Project: Patient Satisfaction with Pain Management. Name of Green Belt(s): Donna Grochow & Maurice Espinoza

Transcription

1 Project: Patient Satisfaction with Pain Management Name of Green Belt(s): Donna Grochow & Maurice Espinoza Name of Champion: Karen Grimley & Zeev Kain, MD Date: March 18,

2 Define Phase 2

3 DEFINE Problem Statement What is the problem? Low patient satisfaction with pain management has been identified as an organizational problem. How do we know it is a problem? The baseline patient satisfaction scores aggregated at the organizational level for satisfaction with overall pain management are at the 26 th percentile when compared nationally. 4 th Quarter 2011 baseline Top Box score =59.08 compared to Avatar Top Box The baseline Top Box scores for How often staff did everything they could to help with pain aggregated at the organizational level for 4 th Quarter 2011 baseline Top Box score =69.83 compared to Avatar Top Box What data to we have on baseline performance? National comparative data from the HCAHPS Patient Satisfaction survey is available at the organizational and unit level. Additionally, nursing has been involved in a multi-center research problem sponsored by the National Database of Nursing Quality Indicators which has resulted in data regarding pain management. What pain does it cause? (impact to patient and/or bottom line): 74% of other benchmarked facilities receive better scores from the patient in regards to pain management, causing the patient to perceive less than optimal care was provided which can lead to poor satisfaction scores, poor publically reported data, decreased reimbursement, and a potential increase in length of stay. 3

4 DEFINE Why is this important? Include Voice of the Customer (VOC): Patients are not satisfied with the pain management that is provided. Why this, why now? ( Burning Platform ): Scores have been low for a long time, Publically reported, Reimbursement issues, Quality of care issues, Affects Magnet Status What will happen if we don t fix this? Potential loss of patients to other providers, Probable decrease in revenue due to decreased reimbursement, Increase length of stay, loss of magnet designation, etc. 4

5 DEFINE Project Charter Project Name: Patient Satisfaction with Pain Management Belt: Donna Grochow & Maurice Espinoza Problem Statement: The 4 th quarter 2011 Top Box patient satisfaction scores aggregated at the organizational level for satisfaction with pain management are (26 th percentile) when compared nationally. Three units, DH32, Tower & Tower 5 have a Top Box score of (<7 th percentile). The baseline Top Box scores for How often staff did everything they could to help with pain aggregated at the organizational level for 4 th Quarter 2011 baseline Top Box score =69.83 compared to Avatar Top Box Three units, DH32, Tower 4 & 5 have a Top Box score of Project Y / Path-Y: Project Y: Patient satisfaction scores with pain management. Path-Y: Mean percent of patients with positive response to the statements: My Healthcare team involved me in the decisions about controlling my pain. My nurse suggested approaches to help manage my pain. My nurse believed my reports about my pain. Team Members: Nursing: Donna Grochow Maurice Espinoza Charlene Miranda-Wood Khaled Al Eid Van Le Holly Wicklas Dan Bernsein Physician: S. Liao, MD I. De Alba MD Patient Relations: Carla Camarillo Pharmacy Lan Zheng Champion: Karen Grimley & Zeev Kain, MD Master Black Belt: Laura Winner/Henry Alvarez Project Goal: To improve the Top Box score in overall pain management to (50 th percentile) on selected units. To increase Top Box scores for How often staff did everything to help with pain to (50 th percentile) on selected units To show improvement in the mean scores of the 3 Path Y statements. Scope: Limited to these areas with current satisfaction scores <7 th percentile: DH 32, Tower 4, & 5 Benefits: Improved patient pain satisfaction scores Decreased length of stay Improved physiological and psychological healing Decreased rate of readmission Decreased rate of outpatient visits Timeline: Define/Measure July-September 2011 Analyze September-December 2011 Improve/Control January-March

6 DEFINE Voice of Customer Patients Nursing Physicians Pharmacists 6

7 DEFINE Voice of Customer What We Currently Have Available: Patient Satisfaction Data (HCAHPS) National Database of Nursing Quality Indicators (NDNQI): Patient Satisfaction with Pain Management Survey Participated in research study to identify issues with pain management All eligible medical-surgical patients were surveyed on 1 day in April 2011 and November 2011 Baseline data available for review What We Need: VOC from nursing, MD group, pharmacists Next Steps: Focus groups with key stakeholders: MDs, nurses, pharmacist, etc Continue to conduct patient interviews & data collection as part of NDNQI study Continue HCAHPS data collection 7

