Kelli Clifton-Graduate Administrative Intern

1. Ambulatory Surgery Center (ASC) Patient Satisfaction: Striving for 5’s Through Patient Communication Kelli Clifton-Graduate Administrative Intern Office of the President/Department of Surgical Services 2010 MHA Candidate-The Ohio State University Summer 2009

2. Agenda • Problem Identification and Purpose of Project • Selection of Pilot Locations • Electronic Discharge Instruction • Olson Discharge Process Re-design • Organizational Impact of Project

3. Problem For the baseline period of Q3 FY 09, the overall ASC patient satisfaction goal was 75.7% (VG). In comparison, the actual overall ASC patient satisfaction score was 71.4%(VG) (4.3%).

4. Purpose of Project Develop a perioperative experience that includes timely, consistent and accurate information for Ambulatory Surgery Center (ASC) patients and families • Directly supports Best Patient Experience (BPE) strategic plan • Specific focus on patient satisfaction, measured by Press Ganey Survey

5. %VG for Questions Within Scope FY 09 (Q1-Q3) -Goal 75.7% (VG) 67.4% 71.5% 68.3%

6. Overview Scope: 12 week pilot focused within Olson ASC Orthopaedics and ENT specialties. Goal Benefit: Increase ENT and Orthopaedics scope questions by 50% VG. Deliverables: Electronic Discharge Instructions Discharge Process Re-design within Olson Discharge Phone Call Tracking

7. Pilot Locations Specialties with “room” to improve PG scores Specialties with n>30 survey response rate Identifiable physician champion

8. Selection of Physician Champion

9. Orthopaedic Procedures within Scope

10. Deliverable 1:Electronic Discharge Instructions (DI)

11. Risks • Illegibility • Static • Lacks patient education • Increase in unplanned re-admissions

12. Options for the Improvement of Discharge Instructions

14. Surgeon can complete instructions either prior to or after surgery • Nurse prints for review with patient

15. Before After

16. Benefits • Comprehensive patient education • Promotes medication compliance • Customized per surgeon/patient • Reduces errors due to illegibility • Immediate electronic documentation

17. Recommendations: Strategically Roll-out Electronic DI 1 Completed during 12 week scope Designate specific “go-live” plan for all pavilions Incorporate IS and clinical staff

18. Recommendations: Strategically Roll-out Electronic DI It is recommended that the Department of Surgical Services completely pilot the EDI process within the Orthopedics specialty before moving on to ENT and other departments. Specifically, it is recommended that additional Orthopaedics physicians are added to the template. At the end of the project, the electronic discharge instructions (EDI) were piloted only within the Orthopaedics specialty. Originally, the plan was to pilot among both Orthopaedics and ENT. During the initial roll out phase, logistical issues such as physician training within PowerChart, physician requests for more customization, and concerns regarding the wording of phrases delayed the ability to roll out the process to other specialties such as ENT. In order to complete the goal, the following steps should be taken:

19. Recommendations: Strategically Roll-out Electronic DI • Collection of Information • Identify surgeons based on case volume and procedure type. For example: include • surgeons who perform knee and shoulder arthroscopies since these procedures were • not included in the original pilot. • 2) If available, collect the current (paper) discharge instructions that the surgeons give to their patients. If pre-printed copies are not available, ask the surgeon to complete the Ambulatory Discharge Instructions Form. • 3) Look for similarities among the discharge instructions. If two or more surgeons communicate the same message, this should be a standard prompt within the EDI template. If only one surgeon communicates a unique message, this can be typed into the “what” box or added specifically for the surgeon. • 4) Once the discharge instructions are identified, decide under which “domain” they should • fall. For example: activity, post-operative medication, diet…. • Collaborate with Information Services Documentation Specialist to have the instructions “built” into the PowerChart note.

20. Recommendations: Strategically Roll-out Electronic DI • Pilot Phase • Once the instructions have been added to PowerChart, select two or three days, where a ‘trainer’ can assist the surgeon in completing the EDI. It is recommended that the sheet entitled Process Map-Generate Discharge Instructions-MDbe used for training. • 2) During the phase, identify questions or concerns raised by physicians and nursing staff. • 3) Using the Request to Amend Ambulatory Discharge Instructions Form, submit any changes to the IS department. • 4) Once the changes have been amended, the EDI will be ready for complete use. • Pavilion Roll-out Phase • Using the above methodology, roll-out the EDI to all pavilions. In addition to the 2G Ambulatory Ortho and ENT notes, there is also a 2G Ambulatory General note. This note can be used as a general template for Ambulatory specialties that lack specific customizations. • 2) After physicians begin to become accustomed to the EDI, begin to add specialty specific instructions using the process mentioned above in the “Collection of Information” section.

