An interview with Lee Ann Hanna, Director of Education, TriStar Centennial Medical Center (HCA), Nashville, Tennessee
Currently the Director of Education at TriStar Centennial Medical Center (HCA), Nashville, TN, Ms. Hanna has over thirty years experience in healthcare settings; sixteen years experience in neonatal, pediatric, and adult critical care; and fifteen years experience in knowledge management and quality improvement. She is a Certified Professional in Healthcare Quality and a National Association for Healthcare Quality (NAHQ) Fellow. Lee Ann regularly presents at nursing and quality education conferences on the local, state, regional, and national levels.
We recently spent some time speaking with Lee Ann about her insights, challenges; and opinions, gleaned from her years of clinical education in a large hospital setting. Here is an excerpt from that conversation:
HealthStream: You have had a long and varied career, on both sides of the educational fence. What, in your opinion, is the biggest change in Pharmaceutical/Medical Device (PMD) training over the last five or ten years?
Lee Ann Hanna: Devices and drugs have been around for a long time; we implement new and/or we convert to the next. The biggest change over the last five to ten years has been that it’s coming at a faster pace. Implementations may come rapidly; sometimes this is based on outcomes data, regulatory directives, availability of products, and/or contract negotiations. Organizations are continuously moving to highest quality and best price. It’s not a good thing or a bad thing. It’s a reality of our economic environment.
While that is the biggest change, there are other changes that affect PMD training. Hospitals must work at higher productivity standards. Seldom do you find hospitals that budget for PMD training. It is usually absorbed by the patient care units. Although some hospitals allow for training cost centers, when all is said and done, training costs still hit the bottom line.
There is a shortage of bedside nurses. This may be due to intermittent shortages related to call-outs, leaves, and turnover, or long term shortages related to supply and demand. Patient care units staff for patient care. Unless a PMD training program is moderate to big and requires extensive training, most of this training occurs during the same hours that bedside nurses are scheduled to deliver patient care. As patient care is the priority, this may lead to distractions and missed training opportunities. There is nothing more frustrating than to be asked to use a device or administer a drug without training. According to the rules and regulations of registered nurses in our state, nurses should not perform nursing techniques or procedures without proper education and practice.
There is also a shortage of clinical educators. This affects the organization’s ability to develop and implement PMD training programs. I am aware of hospitals that do not have clinical education departments or centralized clinical educators. While this work has been decentralized to patient care units, those nurses may not have the knowledge and experience to develop and implement effective and efficient training programs. They may also have to be flexed to patient care to meet staffing needs, which may cause delays and quality issues.
PMD companies face the same challenges as healthcare organizations. Their environment is moving at a rapid pace. Competition and resources are just as challenging for them. These companies must also work in a cost effective and efficient manner, especially when it comes to training. Some PMD companies consider training a value-added service. Some PMD companies will not sell a product unless staff members are educated and competent to use their products. The latter understand that proper use of their devices and drugs will lead to improved outcomes and higher quality. If you take care of quality, everything else falls into place.
HealthStream: How is PMD training more cost effective today than it used to be?
Lee Ann Hanna: In my opinion, online training, alone or paired with classroom activities, is more cost-effective than traditional standup training alone. Online training may be completed on demand by participants and saves resources (class room space, human resources, time, travel expenses, etc.) for both the hospital and the device and drug companies.
By using online training, we can assign it and track it. If a PMD company sponsors the online training it can be updated with changes (appearance, function, label use, discontinuation, etc.). The hospital does not need to rely on clinical educators to develop and review programs, a resource intensive task. I advocate online training for small changes and online training in conjunction with hands-on training for medium to large changes. We call this blended learning or problem-based learning. It is efficient and effective.
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To access the full interview about online medical technology training, fill out the form below.
By Cyndi Tierney , Research Consultant (CG-CAHPS and Other Surveys), HealthStream
Setting Sights on Leadership in the Patient Experience
I
recently met with a hospital’s Patient Experience team. The team leader and hospital executive were committed to improving their results, passionate about the team of champions they assembled… and frustrated about their lack of progress. We talked about a few specific areas of opportunity, and then I asked where the initiative stood with department leaders. It was a long pause before they confided that it was a weak spot. Some department heads were on fire for the cause, while others weren’t supportive. Not dismissive either, they both quickly added. Just not pushing the agenda with the staff, and could I do something about that?
Dead in the Water
Hospitals and systems take varied paths in driving patient experience improvement efforts in their organizations. Some use a traditional top-down approach, some are de-centralized from corporate office and administered by leadership, while others run with a grassroots effort, using staff for the effort to take hold. No matter which route you’ve chartered, there’s a point (okay, sometimes multiple points) where you’re standing still. The water is dead calm and not a breath of wind in sight. Welcome to change.
