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1 TITLE (all caps, Arial 32pt, white, centered) Incorporating Patient Experience into mandatory Quality Improvement Plans:The Journey to Date in Ontario, Canada 017th Annual NRC Picker Patient Centred Care SymposiumSalt Lake City, UTSeptember 27, 2011Dr. Ben Chan, MD MPH MPAP resident and CEO, Health Quality Experience Surveying in Canada BC, Ontario:NRC Picker Alberta, SK:HCAHPS New Brunswick:proprietary survey No consensus on uniform standard Discussions currently on standardizing on at least 11 Discussions currently on standardizing on at least some core Experience in Public Experience in Public patient experience much lower in ED compared to hospital in-patient careMajor Areas for Improvement Major areas for improvement: Timeliness (48% say wait too long to see doctor) Adequate pain control (52% ED vs 78% hosp) One-third of patients do not receive answers they can understand % Percentage of patients who received answers they could understand when they asked important questions: to nurses, 66%.

2 To doctors, 70%44when they asked important questions: to nurses, 66%; to doctors, 70% Explain results of tests in a way you could understand: 65% Information at discharge Danger signs to look out for 51% Whom to call if need help 61% Care for All Act, Care for All Act mandatory QI plans mandatory patient & staff satisfaction surveying Patient declaration of values Quality committees of the Board Executive compensation tied to quality Expand mandate of provincial quality council (now Health Quality Ontario ) equivalent of QIO in USA66 Ontario ) equivalent of QIO in USA Public reporting Support quality improvement activities Recommendations on funding of health services recommendations on clinical practice guidelines & tools Start with hospitals; expand eventually to other sectorsQI Plans What s Their Purpose?

3 Their Potential? A best practice for organizational leadership on quality Limited priorities, set targets & timeframes, identify strategy for improvement, communicate plan Tool for learning among organizations77 Preserve public confidence Engage the public / usersWhat Information to Include About Each Indicator in the Plan?AIM8 MeasureChangeCharacteristics of a Solid QI Plan Defined baseline Defined target that is a reasonable stretch target Clear articulation of a range of change ideas Measures/indicators to monitor whether change idea has been implemented Are Best Practices Not Adopted? Root CauseChangesProviders unaware of how poor performance actually isMeasurement and feedback systemsEasy to forget, busy, too complicated, unaware of best practiceReminder systems, clinical decision supportsPoor processes, non-standardizedRedesigned processesLack of skill to perform best practice, or deteriorationover timeTraining AND skills verification1010or deteriorationover timeWrong, or lack of resourcesTargeted investmentsPatients unaware of their role or options, not engagedPatient engagement education, involvement in designNo incentive or motivation to changeRecognition, rewards, inspiring leadership, accountability, performance Plan FLEXIBILITY Pull to different measures.

4 PrioritiesCOMPARABILITY OF PLANS Need standardized measures Align to provincial priorities12 Achieving the right balanceIndicators for QI Plan: Common Requirements Safety: Include at least one of the following: C difficile, hand-washing, VAP, CLI, falls, pressure ulcers Accessible Include ED wait times for complex patients Effectiveness / Efficiency1313 Effectiveness / Efficiency Include ALC, readmissions, total margin; HSMR if already large enough for public reporting Patient Experience Include at least one indicatorExecutive Compensation Applies to CEO and all of his/her direct reports Discretion left to Boards regarding: % of overall pay at risk Number of targets to meet Ambitiousness of Plans for Patient Plans for Patient in the detailsExperience with QI PlansAfter Year 1 Experience Choice As Priority in QI Plans# Rank as priority 1# Rank as any priority% Rank as priority 1 Acute Teaching41225%Large Community244738% Community244738%Small Community183534%Ccc & Rehab51631%Mental Health22450%TOTAL5311435%Popularity of Topic as Priority Compensation % at risk varies from1% to 25% Implemented during period of concurrent pay and Topic Measures of Patient Experience Choices.

5 % who would definitely recommend this institution to friends/family? HCAHPS: overall rating of quality of care, scale of 0 to 10 NRC-Picker:% who rate their quality as excellent2222 NRC-Picker:% who rate their quality as excellent(from choices - excellent, very good, good, fair, poor) Experience All hospitals that use NRC-Picker requested to include a goal for the global indicator % who would definitely recommend this hospital to family or friends In order to make any progress in this global indicator, hospitals should pick specific ideas for improvement232323 Proposed Choices for Sub-Topic for QI Plans Communication Courtesy/respect Discharge transitions Pain control Physical environment (cleanliness, etc.)2424 Physical environment (cleanliness, etc.) Responsiveness ( call bell response) Food Base either on specific questions or index of basket of Performance Goals:Original Guidance to Field Consider best practice in province or worldwide VAP, CLI rate 0 % definitely recommend at 80-90% among leaders in USA.

