Glossary
EP - Exemplary Professional Practice

EP35EO: Describe and demonstrate the patient satisfaction data aggregated at the organizational level outperform the mean of the database used. Provide analysis and evaluation of data and resultant action plan related to patient satisfaction addressing four (4) of the following: Pain, Education, Courtesy and respect from nurses, careful listening by nurses, response time and other related questions.

Findings:

None of the indicators of patient satisfaction with nursing demonstrated outperformance of the benchmark statistics the majority of the time:

  • Skill of the Nurse does not relate to any of the five required indicators for EP35EO
  • The data presentation for the inpatient areas were not clear:
    • The same benchmark value was used for multiple units (4E, ICU and medical-Surgical for all (8) quarters
    • For behavioral health, data for only to indicators that relate to one of the five required were presented
    • Only 4 inpatient units data were reported

The required format for presentation of the data (graphs and tables) was not used.

The types of benchmark statistics and database cohort groups were not specified on the graph for each of the indicators.

Resolutions:

  • Required HCAHP Nurse Sensitive Questions used
  • Different benchmarks values used for each quarter
  • Behavioral questions omitted
  • Data was presented for six inpatient units (Critical Care Division, 4E Post Partum Unit, 6E, 6W, 7E, and 7W)
  • Required format for presentation of the graphs and tables were used
  • Benchmark statistic and database cohort group specified on the graph for each indicators
  • Updated Action Plan presented in addition to plan previously discussed in original narrative

Jersey City Medical Center utilizes Press Ganey as its vendor for measuring patient satisfaction for our inpatient units. Our data obtained through Press Ganey is benchmarked against a national average. Press Ganey is also our national vendor for HCAHP survey questions as required by the center for Medicare and Medicaid services.

The HCAHP Nurse Sensitive Questions

The HCAHP Nurse Sensitive Questions
*Please note that HCAHPS benchmarks are the same across all units, including critical care, as HCAHPS does have specialty level benchmarks


Analysis and Evaluation:

Patient satisfaction and engagement is a major focus at Jersey City Medical Center and constitutes one of four pillars that drive all strategic planning for the institution. Unfortunately, 5/6 patient care units do not outperform the large Press Ganey Database percentile median comparative the majority of the time. Over the past 3 years we have assessed our survey scores and collaborated with Press Ganey on methodologies to improve our performance. In concert with this, we have developed and implemented several initiatives based on industry best practices and our specific patient responses and comments. As previously discussed, these initiatives resulted in unit based daily huddles, hourly rounding, senior administration rounding on staff and patients, implementation of quiet times, discharge phone calls to all patients, employment of an Engagement Coordinator and associates to round on every patient every day and many other best practices. Despite all of these measures our scores have not consistently improved. Of major concern to us is the consistently low number of survey returns and the risk that we have not reached our targeted demographic. Forty per cent of our patient population is Latino. Please review below for a demographic breakdown of the population of Jersey City by ethnicity:

The HCAHP Nurse Sensitive Questions

 
In discussion with Press Ganey, we determined that Spanish surveys were not routinely sent to our patients. Please review table below.

We have worked with Press Ganey to ensure that Spanish surveys are sent to all patients reporting Spanish as their primary language

Spanish Survey Responsec

Spanish Survey Response

Data Provided by Press Ganey 2013

As is made clear by the table, after working with Press Ganey, June and July have a much higher rate of Spanish surveys being mailed. It is still too early to determine the response rate.

Of similar concern is the overall response rate to surveying. As reported by Press Ganey, the average National response rate is 23.7%. Our survey response rate results fluctuate between 4.7%-9.0%. Our HCAHPS response rate is 16.7% and the National average is 32.7%. Please review the table provided below.

Standard Inpatient Survey

Standard Inpatient Survey

Data Provided by Press Ganey 2013 *National Response Rate for Inpatient is 23.7% National Undeliverable Rate is 3%

HCAHPS

HCAHPS

Data provided by Press Ganey 2013 National Response Rate for HCAHPS is 32.7%

Our belief is that one contributing factor is our high rate of undeliverable surveys. The National average for undeliverable surveys is 3% and our rate has been as high as 11.7%.