A Riptide out to Sea
On my next visit, I met with the directors. As we started to talk, a few were brave enough to voice doubts about requiring staff to use catch phrases with patients. One or two even used the dreaded S word, “My staff members don’t like being scripted.” Now really, who does? Unless you’re in cement on Hollywood Boulevard, scripting feels like a small box in which to stuff your personality.
But enough commentary; let me get back to the point. This is classic resistance. There’s nothing wrong with it, this group is not dysfunctional, but they are not bought in. And if they don’t see the value of using key messages with patients, they sure can’t, or won’t support it. It wasn’t the staff who needed to look at scripting from another vantage point. It was the leadership. They hated the idea of forcing act one, scene one on their staff. No wonder it wasn’t catching on.
Swimming with the Current
I have a checklist I use whenever I travel. There’s nothing on the list that is so esoteric. It’s all basic stuff—toothbrush, shoes, phone charger, etc. I use it because when I don’t, I end up at Wal-Mart, hunting for a battery pack for my laptop. I’m not stupid, it’s just there are better things to do with my brain then remember all my travel items. That’s what the checklist is for.
Key words are a verbal checklist. Whether it’s teaching a medication, rounding in the rooms, or admitting a new patient to the floor, thereare a few critical points you want to cover. My colleague, Bo Hansen, calls them Word Tracks—essential words or concepts that help patients feel important and cared for and help them understand and remember what we are teaching.
That was easy for the group of directors. They got it. They liked it. They could get behind a verbal checklist.
A View from the Shore
You’d think this story would end here. Mid-level leaders had a change of perspective and change of heart. So, all is good, right? Well, no, it wasn’t all good. This wasn’t just a perspective problem; it was also a role problem. What exactly, are these leaders supposed to do? That wasn’t clear at all.
In this initiative, the Patient Experience (PE) team members were frontline staff from throughout the hospital. They were the change agents--the champions who introduced key words to their work areas and talked it up with their co-workers. In the units, on the floors, and around the hospital, they were role-modeling with colleagues.
And where should the leaders have been? On the sidelines, supporting the effort. This wasn’t a group of lazy leaders; it was a group of clueless leaders. They didn’t realize that was their job.
Too often, we are dazzled by a breath-defying best practice. Behind each of those, there’s a set of core leadership skills that ground the team. While the staff is center stage, the leader is encouraging behaviors into habits and publicly connecting those new habits to the changing results. This leader is the authority figure who sets the stage for this new way of life, as an expectation. He or she ultimately manages the group’s performance, rearranging priorities, removing or navigating barriers, and addressing stragglers or non-conformers.
Ships Ahoy
Healthcare professionals are far from lazy—in fact, our field is known for being dedicated and innovative. We are accustomed to learning new techniques, implementing new procedures, and operating new equipment. We learn it, and then we turn around and do it.
Without any guidance for seeing their role as a sponsor and understanding how they function to complement their champion, it’s no wonder these leaders are treading water. The lifeline we need to throw is a leadership checklist, a few key words, and this ship will be soon set sail again. Here’s to the champions who lead this effort, and their unsung leaders, who chart the course and steer the ship. Aye , Aye, Captain!
Learn more about HealthStream Patient Insights/HCAHPS.
To better protect workers from hazardous chemicals, the U.S. Department of Labor’s OSHA has revised its Hazard Communication Standard to align with the United Nations’ Globally Harmonized System of Classification and Labeling of Chemicals (GHS). While the original Hazard Communication Standard, HCS 1983, was commonly referred to as the “Employee Right to Know,” the revised standard now provides for the “Employee Right to Understand.” With the goal of increasing worker comprehension about the hazards in their work environment, the revised standard requires companies to employ the use of a standardized format for Safety Data Sheets (SDSs), as well as new labeling elements for chemicals. OSHA is rolling out this change in phases over the next several years, culminating in a final deadline of June 1, 2016.
New Requirements Aimed at Healthcare Worker Safety
The first compliance deadline is December 1, 2013. By this time, all facilities must provide training on new chemical label elements and safety data sheets. In response to this rule, HealthStream has teamed up with MAXCOM to offer 19 GHS specific training modules that focus on every class of chemical an employee might come across in their working environment.
To address the enormous amount of chemicals used in hospitals, OSHA amended the rule to allow chemical training to be provided by groups of chemicals. They write, “where there are large numbers of chemicals, or the chemicals change frequently, you will probably want to train generally based on the hazard categories.”
Hazardous Chemicals Are Common in Health Care Facilities
Chemicals in use in the healthcare environment may be hazardous due to potential for toxicity, corrosiveness, and reactivity. In addition to the usual routes of exposure by inhalation, ingestion, skin and eye contacts, a health care provider can also inadvertently self-inject a toxic drug intended for a patient.