6 74% average in Ontario2525 Consider decreasing gap from current to best by half Consider pace of improvement seen elsewhereStatistical Variation in Measures Random variation in all measures Greater variability if: Rare event Smaller hospital Small sample size Can lead to difficulty in making determination that a 2626 Can lead to difficulty in making determination that a true improvement took place26 Approach to Statistical Variation Step 1: consider target for an indicator Step 2: calculate % improvement anticipated Step 3: examine (using simple guidelines in next slides, or formal statistical tests) whether this level of improvement could be detected statistically Step 4: if it cannot, consider the following options:2727 Step 4: if it cannot, consider the following options: Consider a more ambitious target Consider making this a multi-year target instead.

7 Do not tie exec comp to indicator this year Consider other indicators for the same problem, with more frequent observations or greater ability to make large change Base the baseline on longer time period ( past 2 yrs) Collect more data ( more surveys)27 Patient Experience SurveyIf last year's score was:This coming year's score would have to reach this level before you could say you ve made a statistically significant improvement:if collect 100 surveys / yr)if 300 surveys / yrif 1000 surveys / yr50%64%58%54%282850%64%58%54%60%73%68%6 4%70%82%77%74%80%90%86%83%28 Assuming same sample size each Variation Some indicators fluctuate during the year Busy ED at Christmas, flu season, March break Options for dealing with seasonal variation: Ensure same-quarter comparisons Compare 2010-11 Q4 with 2011-12 Q4; do not compare 2010-11 Q3 to 2011-12 Q42929compare 2010-11 Q3 to 2011-12 Q4 Use four-quarter or 12-month rolling averages ok to compare Dec09-Nov10 to Apr11-Mar1229 Patient Experience - Data Current challenges with provincial survey: Turnaround time for most recent results 3-5 months Standard reports come only every quarter Sampling frame often makes it difficult to track improvements in a ward where ideas being tested3030 the number of surveys collected per month may be too small to detect early improvement30 Patient Experience Data for Quality Improvement mini-surveys.

8 Select a small number of questions from the NRC-Picker survey that reflect areas for improvement in the plan Create a mini-survey by putting these survey questions on a single or half-sheet of paper3131 distribute to patients just before discharge Let patients deposit anonymously ( into box with a slit) Run continuously during an improvement process, on units where trying new ideas Use to monitor whether intended changes moving quality in the right direction, feed PDSA cycles31 Ideas for Management, Trillium HospitalExample of Broad Range of Change Management at TrilliumRange of Change IdeasChangesPain Management IdeasMeasurement and feedback systemsPain mgt databaseReminder systems, clinical decision supports Standard order setsRedesigned processesPre-procedure protocols, pain mgt plans, narcotics standardizationTraining AND skills verificationPain asmt skills investmentsCreate pain mgt team available for consultsPatient engagement education, involvement in designPt teaching on participating in pain assessmentRecognition, rewards, inspiring leadership, accountability.

9 Performance compPain committee accountable to MACPain Management at TrilliumMeasures to Track Change IdeasPain Management IdeasMeasures of SuccessPain mgt databaseStandard order setsChart audits on usePre-procedure protocols, pain mgt plans, narcotics standardizationChart audits on usePainasmtskills trainingCreate pain mgt team available for consults# of consults,% satisfied w/ teamPt teaching on participating in pain assessment% of pts attending trainingPain committee accountable to MAC# of mtgs, % attendanceCommon Change Ideas Causes Why Is Communication So Poor? Volume of information Lack of general literacy or health literacy Misinterpretation of different terms Stress of ED visit (can t absorb info if feeling 3939overwhelmed or weak from illness) Easy for patients to Change Ideas Improved communication Communication about specific issues: expected wait times, next steps in delivery of care diagnosis, test results discharge plan (what to do, warning signs, who to call)4040 Communications tools: teach back Written discharge Teach Back Can you repeat back to me in your own words what you are going to do when you go home?

10 Requires specific staff training AND skills verification Requires investment of on-going staff time May require some form of on-going monitoring re: its use4141 May require some form of on-going monitoring re: its Written Discharge Instructions Your diagnosis is: _____ Actions to take at home: _____ Take the following medications: _____ Name, dosage, duration, reason for the medication, changes Follow up: _____ (provider appts or tests, date) 4242 Follow up: _____ (provider appts or tests, date) Come back to the ED if you have these warning signs: _____ Who to call if you have questions: Discharge Instructions Considerations in plan: Monitor how consistently they are being used Monitor how understandable they are to for Strengthening QI PlanImprovement InitiativeMethods and Results TrackingTarget Written discharge instructions% of pts w/ written d/c instructions based on audit or survey95%% of pts who could repeat back d/c instructions95%Teach back% of ED staffwith verifiedteach back 60% this year, 4444 Teach back% of ED staffwith verifiedteach back skills based on simulation exercise60% this year, 95% by year 2% of patients who had teach-back done, based on mini-survey60% this year, 95% by year Change Ideas Soliciting ideas for improvement Engagement of patients, families Engagement of Change Ideas Soliciting ideas for improvement Engagement of patients, families Engagement of staffExample.