Recently, considerable energy has been focused on increasing the response rate and decreasing the undelivered survey rate. Surveys are deemed undeliverable for a variety of reasons, including:

  • Expiration of mail forwarding
  • Refusal by the addressee
  • No mail receptacle
  • No forwarding address
  • No apartment number
  • Now deceased

The number of undeliverable surveys is also affected by the improper use of the address 2 field that usually includes apartment numbers. Nursing and Patient Engagement are working closely with the Patient Access Department to audit the use of this field to ensure that all appropriate information is available to Press Ganey.

Understanding that the number of surveys returned has significantly impacted our scores, in 2012 we did a pilot study in the Emergency Department in conjunction with Navio Inc. to determine whether switching to a text or email based survey would improve response rate. We saw an increase in the number of surveys for the first month. The following three months declined to the same response rate as paper based surveys. As a result of these findings, we have decided to stay with Press Ganey mail based surveys. We will continue to monitor the response rates monthly and maintain close communication with Press Ganey as well as the Patient Access Department.

The strategic plan for the Engagement Pillar for 2013 further developed unit based initiatives focused on nurse to patient and family communication, including the expansion of daily patient care rounds, incorporating the use of the white board and improving team work through the implementation of Team STEPPS throughout the institution and specifically on pilot units. Communication with physicians at all levels has been fostered by inclusion of patient engagement scores and discussion in every physician meeting. The CNO has a standing agenda discussion on communication and team approach to patient care at every Medical Executive meeting and at semi-annual physician meetings. The CEO has added patient engagement to the senior executive Monday morning meeting. This discussion is focused on improving process, supporting the needs of the nurses in providing care and eliciting ways to engage our patients and community in the process of care.

Recognizing that all of our efforts have not resulted in consistent improvement in our scores, the CEO and senior team have committed increased financial resources to engaging the Gallup organization to perform a system wide assessment of our culture, population and community expectations and barriers to improving performance. This assessment will form the backbone of a full engagement to work with the organization at all levels to create and sustain a culture of patient and staff satisfaction and engagement. This process has begun and will continue throughout 2013 and into the next three years.

HCAHPS: Courtesy and Respect Analysis and Evaluation

Critical Care Division

The Critical Care Division outperformed the HCAHPS large Press Ganey Database percentile median comparative in seven of eight quarters for inpatient question, “Nurses “always” treated you with courtesy and respect”.

Critical Care Division


4E Post Partum Unit

4E outperformed the HCAHPS large Press Ganey Database percentile median comparative in two of eight quarters for the inpatient question, “Nurses “always” treated you with courtesy and respect”.

4E Post Partum Unit


6E Telemetry

6E did not outperform the HCAHPS large Press Ganey Database percentile median for the inpatient question, “Nurses “always” treated you with courtesy and respect”.

6E Telemetry


6W Medical Surgical

6W did not outperform the HCAHPS large Press Ganey Database percentile median for the inpatient question, “Nurses “always” treated you with courtesy and respect”.

6W Medical Surgical


7E Medical Surgical

7E did not outperform the HCAHPS large Press Ganey Database percentile median for the inpatient question, “Nurses “always” treated you with courtesy and respect”.

7E Medical Surgical


7W Medical Surgical

7W outperformed the HCAHPS large Press Ganey Database percentile median comparative in two of eight quarters for the inpatient question, “Nurses “always” treated you with courtesy and respect”.

7W Medical Surgical

HCAHPS: Careful Listening Analysis and evaluation

Critical Care Division

The Critical Care Division outperformed the HCAHPS large Press Ganey Database percentile median comparative in seven of eight quarters for inpatient question, “Nurses “always” listen carefully to you”.

Critical Care Division


4E Post Partum

4E outperformed the HCAHPS large Press Ganey Database percentile median comparative in four of eight quarters for inpatient question, “Nurses “always” listen carefully to you”.

4E Post Partum


6E Telemetry

6E outperformed the HCAHPS large Press Ganey Database percentile median comparative in four of eight quarters for inpatient question, “Nurses “always” listen carefully to you”.

6E Telemetry


6W Medical Surgical

6W did not outperform the HCAHPS large Press Ganey Database percentile median for the inpatient question, “Nurses “always” listen carefully to you”.

6W Medical Surgical


7E Medical Surgical

7E did not outperform the HCAHPS large Press Ganey Database percentile median for the inpatient question, “Nurses “always” listen carefully to you”.