These groups of chemicals include:
- Chemical disinfectants commonly used in health care facilities are often corrosive and/or toxic. Glutaraldehyde, sodium hypochlorite, iodine, phenols, formaldehyde, and quaternary ammonium compounds are all corrosive. In addition to being corrosive and toxic, some disinfectants such as quaternary ammonium compounds (benzalkonium chloride, Zephiran chloride, Rodalon) also cause contact dermatitis. Glutaraldehyde solution has to be freshly prepared every 2 weeks, and due to its volatile characteristic employees often inhale its vapors. Formaldehyde used for cold sterilization of instruments and as a disinfectant not only has noxious odor but also causes dermatitis and has been shown to cause nasal and other cancers in experimental animals.
- Freons such as Freon 12 (dichlorodifluoromethane), Freon 11 (fluorotrichloromethane), and Freon 22 (chlorodifluoromethane) are routinely used in pathology laboratories (to prepare frozen tissue sections), in aerosol cans as a propellant, as a refrigerant gas, and mixed with ethylene oxide (a sterilant). Freons can freeze the skin and eyes and cause depression of the central nervous system resulting in dizziness, convulsions, and irregular heartbeat.
- Methyl Methacrylate, commonly used in operating rooms for securing surgical prostheses to bone, has to be mixed just before a procedure often resulting in inhalation of the product. Methyl methacrylate affects the central nervous system, is an irritant and may cause low blood pressure and cardiac arrest. The product also has been linked to birth defects, though not cancer.
- Peracetic Acid (PAA) or Peroxyacetic Acid is used to sterilize medical instruments, and also present in laboratories, and patient care units. PAA is a severe irritant, and have been linked to skin papillomas (wart-like tumors), and liver, kidney, and heart problems.
- Solvents (such as Dioxane, Xylene, and Benzene) used mostly as cleaning agents in housekeeping are central nervous system depressants and irritants. Chronic exposure to solvents have been linked to effects on blood formation, kidneys, liver, birth defects, and cancer.
- Anesthetic Gases exposure usually occurs in operating rooms, labor, delivery and recovery rooms; and ER. Gases often leak from the instruments, and in the recovery room are present due to the exhaled breath of post-operative patients. Effects of anesthetic gases on health care employees are similar to the one experienced by patients. Although short-term exposure only causes dizziness and disorientation, long term exposure may cause cancer, birth defects, and liver and kidney damage.
- Ethylene Oxide used to sterilize equipment also exposes employees in surgery units and central supply. Ethylene oxide is a corrosive, causes destruction of red blood cells, and inflammation of lungs. It is also a carcinogen and a fire hazard.
- Cytotoxic Drugs (such as cyclophosphamide, chlorambucil, and melphan) used for treatment of cancer, also cause cancer and damage to the reproductive system of health care employees. Accidental injection of a drug such as mitomycin-C can cause loss of function of a hand; and drugs such as mustine hydrochloride and doxorubicin are powerful vesicants (corrosives). Exposure to the smallest amount of bleomycin can cause severe allergic reaction.
- Pesticides ( Mecoprop, Metolochlor), Rodenticide ( Bromaldiolane and Diphacinone) and Fungicide such as Mancozeb are routinely used by hospitals as a biocide. Most are toxic to the nervous system, damage kidneys and liver, and cause allergic reactions.
Safer Substitutes
Less hazardous products can be substituted for many though not all hazardous chemical products in health care facilities. For example:
- For Ethylene oxide in most instances: safer hydrogen peroxide 7.5% solution, peracetic acid or a mixture of hydrogen peroxide and peracetic acid. Even hypochlorite (bleach)is effective in some disinfection systems. Please note that the substitutes are not suitable for flexible GI endoscopes.
- For Glutaraldehyde: Ortho-phthalaldehyde (OPA) in Cidex (contains only 0.55% glutaraldehyde)
- For common toxic chemicals such as chloroform: dimethoxyethane (DME), Ethyl lactate, methyl tert-butyl ether or methylene chloride; benzene can be replaced by benzotrifluoride (BTF), dimethoxyethane (DME); acetone can be substituted by ethyl lactate, or N-methyl pyrrolidone (NMP) etc.
- For toxic chemicals such as formaldehyde: dimethoxymethane (DEM); Phenol by polyethylene glycol (PEG), and pyridine by isopropyl alcohol.
- For flammable chemicals such as ethyl ether: methyl tert-butyl ether (MTBE), n-octyl tetrahydrofurfuryl ether (n-OTE)
- Waste anesthetic gases can be controlled by a scavenging system.
- For powerful pesticides containing pyrethroids: UV light traps; pheromone traps can be substituted for Cockroach pesticides etc.
Although heath care facilities will never be free of hazardous chemicals, it is increasingly possible to use safer alternatives and better procedures to prevent exposure.