8 MEASURE Voice of Customer (VOC): RN, MD, Pharmacist Focus Group Results Focus groups were held in August 2011 with staff from DH32, 4T, 5T & MICU, MD groups and patient interviews. The focus group consisted of a written survey and verbal roundtable discussion The following themes affecting pain management were identified from the focus groups: Themes 1. Communication 2. Knowledge/Education 3. Process 3. Patient Condition 4. Influence of Supervisors 5. Equipment 6. Complementary Therapy paste 8

9 SIPOC DEFINE 9

10 DEFINE Early Waste Identification DOMOWIT Defects: Lack of communication between MD & RN regarding pain plan of care Lack of communication between RN & aide regarding pain plan of care Lack of communication between RN & patient regarding pain plan of care Lack of communication between aide & patient regarding pain plan of care Lack of communication between MD & patient regarding pain plan of care All routine scheduled medications were due at 0900 and were required to be administered within 30 minutes of the scheduled dose. The med/surg RN s had up to 5 patients with multiple medications. This created a barrier for them in getting to know their patients. Over-processing RN often has to page and/or call MD multiple times for pain medication orders Patient often unaware of when pain medication is available and has to repeatedly ask nurse Motion RN or aide has to answer patient s call light to answer question about when next pain medication is due Over-production: Waiting Adequate/correct pain medication not given timely, patient has to request pain medication HCAHPS Scores: Delayed time period for receiving results: Improved with switch from Avatar (Quarterly results only available when final) to Press Ganey (Preliminary results immediately available) Inventory Transportation 10

11 Measure 11

12 MEASURE Baseline Data for Y Describe how baseline data was obtained Baseline data on patient satisfaction with pain management is based upon a sample size of 123 patient surveys collected from October 2011 through January The data is obtained from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey which is provided by a 3 rd party vendor to 20% of discharged inpatients. Data is available aggregated at the organizational level and the unit level. The data for this project was includes the results of the following: HCAHPS Composite Score: Overall Satisfaction with Pain Management Individual questions that are combined for composite score: How often staff did everything they could to help with pain? How often was pain well controlled? 12

13 MEASURE Performance Measure Operational Definition Baseline Data for Y Data Source Sample Size Who Will Collect Measure Systems Analysis and Location the Data When Will Data be Collected How Will Data be Collected Other Data that should be Collected at the Same Time Patient perception of pain management. Discharged patients are sent a survey with questions about their pain management during recent hospital stay. The instrument asks patients to rate the frequency of events during their care (never, sometimes, usually, always): 1. How often staff did everything they could to help with pain. 2. How often pain was well controlled. HCAHPS survey of discharged patients Survey sent to 20% of discharged inpatients. Sample size dependent on returned surveys Third party vendor: Avatar and Press Ganey Ongoing Survey Data collected via pre-set survey. MSA validation consists of evaluation of incumbent from Press Ganey. Data is reproducable and repeatable,. MSA validation not feasible. Data is attribute data and a Kappa calculation is recommended. Rater repeatability is not applicable for this data because data is collected via anonymous patient survey sent via third party vendor and it is impossible to have rater evaluate measure twice to conduct calculation. Survey is a validated tool and measures patient perception. Patient s perception would be expected to be the same on repeat samples. 13

14 MEASURE Performance Measure Operational Definition Baseline Data for Y Data Source Sample Size Who Will Collect Measure Systems Analysis and Location the Data When Will Data be Collected How Will Data be Collected Other Data that should be Collected at the Same Time Patient perception of pain management. Discharged patients are sent a survey with questions about their pain management during recent hospital stay. The instrument asks patients to rate the frequency of events during their care (never, sometimes, usually, always): 1. How often staff did everything they could to help with pain. 2. How often pain was well controlled. HCAHPS survey of discharged patients Survey sent to 20% of discharged inpatients. Sample size dependent on returned surveys Third party vendor: Avatar and Press Ganey Ongoing Survey Data collected via pre-set survey. MSA validation not feasible. Data is attribute data and a Kappa calculation is recommended. Rater repeatability is not applicable for this data because data is collected via anonymous patient survey sent via third party vendor and it is impossible to have rater evaluate measure twice to conduct calculation. Survey is a validated tool and measures patient perception. Patient s perception would be expected to be the same on repeat samples. 14

15 MEASURE Baseline Data for Y-Template Describe how baseline data was obtained Baseline data from Patient Satisfaction Surveys Selected Units: DH32, Tower 4 & 5 HCAHPS Composite Score: Overall Satisfaction with Pain Management Data on scores based on sample size of 123 patients collected from October 2011 through January 2012 Patient Satisfaction with Overall Pain Managment Tower 4, 5 & DH Top Box % Goal 15

