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Reducing Patient Suffering: A Shared Responsibility


  • Focusing on the Goals of a Best Practice to Better Meet Patient Needs: Rounding with Behavioral Health Patients

    by Deirdre Mylod, PhD, Executive Director, Institute for Innovation

    When transforming the strategic objective of patient experience efforts from service behaviors to truly reducing patient suffering, it’s imperative that we keep the goals and purpose of the work front and center. Often a service behaviors approach seeks to satisfy patients and earn high scores. A holistic patient experience approach, on the other hand, strives to meet patient needs and reduce suffering. Both approaches can improve patient evaluations of care, but when the goal is focused on the patient outcome, and not the scores, it is framed in a way that encourages more compassionate, connected care.

    The process of hourly rounding in the inpatient setting can be viewed through both of these lenses. When considered as a service behavior, rounding can feel like yet another task required from staff to help patients feel more positive about their experience. But hourly rounding is actually a redesign of care. It is a different method of proactively meeting patient needs so  pain is better controlled, toileting needs are assisted more quickly (reducing likelihood to fall), questions are answered more readily, and patients feel more assured that they are being monitored and develop deeper trust in their care team. Hourly rounding seeks to proactively meet patient needs and reduce anxiety. As a result, patient experiences are better—and their subsequent evaluations of care reflect the enhancement.

    Starting with the goals of a practice is particularly important when we need to modify a practice. To modify a practice while retaining the desired benefits, we must be mindful of the intended outcomes. A great example of modifying a process through focus on the goals occurred when NewYork-Presbyterian (NYP) Westchester Division worked to adapt hourly rounding to the Inpatient Behavioral Health setting. They began by understanding the goals of rounding: to proactively meet patient needs and build trust. They acknowledged from the beginning that the process would need to be very different than rounding in an acute care inpatient setting. They evolved the process with their own patient population in mind to bring a new and innovative process to behavioral health care. They sought feedback from patients and staff to stay true to their intentions. As a result, their new process meets the goals of hourly rounding, even though the steps look very different than the typical practice within a medical setting. You can read more in the NYP Westchester Division rounding story.

  • Meeting Unique Cultural & Religious Patient Needs to Reduce Suffering

    by Deirdre Mylod, PhD, Executive Director, Institute for Innovation

    When people experience a health crisis, they often turn to their faith for comfort and support. For those who follow a religious tradition, this can both provide a sense of added strength as well as a continued normalcy in a life otherwise interrupted by a health issue.

    But what if your health issue made it more difficult for you to participate in your religious traditions? And what if the process of seeking treatment created barriers for fulfilling your obligations? Not only would this compound the stress associated with your health condition, you might even put off seeking the treatment that you need.

    At NewYork Presbyterian’s Westchester Division, the leadership team has worked to address this very issue for the Orthodox Jewish patients in their community and have improved patient care as a result.  Our latest Innovation Story highlights their journey.

    For members of the Orthodox Jewish faith, there are numerous traditions and obligations that are incorporated into daily life.  Whether related to prayer, diet, or observations of the Sabbath, these are not merely activities but observances to fulfill God’s law.  For Orthodox patients who need inpatient behavioral health services, the traditional structure of care can make it more difficult to fulfill these religious obligations.  As a result, patients often delayed seeking treatment and, when admitted, families felt the need to vigilantly advocate for their family member’s needs.

    To better meet the unique needs of this patient population, the Westchester Division worked to better understand the religious traditions of Orthodox patients and redesigned care to more effectively support them in the behavioral health setting. They built relationships with the Orthodox Jewish community which allowed for better partnership as well as enhanced training for staff regarding the cultural needs of this patient group. Care was redesigned to create a unit, The Horizon, which specializes in responding to the needs of patients from the Orthodox Jewish faith.

    Now, many of the daily requirements and rituals are built into the way care is provided on The Horizon unit. Staff better understand and respect the significance of these activities. The Orthodox community has greater trust that their religious practices will be supported during inpatient care. And, families have less hesitation when bringing a family member for admission and know that religious needs will be addressed. Care is no longer a barrier to religious observances; it is designed so that patients can participate in and draw strength from their faith traditions.