21. Deliverable 2: Discharge Process Re-design

22. Post-Operative-Recommended Process New Steps Patient taken to recovery room RN visits patient for post-op assessment Status board is updated from “In-OR” to “Post-Op” Surgeon completes discharge instructions via PowerChart Patient remains in Phase 1 until alert Family may visit when called by nurse RN prints discharge instructions and gives to patient in discharge folder RN provides patient education and manages patient expectations RN discharges patient and informs patient of follow-up call/survey Olson Discharge Process Re-Design Pre-Operative-Recommended Process New Step Status board informs PCT/RN of patient arrival PCT/RN goes to waiting room to greet patient and escort back to room Patient undresses and collects valuables in preparation for nursing assessment RN conducts H/P, starts IV, informs patient of plan and potential delays RN informs family that they may visit with patient RN reviews preliminary discharges instructions/ patient education material Surgeon and/or anesthesia may consult prior to case start Patient taken to OR

23. Deliverable 3: Discharge Phone Call Tracking

24. Discharge Phone Call Compliance n=76 n=76 On average 43% of Feinberg patients were called between April and June On average 28% of Olson patients were called between April and June

25. Recommendations for Increasing Discharge Phone Call Compliance 1. Develop a monthly dashboard to track compliance rates across all pavilions 2. Set a goal of 100% follow-up phone call rate 3. Incorporate scripting at discharge: “Thank you for choosing NMH. We will be following your care with a discharge phone call.” 4. Designate one RN the responsibility of assigning call backs

26. Organizational Impact of Project Electronic Discharge Instructions Maximization of current IT investment Promotes provider and staff satisfaction Competitive advantage as a Great AMC Discharge Process Re-design within Olson Reinforces patient education Allows the inclusion of family members Discharge Phone Call Tracking Potential reduction of re-admission rates Additional opportunity to increase patient satisfaction

27. Thank You NMH Senior Leadership Katrina Van Gerpen Karen Anderson Alvin dela Cruz Michael Valitchka Steven Thill Ella Echavez Surgical Services Department Olson ASC Dr. Armen Kelikian Dr. Rakesh Chandra Goran Gavran Jennifer Bloomquist Tia Foster Madge Patyk Anne Findeis Erma Clark

28. Appendix of Supporting Slides

29. ASC Patient Satisfaction-Striving for 5's through Patient Communication Overview Linkage to BPE: Develop a patient experience that includes timely, consistent and accurate information regarding perioperative care for Ambulatory Surgery Center (ASC) patients and families. Problem: For the baseline period of Q3 FY 09, the overall average ASC patient satisfaction score was 71.4% (very good) in comparison to the overall target of 75.7%. Press Ganey scores indicate lower patient satisfaction with 1) information received prior to surgery (67.4%), 2) information given to the patient’s family (71.5%), and 3) instructions to patient regarding home care (68.3%). Goal Benefit: Increase ENT and Orthopedics scope questions by 50% VG. Scope: 12 week pilot focused within Olson ASC Orthopedics and ENT specialties. Post 12 weeks, pilot will be used as template for all NMH ASCs. Deliverables: 1) electronic discharge instructions containing clear and effective directions for patients, 2) a pre-arrival experience providing procedure specific patient education material and information that sets expectations for the day of surgery and home care and 3)analysis of discharge phone call compliance Core Team Required: Olson ASC nursing staff and registration, ENT and Orthopedics physician champion, Specialty offices, Information Services-Technology Management staff, Patient Education Department • 1) ASC overall average Press Ganey score • 2) ENT and Orthopedics Press Ganey Scores for: • information you received prior to surgery • information given to the patient’s family • instructions regarding home care • 3) UHC percentile rankings Milestones Description Date Define 6/15 - 6/29 Measure 6/29 - 7/6 Analyze 7/6 - 7/13 Improve 7/13 - 8/10 Control 8/10 - 9/4 Key Metric(s): Sponsor: Karen Anderson, Director-Surgical Services Project/Process Owner: Kelli Clifton, Graduate Administrative Intern Improvement Leader: Michael Valitchka

30. Project Work Plan

31. Project Tracking Tool

34. Key Facts • 40% of ASC patients are surveyed • 30% response rate • ASC surveys sent within 3 days of discharge • Avg. Patients seen per month • -Olson- • -Feinberg- • -Prentice- • NMH reports % VG

35. Managing Expectations Provider Perspective Patient receives appropriate discharge instructions Patient is aware of follow-up appointments Patient arrives on schedule for surgery Patient obtains accurate diagnostic testing Patient Perspective How long will I spend in the ASC? What foods/medications should I have after surgery? When can my family visit me in recovery? Why do I have to arrive earlier than my surgery start time?