16 MEASURE Baseline Data for Y-Template Describe how baseline data was obtained Baseline data from HCAHPS Patient Satisfaction Survey: DH32, Tower 4 & 5 Question How often staff did everything they could to help with pain? Data on scores based on sample size of patients 109 collected from October 2011 through January How Often Hospital Staff Did Everything They Could to Help with Pain Top Box % Goal 16

17 MEASURE Baseline Data for Y-Template Describe how baseline data was obtained Baseline data from HCAHPS Patient Satisfaction Survey: DH32, Tower 4 & 5 Question How often was pain well controlled? Data on scores based on sample size of patients 109 collected from October 2011 through January How Well Was Pain Well Controlled Tower 4, 5, & DH Top Box % Goal 17

18 MEASURE Baseline Data for Path Y Baseline data collected during participation in a multi-center research study Patient Satisfaction with Pain Management Survey sponsored by the National Database of Nursing Quality Indicators (NDNQI) All eligible medical-surgical patients were surveyed on 1 day in April 2011 and November 2011 Data on scores based on sample size of 53 patients on medical/surgical units Additional data on scores based on sample size of 23 patients on targeted medical/surgical units 18

19 MEASURE Baseline Data for Path Y All Medical-Surgical Units Interventions Implemented February 21,

20 MEASURE Baseline Data for Path Y All Medical-Surgical Units 4.95 NDNQI Survey My Healthcare Team Involved Me In The Decisions About Controlling My Pain April/Nov 2011 UC Mean Benchmark Mean N=53 Patients 20

21 MEASURE Baseline Data for Path Y All Medical-Surgical Units 4.5 NDNQI Survey My Nurse Suggested Approaches to Help Manage My Pain April/Nov 2011 UC Mean Benchmark Mean N=53 Patients 21

22 MEASURE Baseline Data for Path Y All Medical-Surgical Units 5.65 NDNQI Survey My Nurse Believed My Reports About My Pain N=53 Patients UC Mean April/Nov 2011 Benchmark Mean 22

23 MEASURE Baseline Data for Path Y Voice of Customer (VOC): Patient NDNQI Baseline Survey Results-Targeted Units N=23 English speaking patients interviewed on the target units The following lists the questions that the patients were asked to answer along with the responses. Questions # of Yes Responses % 1. Did you expect you would have pain while in the hospital? 18 78% 2. When the staff came into your room, did they ask about your pain often enough? 20 87% 3. Do you understand the pain scale? % 4. Are you comfortable talking about our pain with the staff? % 5. Does the staff inform you of the plan to manage your pain so you understand? 18 78% 6. When you were in pain, did the staff act as fast as you expected? 19 83% 7. Do you believe the staff do everything they can to manage your pain? 18 78% 8. Do you notice any difference in your pain management day to day? 6 26% 22% of the patients did not expect to have pain. 22% of the patients were not informed about plan to manage pain 26% of the patients noticed differences in the management of pain from day to day paste 23

24 MEASURE Baseline Data for Path Y Voice of Customer (VOC): Patient NDNQI Baseline Survey Results-Targeted Units N=23 English speaking patients interviewed on the target units The following lists the questions that the patients were asked to answer along with the responses. Questions UC Mean Benchmark 50 th Percentile 1. My nurse believed my report of pain I had pain medication available when I needed it My nurse suggested approaches to manage my pain My nurse discussed side effects of pain meds with me The pain medications worked well to control my pain My healthcare team involved me in decisions about pain control Our scores were < 50 th percentile in almost all categories paste 24

25 MEASURE Normality Overall Satisfaction with Pain Management-October 2011-January The P-value is Because the P-value is.05 or more, the distribution is considered normal 25

26 MEASURE Stability Is the process stable (Predictable)? Insert control chart to demonstrate stability The process is stable. Overall Satisfaction with Pain Management-October 2011-January

27 MEASURE Capability What is our baseline performance? How well are we meeting expectations (How good is our process)? Percent Defective:

28 MEASURE Baseline Process Map 28

29 MEASURE Filter X s FMEA Filtering of X s to vital few 29

30 MEASURE Pilot Data Collection for X s Revise and pilot data collection to include data on the vital X s identified in C&E Performance Measure Operational Definition Data Source and Location Sample Size Who Will Collect the Data When Will Data be Collected How Will Data be Collected Other Data that should be Collected at the same time Specialist Seen Time, # of Specialists, PFT, Pts wait time. Shadow pts. And measure how many minutes each specialist takes. Doc. How many specialists are seen including PFT CF Clinic 50 Chad Smith During the first week of the month, 8/29/2007 to 10/5/2007 Data will be collected using digital watch, data collection sheet Day of Wk, any pertinent comments or issues noted during observation. 30