    To learn more, read: Innovation Story: Meeting Unique Cultural & Religious Patient Needs in a Behavioral Health Setting


  • Putting a Face on Care: A Reminder of the Power of Connecting

    by Deirdre Mylod, PhD, Executive Director, Institute for Innovation


    NPR recently featured artist Mary Beth Heffernan’s innovative solution to make caring for Ebola patients more personal. Seeing healthcare workers in the news in their protective suits, Heffernan was struck by the idea that the garb, though necessary for safety, likely created even more fear and anxiety for patients. She considered what it would be like to not be able to see the face of the person who was caring for her and how alienating that could be. Her idea was simple and effective: to create photos of the healthcare workers smiling faces as disposable stickers that could be applied to their protective suits. She partnered with a group in Sierra Leone to bring the idea to life. They found that it not only made a difference to patients, staff also appreciated the ability to see their co-workers ‘face to face.’

    This story is a terrific example of innovation to address a particular need — and reflects broader issues for us to consider. There are so many elements of health care that are frightening and foreign to patients. Many of these processes must take place to protect the patient or ensure high quality care. However, patients need to see our faces through these processes, both literally and figuratively. Patients need to see that there is a person providing care - a person who is present with them, who sees them and who also allows him/herself to be seen. 

    To me, the story of the face stickers is a reminder. It reminds us to both work to reduce the fear and anxiety that is created by health care, and to make efforts to remove the more symbolic masks we wear when we are caught up in process rather than in connecting to those we care for.


  • “Tell Me Who is Important to You” - Opening the Door to End of Life Discussions

    by Tamra Minnier, RN, MSN, Chief Quality Officer, University of Pittsburgh Medical Center


    Tamra Minnier, Institute for Innovation Founding Executive Council member, and Chief Quality Officer at the University of Pittsburgh Medical Center submitted this guest blog which is very timely, because today, April 16, is National Healthcare Decisions Day. It’s a day that calls attention to the importance of end of life decision making and completing necessary advance directive documentation. Resources are available at
    www.nhdd.org.

    During a recent Founding Executive Council discussion, Tamra commented about the practice of asking patients about their emergency contacts and a strategy for expanding that practice to deepen the relationship and trust between clinician and patient.

    When patients are admitted, we routinely ask for their emergency contacts. This is an important question and creates an opportunity to take this simple exchange of information a step further. At UPMC, we encourage nurses on the floor to repeat this question – not merely to understand who to call in an emergency, but to understand who is important to the patient. We frame the question a little differently by saying: “Tell me who is important to you.” We explain to the nursing staff that the purpose of this question is to begin to get to know the patient as a person and what matters to them. For the patient, by asking the question, it also demonstrates that their nurse wants to know about their unique circumstances and relationships. Who is important to you doesn’t just elicit a list of names; it gives the patient the opportunity to name the people in their life who are loved, needed and share in their journey. It allows the patient to place him or herself within the context of their own family or chosen community.

    It’s interesting to think about how this practice could be expanded to prompt further decision making – and even end of life. What if, after finding out who is important to the patient, we made it a standard practice to follow up with “Is that the person you’d want to make decisions if you couldn’t?”  If the patient says “yes,” it creates a wonderful opportunity to provide an advanced directive choice form such as Five Wishes®. The patient and family can take the form home and discuss at their kitchen table. Can you imagine what could happen?


  • Patient Perception of Care Coordination: The Power of Teamwork

    by Deirdre Mylod, PhD, Executive Director, Institute for Innovation

    Care Coordination is an often used term. With so much focus from so many sources, it’s not surprising that it can be defined in many different ways. Care coordination is described as an element of efficiency, the process of hand offs, the support of a navigator or the role of multi-disciplinary teams. But from the patient point of view, the definition may be the most basic, simply: the perception of staff working together as a team to provide care. When care runs smoothly, events occur as expected, care providers provide consistent information and seem to support and respect one another, patients feel reassured that they are in good hands. Conversely, when elements of care break down and feel fragmented, patients are left to wonder if they may slip through the cracks. Dr. Tom Lee often notes that while patients have always experienced some level of fear and anxiety about their disease and treatment, they are increasingly afraid that care is not as well coordinated as it needs to be to keep them safe.