7E Medical Surgical


7W Medical Surgical

7W outperformed the HCAHPS large Press Ganey Database percentile median comparative in one of eight quarters for inpatient question, “Nurses “always” listen carefully to you”.

7W Medical Surgical


HCAHPS: Response Time Analysis and evaluation

Critical Care Division

The Critical Care Division outperformed the HCAHPS large Press Ganey Database percentile median comparative in seven of eight quarters for inpatient question, “Call button help “always” as soon as wanted.

Critical Care Division


4E Post Partum

4E outperformed the HCAHPS large Press Ganey Database percentile median comparative in five of eight quarters for inpatient question, “Call button help “always” as soon as wanted.

4E Post Partum


6E Telemetry

6E outperformed the HCAHPS large Press Ganey Database percentile median comparative in one of eight quarters for inpatient question, “Call button help “always” as soon as wanted.

6E Telemetry


6W Medical Surgical

6W did not outperform the HCAHPS large Press Ganey Database percentile median for the inpatient question, “Call button help “always” as soon as wanted”.

6W Medical Surgical


7E Medical Surgical

7E outperformed the HCAHPS large Press Ganey Database percentile median comparative in one of eight quarters for inpatient question, “Call button help “always” as soon as wanted.

7E Medical Surgical


7W Medical Surgical

7W outperformed the HCAHPS large Press Ganey Database percentile median comparative in one of eight quarters for inpatient question, “Call button help “always” as soon as wanted.

7W Medical Surgical


HCAHPS: Pain Analysis and evaluation

Critical Care Division

The Critical Care Division outperformed the HCAHPS large Press Ganey Database percentile median comparative in seven of eight quarters for inpatient question, “Pain “always” well controlled”.

Critical Care Division


4E Post Partum

4E outperformed the HCAHPS large Press Ganey Database percentile median comparative in three of eight quarters for inpatient question, “Pain “always” well controlled”.

4E Post Partum


6E Telemetry

6E outperformed the HCAHPS large Press Ganey Database percentile median comparative in two of eight quarters for inpatient question, “Pain “always” well controlled”.

6E Telemetry


6W Telemetry

6W outperformed the HCAHPS large Press Ganey Database percentile median comparative in five of eight quarters for inpatient question, “Pain “always” well controlled”.

6W Telemetry


7E Telemetry

7E did not outperform the HCAHPS large Press Ganey Database percentile median comparative for inpatient question, “Pain “always” well controlled”.

7E Telemetry


7W Telemetry

7W outperformed the HCAHPS large Press Ganey Database percentile median comparative in one of eight quarters for inpatient question, “Pain “always” well controlled”.

7W Telemetry

Updated Action Plan

In 2013, we have implemented a new patient engagement plan which incorporates the principals of communication, teamwork and responsiveness of nurses. This plan was developed collaboratively between the Department of Nursing and the Engagement team. The Action Plan is a three-phased, two year plan which incorporates the Interdisciplinary team.v

Yvonne Sellerolli RN, BSN, Patient Engagement Coordinator is an integral member of this team. She has recently employed three (3) Patient Engagement Associates whose primary functions are to round on the Medical/Surgical units and facilitate communication between patients, their family and their care givers. They partner with staff to create a culture of collaboration for patient engagement. They perform and utilize service excellence scripting and service recovery strategies. Please refer to (Appendix EP35EO-A) for a Job Description.

The revised plan focuses in on the HCAHPS scores and incorporates the following tactics: Please refer to (Appendix EP35EO-B) for the Engagement Plan.v

  • Create an enhanced patient engagement culture
  • Increase HCAHPS “Communication with Nurses”
  • Increase HCAHPS “Communication with Doctors”
  • Increase HCAHPS “Responsiveness of Hospital Staff”
  • Increase HCAHPS “Pain Management”
  • Increase HCAHPS “Communication about Medication”
  • Increase HCAHPS “Hospital Environment”
  • Increase HCAHPS “Discharge Information and Transitions of Care”
  • Support and execute the Service Excellence/Engagement Plan
  • Increase staff accountability/involvement in hospital engagement strategy