31 MEASURE Voice of Customer (VOC): RN Focus Group Results Focus groups were held in August 2011 with staff from DH32, 4T, 5T & MICU. The focus group consisted of a written survey and verbal roundtable discussion The following themes affecting pain management were identified from the focus groups: Themes 1. Communication 2. Knowledge/Education 3. Process 3. Patient Condition 4. Influence of Supervisors 5. Equipment 6. Complementary Therapy paste 31

32 MEASURE Voice of Customer (VOC): RN Pareto Chart August 2011 Focus groups were held August 2011 with staff from DH32, 4T, 5T & MICU. The focus group consisted of a written survey and verbal roundtable discussion The following themes affecting pain management were identified from the focus groups: Pareto Chart of C C Percent C2 0 Communication Knowledge/ Education Process Patient Condition paste Influence of Superiors Equipment Complimentary Therapy C Percent

33 ANALYZE Analyze Which X s are key? 5 Whys Cause & Effect Analysis 33

34 Analyze 34

35 ANALYZE Fishbone Results from Brainstorming on ALL potential X s 35

36 ANALYZE Cause & Effect Summary Multiple Inputs were originally identified in the SIPOC Common themes were identified via surveys and focus groups These were then rated within categories Patient Satisfaction with Pain Management RN Role in Pain Management MD Role in Pain Management The C & E methodology identified the top Inputs/themes with scores as seen in the next slide The top ranked Inputs/themes guided the work for the Improve phase paste 36

37 ANALYZE Cause & Effect paste 37

38 ANALYZE Cause & Effect Top Five 1. Patient Knowledge-Expecations of Pain Control 2. Caregiver Knowledge-Inconsisent Pain Management paste 38

39 ANALYZE Analyze: 5 Whys of Pain 39

40 ANALYZE Analyze: 5 Whys 40

41 ANALYZE Analyze: 5 Whys 41

42 ANALYZE Analyze: VOC-Nursing Pareto Chart of C C Percent C2 0 Communication Knowledge/ Education Process Patient Condition Influence of Superiors Equipment Complimentary Therapy C Percent Cum %

43 Improve 43

44 IMPROVE Ease v. Impact Based on key X s identified, what improvements were identified? Impact of Change on Patient Perception of Pain Managment Ease of Implementation Pain Scale Poster Pain Goal & Medication Poster Huddle Education Quick Education Sheet Campaign Pain Score Dashboards Pain Score Reports to MD MD Pain Management Education Communication Reminders to MD Require Pain Consult for Chronic Pain Patients Pain Free Campaign-Lounges, Workroom & Intranet Improve Pain Resource Website Visibility 44

45 IMPROVE Interventions What X s were selected for modification? Communication Education What are the Interventions and the key X s they address? Improved Communication: Pain Scale Poster Pain Goal & Medication Poster Poster Campaign-Lounges & Workroom (Potentially) Improve Pain Resource Website Visibility (Potentially) Nursing Education Huddle Education Quick Education Sheet Developed Pain Score Dashboards MD Education Pain Score Reports to MD Communication Reminders to MD Pilot interventions and collect data 45

46 IMPROVE Visual Pain Tools in Every Patient Room 46

47 IMPROVE Ongoing Education-Example 47

48 Control 48

49 CONTROL Control Plan Control Plan to keep Improvements in place Reaction plan/feedback mechanism 49

50 CONTROL Control Plan Control Plan to keep Improvements in place Reaction plan/feedback mechanism 50

51 CONTROL NDNQI Pain Management Study Pre & Post Results Interventions Implemented February 21,2012 NDNQI Pain Management Study Pre-November 2011 & April 2012 Post-April 2012 NDNQI Benchmark My Nurse Believed My Reports About My Pain My Nurse Suggested Approaches to Help Manage My Pain My Healthcare Team Involved Me in the Decisions About Controlling My Pain Evaluation: 1. The questions, My Nurse Believed My Repots About My Pain and My Healthcare Team involved Me in the Decisions About Controlling My Pain improved and out-performed the mean post intervention. The focus of the project was centered on the patient perception of the teams involvement/interest in pain management. These questions reflect that focus. 2. The question, My Nurse Suggested Approaches to Help Manage My Pain scored lower in the post measurement. The focus of the project did not work on this topic, therefore the results are not surprising. 51