    One of the Institute projects is to better understand patient perceptions of coordination and teamwork. An interactive set of findings regarding patient perception of care coordination demonstrates how patient-level characteristics create risk or resiliency in patient perceptions of staff working together as a team. For example, within the inpatient setting, maternity patients and surgical patients perceive more teamwork than medically treated patients. Regardless of service line, inpatients admitted through the emergency department are less likely to feel that staff worked together as a team.  In both inpatient and medical practice settings, patients’ own health influences their perception of teamwork with patients in poorer health perceiving less optimal teamwork among caregivers. Importantly, we also see that the perception of teamwork is vital for more global evaluations of hospital care such as overall rating of a hospital experience or intent to recommend the hospital to others. Patients that give an optimal response (i.e., top box rating) to a measure regarding staff working well together are dramatically more likely to both rate the hospital as a 9 or a 10 and to indicate that they are certain they would recommend the hospital.
     

    Also available as a resource is a curated annotated bibliography on Care Coordination which highlights recent studies addressing improvements in processes as well as communication. The impact of teamwork is also emphasized with evidence showing how perceived teamwork in the Emergency Department setting is associated with overall perceptions of care and the confidence patients have in their care providers (Kipnis, A., Rhodes, K. V., Burchill, C. N., & Datner, E. (2013). The relationship between patients' perceptions of team effectiveness and their care experience in the emergency department. The Journal of Emergency Medicine, 45(5), 731-738.) 

    Improving patient perceptions of staff working well together will rely on the process improvements that are the focus of many care coordination efforts. That is, patients will certainly benefit from programs to prepare them for transitions, smooth hand offs and streamlined processes. It is equally as important to acknowledge, however, the way personal interactions among staff convey a sense of teamwork to patients and influence their perception of care and safety. To fully tackle coordination of care from the patient’s point of view, cultural issues of respect, mutual support and shared purpose will need to be addressed. Process improvements will get us part of the way there, however, to truly deliver on patient needs and reduce suffering, we must build culture that embeds teamwork within practices.


  • Encouraging End of Life Discussions to Improve Care, Enhance Patient Decision Making and Reduce Suffering

    by Deirdre Mylod, Executive Director, Institute for Innovation

    My mother died this past 4th of July—a fitting date for a woman who had taught American History and could recite Longfellow’s "Paul Revere’s Ride" from memory. It was sad, and hard, and I miss her.

    In one respect, however, I consider myself to be lucky: I know with certainty that she had what she wanted at the end. We had been talking about her end of life choices for 15 years. I knew what she valued. I knew what trade-offs she was willing to make.  We’d long agreed that when the time came, her job would be to call the shots and my job would be to make sure that her requests were heard. While the conversations were hard, they also bestowed an inconceivable comfort and assurance when I needed it the most. There is great peace in knowing I did what I’d promised and in never having to wonder if we did the right thing. I know we did, because she decided what the right thing was for herself.

    This month our Founding Executive Council (FEC) members met and discussed the barriers and challenges of ensuring that clinicians and caregivers support end of life discussions with patients. It was a rich and varied conversation. Some of the usual barriers emerged in terms of the discomfort that clinicians have with talking about death in general, the uncertainty of when in the course of a patient’s trajectory to raise the topic, as well as the concern over how to prepare a patient for the conversation itself and how to offer the right time and space for the discussion.

    Not surprisingly, findings from national patient experience data underscore the benefits of having end of life conversations for patients, their families and even the hospital organization. Patients who report being given information about their end of life options evaluate their hospital experience more favorably. And family members who have experienced hospice care for a loved one almost never report that hospice care was begun ‘too early.’ With benefits that are so apparent, why aren't end of life discussions more common? What can we do to encourage and support them?

    The FEC members discussed a number of initiatives within their own organizations to promote good end of life discussions and documentation. A few key themes and approaches emerged, including:

    • Learn by doing. Several FEC members described training programs in place to help staff know when and how to broach the topic. Interestingly, one organization encourages their clinicians and caregivers to address their own end of life planning as part of their training. By going through the process and formalizing their choice of alternate decision-makers and value trade-offs, they become more comfortable with the process and have authentic personal experience to share.
    • Start the conversation early. Another theme that emerged was the move to make end of life discussions a more routine part of care that is addressed earlier in the patient’s trajectory. By standardizing questions, discussion and documentation for patients– not just those in decline–some of the emotional intensity is removed so that clinicians become more comfortable with the topic and there is more time for patients to thoughtfully consider their wishes.
    • Use words that convey a personal connection. We also discussed the importance of language and the choice of words that are used. For example, asking a patient “What do you hope for?” allows a clinician to elicit information about goals and values but importantly conveys an emotional concern for the patient and an interest in sharing in their hopes.
      