In addition, the Department of Nursing is in the process of initiating the TeamSTEPPS program. TeamSTEPPS is an acronym for Strategies and Tools to Enhance Performance and Patient Safety. The objective is to improve teamwork and communication, particularly with the interdisciplinary health care team, which will create a culture of safety. All of our Educators enrolled in a TeamSTEPPS program and became Master Trainers and they are key to the implementation of this process hospital wide. Educators that attended the sessions include: Ebony Samuels RN, MSN, Nurse Educator, Randa Francis RN, MSN, CNM, WHCNP-BC, Maternal-Child Health Educator, Michele Dickerson RN, MSN, RNC-NIC, NICU Educator, Nicole Sardinas RN, MSN, CCRN, Director of Education, Colleen Masterson RN, BSN, Nurse Educator. To date this process has been presented at Administrative Conference, to Nursing Administration, and Nursing Leadership. Several training sessions for the residents, hospitalists and primary physicians has been established as well as sessions for the nursing staff on the pilot units. The pilot units are: Newborn Intensive Care Unit, 7 East (Medical/Surgical), and Maternal/Child Health (4 East and 4 West). These pilot units were chosen because they have unit-based educators who are Master-Trained and can participate in the roll-out. A core team will be selected from each unit who will be the champions of the project and will assist with any problems that arise. Please review Action Plan in (Appendix EP35EO-C)

Additionally, nursing has also reinvigorated the Hourly Rounding process on the units. Hourly Rounding is performed on every patient and the four (4) P’s are addressed (Pain, Position, Potty and Placement). The goal of the rounds is to increase patient safety and decrease the incidence of call bells as well as to increase patient satisfaction. The nurses and the Patient Care Technicians initiate these rounds on the units and the Patient Engagement Associates, as well as the Managers and Directors audit directly with the patients to ensure that rounds are being performed. Please review (Appendix EP35EO-D and EP35EO-E and EP35EO-F ) for hourly rounding brochure, power point and rounding audit tool.

Furthermore, nursing is in the process of establishing a Call Center to prevent readmissions. The RelayCare software package was purchased which is a methodology whereby patients with specific identified diagnoses, those most frequently readmitted, are called post-discharge to insure compliance with discharge instructions and medication regime. The diagnoses that we are most focused on include: Pneumonia, Congestive Heart Failure, Diabetes and Acute Myocardial Infarction. The software provides clinical decision support tools, questionnaires for the patients and a plan of care as well as reference material and educational tools. This project improves patient satisfaction in that it follows-up on discharge information and insures that the patients are taking their prescribed medication and have made a follow-up doctors visit. The Call Center will assist our patients with this process and insure that the discharge instructions are being followed. The Call Center will also make the appropriate referrals and work very closely with the community navigators to prevent the patient from being admitted. The project comes under the auspices of Mabel LaForgia RN, MSN, CCRN Director of Research and Evidence Based Practice. Ingrid Cardenas RN, BSN is the recently hired Nurse Manager of this area. Please review (Appendix EP35EO-G) for meeting minutes from implementation team.

The Department of Nursing, in collaboration with Dr. Shu M.D., Pain Management physician from the Department of Anesthesia, is in the process of initiating a Pain Management Team. The Pain Management Team includes: (See table below)

EP35EO_Table5

An initial meeting has been held in order to establish the goals of the Team as well as a process for choosing the patients and establishing the rounding process. Please review (Appendix EP35EO-H) for recent meeting minutes. Dr. Shu also developed a Race To Zero guideline to in order to outline roles and responsibilities and to insure that the team is assessing properly as well as providing an appropriate plan of care relating to pain management. Please review (Appendix EP35EO-I) for a sample of the tool. It was determined that Dr. Shu and Dr. Padma would screen the patients to be visited based on a pain scoring assessment generated from Sorian (EMR). Please review a screen shot of tool in (Appendix EP35EO-J). Dr. Shu decided that five (5) patients per day would be selected as a start. The team would visit these patients and complete a short tool on the level/extent of their pain and the responsiveness of staff. Please review (Appendix EP35EO-K) for a sample of the rounding tool. Dr. Shu will consult with the primary physician regarding any ongoing pain issues which remain unresolved. Follow-up visits will be made on these patient’s to ascertain success of the intervention(s). The Pharmacist will round with the team at least twice per week in order to make recommendations as to narcotic equivalencies, duration of action, potential interactions, and mechanism of elimination. He/she will track medication usage during the hospital stay.