MAXCOM’s GHS Training Library provides a basic overview of the hazards associated with every class of chemical a healthcare employee could typically be exposed to and how an exposure to these chemicals could affect him/her in the course of performing their everyday workplace duties. Additionally, this training provides valuable information about the degree of risks or hazard levels associated with chemicals specific to a healthcare environment, and finally employees are provided details about the information contained within each section of the new Safety Data Sheet, GHS label elements and the pictograms recently adopted by OSHA.
Learn more about Maxcom training here.
By Bo Hansen, RN, MBA, Consultant
Like it or not, first impressions are lasting; and, if they are negative they can be difficult to overcome. We don’t get a second chance at first impressions! They are deeply embedded in our memories and often turn into a lasting prejudice with hefty price tags attached. The cost of being indifferent, unkind, careless, non-communicative, or unprofessional may cost someone the opportunity of a great job or thwart a new friendship. In the case of patients’ first impressions of a hospital, a negative one may cost the hospital hundreds of thousands of dollars in CMS reimbursement, and it may take the hospital years to regain the trust of its community.
First impressions Count
First impressions to patients admitted through the emergency department (ED) are powerful. Visits to the ED are always unplanned and disruptive of lives, and they may be life altering. Whether patients suffer minor injuries, unexplained illnesses, or severe trauma, they arrive at the ED, often alone, in a state of fear and worry about what is going to happen to them. They are not in control of their life; they feel helpless and vulnerable. How they are received by the first person of contact is critical to their impression. Is the person friendly, making the person feel like he is in good hands? Trusting that we will be safe when we are vulnerable is critical. Patients trust that the doctors and nurses will treat their physical illness and injuries. Equally strong is their trust that the same physicians, nurses, and ED staff will comfort them, calm their fears, and reassure their loved ones. Violating that trust can be a serious mistake in terms of damage to the hospital’s reputation, patient loyalty and HCAHPS scores.
High scores in ED equates to high H-CAHPS scores
We know 50 to 60% of all inpatients are admitted to the hospital through the emergency department. Since the inpatient HCAHPS survey asks questions of discharged patients that are prefaced by the words “During your hospital stay,” it means that more than half of all inpatients include their ED experience in their feedback in the post discharge survey.
In an effort to better understand the relationship between the ED experience and the inpatient experience, HealthStream completed a study of 551 hospitals that surveyed both their inpatients and their ED patients. One important finding of the study showed that patients admitted through the ED scored significantly lower on all HCAHPS measures than those who were not!
The study also revealed that hospitals that score high on ED Overall Satisfaction also tend to have high HCAHPS scores. This relationship is stronger in higher-performing hospitals than in lower-performing facilities. We can conclude that hospitals with high patient satisfaction scores in the ED are likely to see that satisfaction carry over to inpatients who are admitted through the ED. Consequently, hospitals that want to maximize their chances of high HCAHPS scores and associated reimbursement should take a close look at how their EDs are performing.
First Impressions That Pay (We Are Talking $Millions!)
The degree of care, kindness, timely information, and attentiveness that the patient and family receive from ED staff determines the first impression of the hospital. Beyond the best practices most commonly discussed, such as rounding, smiling, clear explanations of pending tests and results, etc., what else could the ED staff contribute to meet the patients’ expectations of hospital experience?
From my days as an ED staff nurse and manager, I have a few examples of how the ED staff can enhance patients’ ED experience. There are many more than the ones I have listed, but these address some of the areas of opportunity that I see in EDs today:
- Hire the right people with the right attitude to greet your patients and families.
- Replace silos with bridges. Know the value of reaching out to other departments. Let them know you are friendly. (ED staff sometimes has a reputation of being grumpy with their colleagues in other departments). Ask what you can do to help speed up the transfer of patients from the ED to their unit. Would it help if the ED nurse starts the care plan, the doctor’s orders right away? Getting the patient transferred to a unit is not THEIR (the unit’s)problem, it is OUR (everyone’s) goal to make it happen!
- Adopt an attitude that tells patients you understand their sense of urgency. Once admitted, your patient wants to get out of the ED and into a bed to start treatment, recovery, rest, and healing. He doesn’t understand why it can’t happen right now! Be empathetic and keep your patients updated at least every half hour on how long it will be before they can get to their bed.
- If your patient is spending extended time in the ED, treat them like guests. Keep up with the comfort measures. Offer extra pillows, blankets, ice, juice, or snacks.
- Start the care plan if your patient is held more than two hours in the ED after being admitted. It is the right thing to do for your patient.
- Being one team with a shared goal is one of the fundamental requirements for creating a positive patient experience. Include ancillary and support staff in department meetings. Make sure your phlebotomists, IV team, radiology technologists, housekeepers, and registration staff have the attitude and training that provides the first class service experience that you intend for your patients.