    Don’t all of us need someone to understand our hopes? At the end of life, this may be the most important medicine of all. Let’s keep the conversation going. Please email Institute: End of Life Best Practices and let us know what your organization is doing to promote end of life discussions and decision-making.


  • Do Healthy Patients Have Higher Expectations or Do Sicker Patients Have More Unmet Needs? The Relationship between Health Status & Patient Needs

    by Deirdre Mylod, PhD, Executive Director, Institute for Innovation

    When patients provide feedback about care quality, they bring a complex mix of needs, expectations and evaluations to the equation. Some believe that a healthier person brings with them higher expectations of speed, convenience and amenities from their healthcare experience. The assumption is that healthier patients are more critical because their relative good health affords them the opportunity to compare their experience to other types of service environments. 

    Evidence shows, however, that healthier patients are more likely to offer positive evaluations of care. Following are key insights on this topic from the Institute Findings Library.

    Better Self-Report of Health Status = Higher Patient Experience Scores

    Not surprisingly, maternity patients are most likely to report excellent (44.1%) or very good (41.7%) health. Medical patients most likely to report fair (28.1) or poor (9.3%) health, with fewer reporting excellent (7.2%) or very good (19.4%) health. Surgical patients fall in between with a fairly large group reporting excellent (12.5%) or very good (34.4) and few (<5%) reporting poor health.

     

    Within each Inpatient service line (maternity, medical and surgical), patients who self-report as being in excellent health are the most likely to recommend the hospital. As health status worsens, evaluations also decline. Similarly, patients with poorer health status are consistently less likely to rate their hospital as a 9 or a 10.

     

    In the Medical Practice setting, it is most common for patients to evaluate their own health as either very good (33.3%) or good (34.3%).



     As in the Inpatient setting, similar patterns occur: patients in poorer health are less likely to recommend their care provider to others; they are also less likely to evaluate their provider as a 9 or a 10.

     

    Patient experience indicators give us insight into which elements of care are consistently meeting patient needs and where unmet needs still remain. It is intuitive that patients with more complex health issues may be less likely to have their needs met. Our health care system has become increasingly specialized in order to treat the sickest of patients from a technical perspective; however we may not be addressing the needs of our patients along the way.

    When looking within the inpatient setting at the medical and surgical populations, we find that the attributes of care least influenced by patients’ health status relate to courtesy, amenities and perception of skill. In contrast, the elements of care that are most impacted by health status include discharge preparation, pain control, responsiveness to concerns, emotional support and involvement in decision making. Sicker patients have greater needs related to their care.

    By understanding the different needs of sicker patients, providers can more appropriately respond and support them during their care.  In addition to sophisticated clinical quality, these patients need support to navigate the stress of their health issues, control over decisions that matter and education to engage in their own self-care. 

  • Interactive Findings Library: Impact of Patient-Level Risk Factors on Experience

    by Deirdre Mylod, Executive Director, Institute for Innovation

    The Institute for Innovation now offers a growing set of findings that use national data to provide insight into the complexity of the patient experience. The first set of findings includes an interactive library that allows site visitors to dig into patient-level risk factors that are associated with how patients view care. 

    Three topics are available, including:
    • Coordination of care - patient perception of teamwork
    • Shared Decision Making- patient perception of being involved in decisions
    • Drivers of Variation- patient overall ratings and likelihood to recommend 

    Findings are available for Inpatient and Medical Practice populations. After selecting the topic of interest and setting, you can choose different categories of patient-level factors such as patient demographics, social determinants of health, care processes or attributes of care. Each category provides a graphic display of charts and findings from a national data set. When you find a slide or set of results that you want to share, you can print them right from the tool. There’s a lot to explore!

    To get you as excited as I am about the powerful insights in these findings, I’d like to highlight one insight about maternity patients that can be gleaned from these results. Traditionally we think of maternity patients as offering relatively positive evaluations of their inpatient experience, and the national data does show that their ratings are more favorable than the medically treated group. 



