiring AIDET
What Else Is Going On?
Using the best practice guidelines assess the discharge process at your facility using observations, feedback from your patients and families and your staff
Start with something small and work up to the bigger things to change
Solicit leadership support Align goals of hospital and unit leaders
Take Aways – what can you do?
Please consider sharing specific things that are working in your facility
Questions?
Sharing or Questions
For more information about the discharge or case management process at Finley Hospital please contact either:
Teresa Neal, Director Of Performance Improvement, 563-589-2553 or [email protected]
Cindy Weidemann, Risk, Safety and Survey Readiness Coordinator 563-589-2607 or [email protected]
Chris Wilson, Director 4MS and Rehabilitation, 563-557-2788 or [email protected]
Contact Information