- Act in a way that makes the patients glad they chose your hospital for their care.
- Every time we are in front of our patients, we are “on” or as Disney describes it, we are “on stage. ” How well we perform determines the lasting impression with leave with our patients.
- Pretend you are a patient in your ED. How would you rate your ED experience?
Learn More About HealthStream Patient Insights/HCAHPS.
Learn More About HealthStream’s HCAHPS Preparation and Improvement Library.
By Hayden M. McKaskle, Consultant (HCAHPS and Other Surveys)
Soon after I joined HealthStream several years ago, I had the pleasure of reviewing HCAHPS patient satisfaction scores for a client hospital. I had spent considerable time preparing for this review and had run a number of special reports in addition to the lengthy quarterly report they receive. Their scores were ok but not great, and they had seemingly plateaued over the last few quarters. Since they really didn’t have an issue with negative scores, I simplified the strategy for them as best I could. This hospital only needed to move a handful of patients each month from “Usually” to “Always” and from “7s or 8s” to “9s and 10s.” In other words, if they could “wow” and move a few more each period to Top Box, their scores will steadily improve and in time, prove to be exceptional.
Thinking About the Meaning of “Top Box”
Just when it seemed like the CNO and the CEO were buying into this approach, the CEO asked a simple yet profound question, “What makes a score Top Box”? Interestingly, another CEO had recently asked a similar question during a review of their employee satisfaction results. The timing of these questions sent me on a quest to find a better answer to this question. In part one of this blog, we will explore this question from a patient perspective. In part two, we will attempt to address this question from an employee viewpoint. After delivering several hundred report reviews for Patient, Employee, and Physician surveys, I have found numerous insights within the data. These have helped a number of clients. As helpful as the data can be, it was within the verbatim comments of patients that I really began to find an answer to my question.
Top Box: What Do Patients Say in HCAHPS Surveys?
” Nurse A____ was very attentive like I was the only person in the hospital that mattered to her.”- “They made me feel like I was at home.” “…they took care of me like I was a king.”
- “It was wonderful, like staying in a hotel.”
- And a personal favorite of mine, “They took care of me like I was a newborn baby.”
These are actual comments selected from thousands made during 2012. These are not isolated occurrences; similar ones appear scores of times in reports for high scoring hospitals as well as lower scoring ones. Most of these exceptional comments have the staff member’s name included, and these have been edited for the purposes of this blog. I believe that it takes great effort to remember the names of caregivers during moments of great stress and sickness, so the mere mention of actual names adds even more significance to these comments. Although the above patient comments may appear to be very general and perhaps difficult to mine for improvement strategy, consider the following comments:
- “She did everything possible to make me comfortable and even sent me a note after I got home. I couldn't find a better hospital.”
- “Nurse J___ was off on the day of my discharge, but she came in the day before and thanked me for letting her take care of me.”
- “(The CNA) would come and hug my neck and cry with me those times when I was down. She wasn't just there for a paycheck or only what was medically required from her.”
- “The nurses were very fast, very prompt, and they did things that weren’t on their job description. They did things below their status, and that was very nice. They do things that RNs usually don't do.”
Although comments about nursing make up the majority of patient comments, the exceptional ones are not limited to just nursing. Someone once said that everyone impacts patient satisfaction. The following comments illustrate the truth in that statement.
- “The person who came in and cleaned my room just asked me how I was doing. I said gee I would like somebody to get me some ice. She brought me two bags and I just thought that was awesome.”
- “The housekeeping supervisor asked me if I needed anything, and she would get it for me. Having her there was very nice.”
- “The technician, John, was great. He talked me through my test. I was really scared and crying, and he was very good and had a good bedside manner.”
- “Dietary came every morning and asked if I enjoyed my meals and asked if there was any way that they could make it better for me. I have never had anyone treat me this way. They treated me like royalty.”
Even though all of these comments come from inpatient surveys, often a high percentage of admissions come from the ED. That initial experience in the ED can influence an inpatient’s expectations for care in the hospital - for good or for bad. Even in the hectic and crisis oriented atmosphere of the ED, patients are often touched by personal and exceptional care.
- “Dr. S_____ in the ER is very good. I have never had a doctor call me after I was in the ER.”
- “Dr. John, I met him in the emergency room, and he followed with me all the while I was in the hospital. He was there every morning and he was good to me. He was like my son.”
- “Melissa and TJ were in the ER. They were both equal, as far as hanging with me, keeping me informed, and making sure I had anything I needed. They kept my wife informed about what was going on.”
- “The ER staff had just heard that my son had passed away. They all gave me hugs and that made me feel better.”
Doctors are also mentioned for providing exceptional inpatient care. Here are just a few:
- “Even the doctors came in and sat down to talk to you as if you are a real human being. The hospitalist pulled up a chair and sat down and talked with me several times.”