52 After key interventions implemented, Audit Results: March 2012 CONTROL Is the pain tool in the room? Visual Pain Tool is present in room 1 0 Yes No No Answer Visual Pain Tool Present in 99% of Pilot Unit Rooms 52

53 After key interventions implemented, Audit Results: March 2012 CONTROL 90 Is the staff RN utilizing the tool? Yes No No Answer 6 Visual Pain Tool is being used by 68% of RNs Education regarding tool was provided 53

54 Right after key interventions implemented, Audit Results CONTROL Can the patient see the tool? Yes No No Answer 0 Visual Pain Tool is visible to 96% of patients 54

55 Right after key interventions implemented, Audit Results CONTROL Does the patient understand the tool? Yes No No Answer 2 82% of patients understand the tool Education regarding tool was provided 55

56 Right after key interventions implemented, Audit Results CONTROL 100 Does the patient like the tool? Yes No No Answer 78% of patients like the tool 56

57 Opportunity for Spread Could other areas of the organization benefit from a similar improvement effort? Plan is to disseminate interventions to entire organization once pilot is completed and any needed changes are finalized. 57

58 Right after key interventions implemented, Audit Results CONTROL Is the pain tool helping you and your nurse manage your pain effectively? Yes No No Answer 64% of patients think pain tool is helping team to effectively manage pain Education regarding tool was provided 58

59 CONTROL? Final Data for Y-Template HCAHPS Composite. Overall Satisfaction with Pain Management on DH32, Tower 4 & 5 (Pilot Units) Data on scores based on sample size of 619 patients discharged from September 2011 through December Baseline: Sept 2011-January 2012 Overall Pain Management Patient Satisfaction Pilot Units Improve Phase Begun January 2012: 1. Education 2. Pilot Pain Poster and Pain Thermometer 3. Flexibility added to medication administration policy 4. Patient Education: Pain Management Video Installation of revised White Boards & New Pain Tools in medical/surgical units Essence of Nursing-Oct-Dec classes- Focus on patient-centered care/pain management Top Box % Goal 59

60 MEASURE Final Data for Y-Template Baseline data from HCAHPS Patient Satisfaction Survey: DH32, Tower 4 & 5 Question How often staff did everything they could to help with pain? Data on scores based on sample size of 619 patients discharged from September 2011 through December How Often Hospital Staff did Everything They could to Help with Pain Data collection/focus groups: August 2011-January 2012 Installation of revised White Boards & New Pain Tools in medical/surgical units Baseline: Sept 2011-January 2012 Improve Phase Begun January 2012: 1. Education 2. Pilot Pain Poster and Pain Thermometer 3. Flexibility added to medication administration policy 4. Patient Education: Pain Management Video Essence of Nursing-Oct-Dec classes- Focus on patient-centered care/pain management Top Box % Goal 60

61 MEASURE Final Data for Y-Template Baseline data from HCAHPS Patient Satisfaction Survey: DH32, Tower 4 & 5 Question How often staff pain was well controlled? Data on scores based on sample size of 619 patients discharged from September 2011 through December How Often Pain Was Well Controlled Patient Satisfaction Data collection/focus groups: August 2011-January 2012 Installation of revised White Boards & New Pain Tools in medical/surgical units Essence of Nursing-Oct-Dec classes- Focus on patient-centered care/pain management Top Box % Goal 61

62 Overall Pain Management Patient Satisfaction Top Box % Goal paste 62

63 MEASURE Percent Probability Plot of Always1 Normal Normality Mean StDev N 11 AD P-Value <0.005 Overall Satisfaction with Pain Management-October 2011-January Always The P-value is < Because the P-value is not.05 or more, the distribution is considered normal 63

64 MEASURE Proportion Tests performed with unequal sample sizes 3 Stability Is the process stable (Predictable)? 4 P Chart of Always Sample Insert control chart to demonstrate stability UCL=1 _ P=0.659 LCL=0.249 The process is stable. Overall Satisfaction with Pain Management-October 2011-January

65 MEASURE Proportion Binomial Process Capability Analysis Pain Post Intervention P Chart Capability UC L= _ What is our baseline P= performance? 40 How well are we meeting LC L= expectations (How good is our process)? Sample Tests performed w ith unequal sample sizes % Defective 60 Rate of Defectives Sample Size Cumulative % Defective H istogram % Defective Sample Summary Stats (95.0% confidence) % Defectiv e: Low er C I: Upper C I: Target: 0.00 PPM Def: Low er C I: Upper C I: Process Z: Low er C I: Upper C I: Frequency Tar Percent Defective: % Defective