    However, when we consider the impact of the health of patients, we find that the higher scores for the maternity group are likely a function of the fact that they are healthier than other patients in the hospital. They are far more likely to report that their own health is Excellent or Very Good.  But when self-report of health is controlled for, maternity patients are actually less likely to rate their hospital stay as a 9 or a 10 as their medically treated peers with similar health status. 



    These findings represent the first phase of analysis for the Institute work and offer descriptive patterns that help to better understand how needs are being met for different groups of patients. We’ll be building on these results in 2015 by adding national results that describe the impact of organization characteristics. The patterns in these patient-focused findings remind us that health care is complex, and our response to patients must be complex and informed by evidence. By better understanding how patients groups with similar needs experience care, we’ll be positioned to redesign process to better meet those needs. Doing so will bring greater value to the patient - and greater focus to our mission to reduce patient suffering.

  • Reducing Patient Suffering: Celebrating a Year of Work

    by Deirdre Mylod
    In late August our Founding Executive Council met as part of its quarterly update and brainstorming session. I am always energized and excited by the conversation and ideas that are shared. We discussed the extension of the suffering framework  to include clinicians and caregivers and what it might mean to more actively work toward spreading empathy, trust…and even hope. This meeting was particularly significant because it represented the first anniversary of the formal work of the Founding Executive Council. It was just last year in August 2013 that the group first came together for discussion, though many of the members had been contributing their thoughts and suggestions that shaped the Institute for Innovation in the months prior.

    Looking back on the past year, much has been accomplished. And of course, the work also shows us how much more there still is to do. The Founding Executive Council went through a consensus process in 2013 to identify the four prioritized projects that have become the Institute’s focus. And coming this Fall, the first results from those projects will become publicly available on our website. We look forward to sharing these findings with the industry, and most importantly to hearing feedback and sparking conversation.

    I’m inspired by a quote from Thict Naht Hahn, who said “If you have a great aspiration, it’s because you have seen suffering, have awakened to the presence of suffering and want to put an end to it.” Our work is grounded in the premise that patients suffer and that our goals must include treating medical illness within the larger context of holistically reducing patient suffering. The acknowledgement of patients’ wider experiences has inspired our work and led us to lofty aspirations. We’re excited to watch the journey unfold and to have you along with us.


  • Putting Patient Needs First

    by Deirdre Mylod, PhD, Executive Director, Institute for Innovation
    The Institute for Innovation has been hard at work over the last several months. These are exciting times with tremendous engagement and enthusiasm for how we can better understand what patients need.

    In November, the Founding Executive Council convened in person and spent three hours in a working session. Together, the Council worked to define vision statements for each of the four prioritized research projects, and discussed the concepts around reducing patient suffering and better addressing patients’ needs. That conversation continues to dynamically evolve over our quarterly meetings.

    Subject Matter Expert work groups have been formed for each of the projects and regular meetings are underway. Initially, the groups brainstormed many possible research questions to address under each topic and then engaged in a formal consensus process to prioritize the specific areas of focus. These groups are now reviewing and reacting to the findings resulting from the first phases of our analytic work.  

    Last week I had the opportunity to visit the Mayo Clinic to learn more about their innovations in healthcare delivery and their efforts to create optimally-functioning teams. The strength of their culture was readily apparent as we met with key researchers and leaders throughout the organization. I was struck by the fact that literally every single person I met with spontaneously invoked the Mayo core value that “the needs of the patient come first.”

    Efforts to reduce patient suffering require that we first seek to understand patients’ needs and keep those needs top of mind. Imagine my delight to see an exhibit of the historic Mayo headline, “Dr. Mayo Dedicates New Clinic to Relief of Human Suffering in Cornerstone Ceremony”. 

    During the dedication of this building, Charles H. Mayo, M.D., said: “Intelligence with knowledge enables wisdom to extend the highest service. Such service has made necessary this building, which we now dedicate to the relief of suffering humanity through diagnosis, treatment, and cure of disease, and the healing of wounds.” A compelling reminder that reducing suffering has always been at the forefront of great care.

    I’m looking forward to attending the Cleveland Clinic’s fifth annual Empathy in Innovation Summit next month. I’ve participated in this event each year since its inception and always come away inspired by the merging of strategy, tactics and shared purpose.  Their work to promote empathy is a necessary piece of the puzzle to acknowledge and take action to reduce patient suffering. I hope to see you there.

    Image courtesy of Mayo Clinic and Rochester (Minn.) Post Bulletin