- “Dr. A_____ made sure I understood and he makes you feel like you are the only patient he has. He is wonderful.”
- “He didn't seem in a hurry or a rush to get out of my room. I really appreciated that. I just loved the way he approached me.”
- “I appreciated that she had conversation with me rather than just as a patient. She listened to what I had to say, instead of me being just a patient.”
- “I was really surprised that the doctor who discharged me called me at home and talked to me about my health. I have never had that happen to me before.”
- “He is very attentive and listens. He is calm and explains everything. I think he is a wonderful doctor.”
The Secret to Great Patient Experiences
After reading so many more comments like these, I am convinced that the secret in the sauce is really very simple. Those caregivers that make a difference for patients do so in small yet profound ways. They listen. They take time. They look for ways to take just one more step than required during a round - something that connects with the patient as a fellow human being.
There is so much that needs to be done each and every day, indeed so much professional noise that can get in the way of providing an exceptional care experience. Paperwork, shift reports, hourly rounding, and the like all must be done but each of us must make an effort to add value for the patient, in our jobs, and in our lives each and every day. Often that added value comes from things that may seem small at first glance but can make all the difference in the world for a patient. We have to make an effort to look for these “extra steps” in spite of the professional noise.
Exceptional patient perception is never about professional credentials, education, or the like. It is about people connecting with people - not patients. As I wrote in one of my first blogs, Healthcare is after all, a people business. Getting to “Top Box” then, is no different. It is all about people doing more, going farther, paying more attention, and listening intentionally. There is certainly a bit of prescriptive medicine somewhere in there for all of us.
Learn more about HealthStream Patient Insights/HCAHPS.
By Lee Ann Bryant, Associate Product Manager, HealthStream
With small and medium practices in mind, CMS has put together the following checklist of ICD-10 tasks, including estimated timeframes for each task. Depending on your organization, many of these tasks can be performed on a compressed timeline or performed at the same time as other tasks. This checklist is designed to provide a viable path forward for organizations just beginning to prepare for ICD-10. CMS encourages those who are ahead of this schedule to continue their progress forward.
Planning, Communication, and Assessment -- Actions to Take Immediately
To prepare for testing, make sure you have completed the following activities. If you have already completed these tasks, review the information to make sure you did not overlook an important step.
- Review ICD-10 resources from CMS, trade associations, payers, and vendors
- Inform your staff/colleagues of upcoming changes (1 month)
- Create an ICD-10 project team (1-2 days)
- Identify how ICD-10 will affect your practice (1-2 months)
- How will ICD-10 affect your people and processes? To find out, ask all staff members how/where they use/see ICD-9
- Include ICD-10 as you plan for projects like meaningful use of electronic health records
- Develop and complete an ICD-10 project plan for your practice (1-2 weeks)
- Identify each task, including deadline and who is responsible
- Develop plan for communicating with staff and business partners about ICD-10
- Estimate and secure budget (potential costs include updates to practice management systems, new coding guides and superbills, staff training) (2 months)
- Ask your payers and vendors—software/systems, clearinghouses, billing services—about ICD-10 readiness (2 months)
- Review trading partner agreements
- Ask about systems changes, a timeline, costs, and testing plans
- Ask when they will start testing, how long they will need, and how you and other clients will be involved
- Select/retain vendor(s)
- Review changes in documentation requirements and educate staff by looking at frequently used ICD-9 codes and new ICD-10 codes (ongoing)
For the full ICD-10 Implementation Guide for Small and Medium Practices, click here.
If you would like more information on how HealthStream and Precyse can help your organization prepare for ICD-10, click here.
By Nicholas Dowd, Senior Consultant (HCAHPs and other Surveys), HealthStream
The commitment to excellence is truly a team effort at Avera Sacred Heart Hospital (ASHH). They have been involved in – and seek out – opportunities to collaborate with facilities from across the nation to share best practices and processes to improve overall quality. For example, they were active participants in the CMS Demonstration Project and have proactively participated in programs such as the QUEST initiative, the IHI 100k Lives Campaign and the 5 Million Lives Campaign. They are also currently participating in the CMS initiative “Partnership for Patients. ASHH sees participating in each of these collaboratives as means to improve evidenced-based care, patient perceptions of care and enhanced patient safety.
Their deep level of commitment to continuously improving quality is a unifying thread that runs throughout the hospital, touching every employee. This team effort starts with transparency of performance data. Performance data at the unit level is posted on the hospital’s intranet enabling all employees to see results. Using the “push” feature of HealthStream’s Insights Online product, leaders can schedule and post results via e-mail to those front-line staff that need that information to manage more effectively. Those data are also an integral part of the work of ASHH Patient Services Council and a variety of performance improvement teams at work on a daily basis..jpg)
The current areas of focus for the hospital include:
- Decreasing overall readmissions
- Evaluating and implementing best practice solutions to reduce hospital harm
- Maximizing use of the electronic medical record
Read the full success story here.
