What are the things you should always do?
Program funds projects with positive effects
In the 25 years since the Picker Institute was founded to focus on patient-centered care, the organization has specialized in talking about the positive part of healthcare — the things that should always be done that benefit the patient and family — rather than about those never events that make headlines.
Now, Picker has created an entire program that focuses on developing pilot projects for what they call "Always Events," proving their worth, and spreading the word about their impact. Two years ago, the Picker board wanted to accelerate action on patient-centered care, says Dale Shaller, principle of Shaller Consulting in Stillwater, MN, and one of the key architects of the program. More than 150 people worked on creating the Always Event program, including patients and their families, physicians and other providers, thought leaders, measurement experts, and other stakeholders from the healthcare world.
Always Events are defined as follows:
- Significant: Patients have identified the experience as fundamental to their care.
- Evidence-based: The experience is known to be related to the optimal care of and respect for the patient.
- Measurable: The experience is specific enough that it is possible to accurately and reliably determine whether it occurred.
- Affordable: The experience can be achieved by any organization without substantial renovations, capital expenditures or the purchase of new equipment or technology.
Patient-centered care
In 2010, the project kicked off, with participants determining that two things were vital to every aspect of patient-centered care: communication and care transitions. Those were to be the initial focus of Always Events projects. A call for proposals resulted in more than 80 applications; Picker granted funds to 21 of them for demonstration projects, and another 19 graduate medical education grantees agreed to incorporate Always Events into their projects.
These projects are discussed by grantees at monthly teleconferences, and results are shared with the world at large through a compendium of stories and tools available on the Always Events website (http://alwaysevents.pickerinstitute.org/).
Picker is probably best known for its family of satisfaction surveys — Consumer Assessment of Healthcare Providers and Systems (CAHPS) — which give quarterly feedback on how hospitals are doing from the patient perspective. Shaller says that it is increasingly clear that patient perception matters to outcomes. Next year, Medicare will address that fact through payments related to how a hospital does on issues of communication, transitions of care, and the responsiveness of staff, he notes. "There is more weight attached to this now."
Organizations seeing positive results
So there is data that this is important, there is increasingly money tied to it — why a program to put more emphasis on it? Because, says Shaller, "we have known for some time that this isn't just frosting; it matters. We know these things need to be done, but they aren't getting done. This is a device to get organizations to pay more attention." Playing the National Quality Forum's phrase "Never Events" in a positive way engages providers, too, he adds. "Most people get into healthcare to help people. It is an optimistic thing, and they love this idea. Rules and regulations beat them down. They feel beleaguered. This is something positive for them to respond to."
It's only been a year, but many organizations are starting to see their projects reap positive results.
At the University of Pittsburgh Medical Center, a program called Guardian Angels helps people who come to the hospital after a family member has been involved in a trauma or serious event like a transplant surgery navigate the system. The idea was hatched after staff shadowed patients and families as they traversed the healthcare system and realized that figuring out what you should or could do is difficult when you are in a state of shock over a sudden event. Nursing and social work students fill the role of angel for patients and their families. Sometimes they do no more than show people where to go.
Another example is Vanderbilt University, says Shaller, which created a fall prevention video for patients and their families and is tracking how many people watch it, whether they report it as being useful, and the rate of falls before and since it was created.
Some ideas originate from programs designed to help specific populations with special needs, like pediatrics. At St. Jude's in Memphis, parents of patients will soon have access to a mentoring program, says Kathryn Berry-Carter, CAVS, CVA, director of volunteer services for the facility. Those who have been through the process are trained to assist those who are new to the hospital in whatever way they need. "They know what it's like to have a child who is extremely ill and can provide a kind of support that a staff member can't," she says.
Currently, they are putting together policies and procedures and will roll out a pilot in the solid tumor clinic starting in March, with between nine and 12 families and three to six mentors. After three months, they will assess how it is going using focus groups, satisfaction surveys of staff, mentors, and families, and then decide where to go.
Berry-Carter says research indicates that parent-to-parent mentoring can reduce anxiety, improve the ability of parents to cope in the hospital, and thus allow parents to be more present for the patient. That can have a positive effect on the patient's health, too, she says. "Treating the family helps treat the child's illness."