36. Great Academic Medical Centers with Electronic Discharge Instructions

37. Olson ASC Waiting Room Process Map Receptionist Registration • Greet patients and family • Direct patients to Registration • Monitor status board/cases • Round throughout the area • Call interpreter services/chaplain • Direct families to hospital locations • Verify patient information • Provide reference for advance directives • Validate parking • Organize patient packets • Assist receptionist with calls when available ASC Waiting Room-Current Process Patient arrives at ASC and checks into Receptionist desk by giving his/her name Receptionist pulls patient packet and gives to patient Receptionist asks patient to verify personal information and sign advance directives, financial responsibility, personal property forms and health screening form Receptionist verifies ID bracelet, places bracelet on patient, gives family privacy card containing tracking number and validates parking Patient told to be seated until called by Patient Care Technician or nurse ASC Waiting Room-Recommended Process Patient arrives at ASC and checks into Receptionist desk by giving his/her name Receptionist greets patient/family, explains privacy number, gives trifold, gives information about refreshments location, and directs them to ASC/Olson Registration Area Registration asks patient to verify personal information, sign advance directives, financial responsibility, personal property forms and health screening form Registration verifies ID bracelet, places bracelet on patient, validates parking and gives patient trifold to review while waiting Patient told to be seated until called by Patient Care Technician or nurse Staff Responsibilities

38. Olson Pre-Operative Process Map Pre-Operative-Current Process Status board informs PCT/RN of patient arrival PCT/RN goes to waiting room to greet patient and escort back to room Patient is told to undress and collect valuables in preparation for nursing assessment Nurse conducts H/P assessment, starts IV, informs patient of plan and potential delays Nurse informs family that they may visit with patient Surgeon and/or anesthesia may consult prior to case start Patient taken to OR Pre-Operative-Recommended Process Status board informs PCT/RN of patient arrival PCT/RN goes to waiting room to greet patient and escort back to room Patient is told to undress and collect valuables in preparation for nursing assessment Nurse conducts H/P assessment, starts IV, informs patient of plan and potential delays If completed, RN reviews preliminary discharges instructions/ patient education material Nurse informs family that they may visit with patient Surgeon and/or anesthesia may consult prior to case start Patient taken to OR New Steps

39. Olson Post-Operative Process Map Post-Operative-Current Process Patient taken from OR to recovery room by anesthesia team RN visits patient for post-operative assessment Status board is updated from “In-OR” to “Post-Op” Patient remains in Phase 1 until alert Family may visit when called by nurse Nurse goes over discharge instructions from physician Patient discharged from ASC Post-Operative-Recommended Process Patient taken from OR to recovery room by anesthesia team RN visits patient for post-operative assessment Status board is updated from “In-OR” to “Post-Op” Surgeon complete discharge instructions via PowerChart Patient remains in Phase 1 until alert Family may visit when called by nurse Nurse prints completed discharge instructions and gives to patient in discharge folder Nurse provides patient education and manages patient expectations Nurse discharges patient and informs patient of follow-up call/survey New Step

40. Log into Power Chart Select patient from patient list or by medical record number Select Notes 2G Tab and then ADD to generate discharge note Select Encounter Pathway tab, search for note…..Ex. 2G Ambulatory Ortho Click note name to highlight and “Add to Favorites” for quick accessibility Double click on note name to open and generate discharge instructions Click hide structure or show structure to select instructions or preview document When complete, sign note by selecting ‘Discharge Instructions” as the Type Discharge Instructions for Medical Staff

41. Discharge Instructions for Nursing Staff Log into Surginet Select patient from patient list or by medical record number Select Reports and Summaries Select Specific Discharge Summary Print Discharge Instructions for Patient

42. Updating PowerChart Discharge Instructions If you need to update information within the discharge instructions…. Use the Request to Amend form and send to IS for assistance