The U.S. healthcare system has been engaged in significant quality-focused activity over the last decade, as hospitals responded to numerous mandates aimed at improving patient outcomes and safety. The healthcare quality movement began in earnest with The Institute of Medicine (IOM) Report “To Err is Human,” which highlighted the high number of medical errors occurring in U.S. hospitals. Now 2010’s Affordable Care Act is motivating and requiring hospitals to pursue new and focused methods of shoring up gaps as the Centers for Medicare & Medicaid Services (CMS) and private insurers start to make serious inroads on tying quality and patient safety outcomes to reimbursement. Hospitals are taking this latest reform move seriously. In a recent HealthLeaders Media survey of 244 healthcare leaders, more than 90 percent said not only is patient safety one of their top five priorities, it is “an integral part of their organization’s strategic plan.”
High-Performing Hospitals Make Education a Priority 
With so much at stake, how can hospitals move the quality needle in a meaningful direction? While most healthcare organizations already have a quality agenda, getting specific initiatives to cascade down to frontline staff continues to be a challenge. Increasing evidence shows, however, that hospitals are driving quality and patient safety improvements through exceptional education programs. In fact, these high performers share one common habit: they consistently count workforce education and training initiatives among their organization’s highest goals. A 2007 Commonwealth Fund report on hospital quality improvement strategies found that those organizations consistently raising quality of care have deployed improved educational and training materials for clinical staff in key quality areas, including error reduction, hand-washing, and infection prevention. Yet another survey reviewing quality improvement trends across 470 organizations several years after the IOM report found that those “hospitals with high levels of perceived quality … fostered staff training and involvement in QI methods.”
Training Can Lead to Powerful Hospital Improvements
Hospital learning programs that are tied to organizational quality goals and aimed at physicians--physician assistants, nurse, allied staff, and frontline workers--may result in improved patient outcomes in key areas such as mortality, readmission, and infection rates. They also may lead to highly engaged and satisfied employees; stronger physician alignment; improved patient satisfaction; and ultimately higher reimbursement.
This white paper includes:
- The Urgent Need for Innovative Training Programs
- Four Key Trends Impacting Workforce Learning
- Nurse Education and the Widespread Benefits of High-Impact Training
- Creating Targeted Learning
- Case Study: Capella Healthcare
- Case Study: Portneuf Medical Center
- Preparing for the Future, Using Training
Download the White Paper.
B
y Hayden M. McKaskle, Consultant (HCAHPS and Other Surveys), HealthStream
A number of our large system clients decided to expand their physician survey in 2012 to include physicians that had not been surveyed in the past with our Physician Insights Survey. These are physicians who are not based at the hospital and may only rarely be at the facility. They can be thought of as outpatient-only or perhaps referring physicians.
Once the data were collected and finalized, the two reports delivered to the client provided some interesting contrasts and similarities between these two major groupings of physicians - those based in or working primarily in the hospital and those that are based outside of it.
What Drives Satisfaction for Referring Physicians?
The top ten key drivers for the outpatient only physicians consistently reflected three major topical areas and these are:
1) Administration Communication and Responsiveness
2) Emergency Department
3) Operational Areas
EHRs Remain a Challenge for Some Clinics
Operational Areas include much of the day to day interactions the physician and staff have with the hospital. Among these were “Scheduling Outpatient Surgery,” “Scheduling Diagnostic Tests,” and questions pertaining to “Clinical Information Systems” areas. 
Clinical Information Systems generally had three of the top ten key drivers and these included transfer of data from hospital to office EHR. Although many hospitals I work with have well established EHRs in the hospital itself, connecting to disparate and diverse EHRs in outlying clinic offices is not yet as mature. This is both a capital and technical challenge for many hospitals and will continue to be so for some time.
It’s Valuable to Focus on Patients’ Emergency Department Experiences
Emergency Department items generally had two and sometimes three questions represented in the key drivers. “Patient Satisfaction” or what the physician’s patients report to them about their experience in the ED is usually the highest rated of the ED questions. “Efficiency of the ED” can also be considered operational in scope but it is also usually a key driver as well. Depending on the overall satisfaction scores for the hospital, a third ED question may well appear in the key drivers and this might be “Prompt Communication” about their patient’s ED visit or perhaps the “Quality of Written Reports” about their patient provided by the ED. It should also be noted that Hospitalist-related questions also appear in key drivers from time to time, depending on the hospital.