This kind of mentoring has been ongoing in an informal way for as long as parents have met in the waiting rooms of children's hospitals and pediatric wards. "We want to formalize it, provide training and expertise, and ensure they can do an even better job," Berry-Carter says. Chaplain services, social workers, psychologists, providers, and Berry-Carter are all working on the program, along with several parents from the family advisory council.
Berry-Carter says the team has worked to develop a timeline, a name and logo for the program, the qualities and qualifications of mentors, and processes for ensuring there is a diverse group of mentors available for the diverse patient and family base that goes to St. Jude's. The group has created policies on where mentoring should occur, how to match mentors and parents, the screening and interviewing process, training, debriefing protocols for the mentors, and what items should be reported from the mentor to the staff. Confidentiality is an issue, given privacy laws, so they are creating forms and determining how to submit them. IT is getting involved in that part, Berry-Carter adds. Importantly, the group is also creating hard goals for the program. That's key to getting a Picker grant — Always Events have to be evidence-based, which means a degree of formality is imperative.
Getting to know patients
At the University of Minnesota Medical Center and Amplatz Children's Hospital, nurse manager Cheristi Cognetta-Rieke, BSN, RN, was working on her doctorate and came up with a project that works for both her degree and the Picker project. Called MyStory, the idea is to ensure that children in the hospitals are not treated as a disease or a room number, but as whole human beings.
"There is a lot of literature that if you want better outcomes, children need to be involved in their care planning and care delivery," Cognetta-Rieke says. "But often, the provider will go into the room and talk to the parents, not the child." Compare that to almost any other situation where an adult is in a situation with an adult and child: The child is almost always greeted first. "We just don't involve kids in acute care settings as much as we should."
Her idea was to create some sort of document that would provide caregivers with information that the patient wanted them to know about him or her, determine its best placement, and then teach caregivers how to make use of it.
She met with patients and their families to determine what information would be most helpful for the providers to know, such as what comforts them, what frightens them, their favorite music, or their goals. One item might help a nurse who is trying to calm a patient for a procedure, while knowing what big events are coming up might help a physician tweak a treatment so that it allows the patient to attend.
After figuring out what questions to ask patients, Cognetta-Rieke had to figure out what to do with the information. Putting it on the door or just inside the door was one idea, but that wouldn't allow providers in other parts of the hospital to have access to it. If a patient was going from her room to dialysis, how would the dialysis clinic know what it should about the patient? They decided to put it in the electronic medical record. It's now one of the first fields a provider will see in the record, she adds.
Next was a way to get providers to make use of the information. "This isn't a nicety, but a necessity," Cognetta-Rieke says. "They are obligated to know this stuff." To that end, patients and parents are asked questions relating to the MyStory project and the results are to be posted quarterly for patients, the public, and providers alike to see, using a dashboard similar to any other quality improvement program.
The first set of results is due out in early January, but already there are anecdotal reports of positive results. Patients say that the care is gentler, and parents say there is more direct communication with their kids. They feel more comfortable not being in the room when a provider is there because the providers themselves know what calms and distracts the children.
Cognetta-Rieke says she can tell from her knowledge of particular patients whether it's working. One patient, for instance, put in her MyStory that she was afraid of people in white coats. Now, when Cognetta-Rieke is on that patient's unit, she can look outside the door to her room and see white coats hung up: Providers aren't wearing them in the room.
"I don't know that you can ever prove that this kind of thing directly leads to improved outcomes," says Cognetta-Rieke. "Maybe we can look at length of stay or pain management." In short order, she says she expects results to spur expansion of the program to adult inpatients and outpatient settings.
In the end, Shaller says it all comes down to asking patients and their families what they want and what they need, and then acting on it. In a year, the Picker Institute will hold a grand conference to release information about the projects involved. Meanwhile, participants and others can make use of tool kits, suggestions, and strategies available on the Always Event website.
For more information on this topic, contact:
- Dale Shaller, Shaller Consulting Group, Stillwater, MN . Telephone: (651) 430-0759.
- Cheristi Cognetta-Rieke, BSN, RN, Acute and Critical Care Float Pool Nurse Manager, University of Minnesota Medical Center, Fairview and University of Minnesota Amplatz Children's Hospital, Minneapolis, MN. Telephone: (612) 273-4123. Email: [email protected].
- Kathryn Berry Carter, CAVS, CVA, Director of Volunteer Services, St. Jude Children's Research Hospital, Memphis, TN. Telephone: (901) 595-2277. Email: [email protected].
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