Communication and Responsiveness are Key
“Communications” as well as “Responsiveness” of the Administrative Team were always in the top ten key drivers for this group and usually in the top five. They were also very highly correlated emphasizing their level of importance to this segment of physicians. This is also consistent with the results for hospital based physicians. Although that may seem intuitive at first glance, Communication and Responsiveness may well represent the greatest challenges facing hospital executives relative to physicians outside the hospital.
Communication with administration has always been important to physicians that are based at or come into the hospital on a regular basis. The higher scoring hospitals for physician satisfaction usually have a visible C-suite that communicates frequently and consistently well with their physicians. Although this is known and understood by most CEOs, it continues to be a challenge for many and an impediment to improving physician satisfaction. If Communication and Responsiveness are challenges when physicians are regularly in the hospital, imagine how much more difficult it is when physicians are essentially never at the hospital?
Suggestions from High-Scoring Hospitals’ CEOs for Physician Satisfaction Improvement
I have had an opportunity to discuss this challenge with a number of CEOs from high-scoring hospitals. A number of suggestions came out of these discussions including:
1) Visit the Clinics
Many CEOs make a point to personally visit outlying clinics on a regular basis, perhaps monthly or quarterly. These visits are usually planned well in advance and the schedule is communicated with the physicians in multiple ways to maximize physician involvement. These are great opportunities to inform the physicians of progress on action plans that emerge from the survey and this helps reinforce responsiveness and communication perception.
2) Divide and Conquer
The larger facilities have many physicians and clinic offices making frequent visits even more challenging. Although some direct interaction with the CEO will always be critical, consider assigning groups of physicians to other members of the C-Suite. By doing so, physicians will gain a better perspective and understanding of the senior leadership team while helping other members of the C-suite better understand physician needs.
3) Develop Key Relationships and Alliances
Hospitals with high scores for physician satisfaction in the active medical staff usually have a CEO who has built a close partnership with one or more of the physician leaders within the hospital. These may or may not be members of the physician leadership council but are generally respected and recognized as leaders by other physicians. Although the physicians outside of the hospital are generally more fragmented, this approach can still be effective. Having close relationships with such physician leaders can, in effect, multiply the efforts of the C-suite in communication and responsiveness.
There are other approaches, of course, but these represent a good start. Take time to invest in physician relationships, especially with those that refer to the hospital. It is an investment that will continue to deliver dividends such as growing referrals, over time.
Learn more about HealthStream Physician Insights satisfaction surveys.
[This blog post introduces the eighth and final installment of HealthStream's new Accountable Care Organization (ACO)-focused white paper series. As the last of eight sponsored papers, it addresses the phased implementation of healthcare reform under the Affordable Care Act.]
Over two years after the Patient Protection and Affordable Care Act (PPACA)1 was signed into law, a total of fifty-five (55) healthcare reforms have gone into effect (2010-26, 2011-17, 2012-9, 2013-2, and 2014-1) and thirty-seven (37) more are in the process of being implemented (2011-3, 2012-2, 2013-11, 2014-18, 2015-1, 2016-1, 2018-1) over the next six years. The number of reforms is staggering. As a result, this white paper will go down the “yellow brick road” of healthcare reform and review all of the actions besides the constitutionality of the “individual mandate”. This white paper is a summary of the PPACA legislation, implemented provisions, identified provisions of 2010, 2011, 2012, 2013, and 2014, and those provisions waiting to be implemented.
Putting Healthcare into an Economic Context
As we consider the concepts and impacts of healthcare reform, including Accountable Care Organizations (ACOs), it is still quite clear that healthcare is a huge and growing sector of our economy. The share of total health expenditures funded by the government has also been rising quickly. By the end of this decade, it is forecasted that half of all healthcare spending will be due in p art to rapidly growing government healthcare programs. Healthcare entitlement programs like Medicare and Medicaid have grown beyond their original estimates in both enrollment and cost, putting us at financial risk for properly funding these programs through a recovering economy, a growing uninsured population, and an eroding tax base.
The following facts and figures provide us with additional insights as to the current trends of our healthcare system:
In 2010, the United States spent $2.6 trillion on health care, or 17.6 percent of GDP.
- By 2020, the government is expected to control 50 percent of all health care spending.
- Medicare spent $520.4 billion in 2010 and holds close to $37 trillion in unfunded obligations.
- 20.4 million Americans were enrolled in Medicare in 1970, compared to 47.5 million Americans in 2010, and 80 million are expected to be enrolled by 2030.
- Total federal and state spending on Medicaid is estimated to have been $401 billion in 2010 and is expected to reach $840 billion by 2019.
- While 22.9 million people were enrolled in Medicaid in 1990, enrollment has increased to include close to 54 million Americans. Under PPACA, Medicaid will expand to include as many as 25 million additional individuals.
- Nationwide, states enacted 2,156 benefit mandates in 2010.
Download the White Paper.