Ihi Patient Family Experience Of Hospital Care White Paper 2011 (1)

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Innovation Series 2011 Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care 23 The Institute for Healthcare Improvement (IHI) is a…
Innovation Series 2011 Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care 23 The Institute for Healthcare Improvement (IHI) is a not-for-profit organization leading the improvement of health care throughout the world. IHI helps accelerate change by cultivating promising concepts for improving patient care and turning those ideas into action. Thousands of health care providers participate in IHI’s groundbreaking work. We have developed IHI’s Innovation Series white papers as one means for advancing our mission. The ideas and findings in these white papers represent innovative work by IHI and organizations with whom we collaborate. Our white papers are designed to share the problems IHI is working to address, the ideas we are developing and testing to help organizations make breakthrough improvements, and early results where they exist. Copyright © 2011 Institute for Healthcare Improvement All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form or by any means, or repub- lished under any circumstances, without the written permission of the Institute for Healthcare Improvement. How to cite this paper: Balik B, Conway J, Zipperer L, Watson J. Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available on www.IHI.org) Acknowledgements: The authors are deeply grateful for the wisdom and expertise shared by so many in the work represented in this white paper. The voices of patient and family partners shaped much of the thinking and kept the entire team focused on the “True North” of meaningful and productive partnerships with patients and families. Many leaders and organizations shaped the world of patient- and family-centered care long before there was more widespread interest. They shared a belief that a strong partnership between consumers and health care professionals and organizations is the best path to care that heals and promotes health. We also thank the expert reviewers who provided a vital critical assessment of the paper: Kari Barrett, Service Excellence Coordinator, Bellin Health; Maureen Connor, PFCC Consultant; Jane Englebright, CNO and Vice President, Clinical Services Group, Healthcare Corporation of America; Martha Hayward, Executive Director, Partnership for Healthcare Excellence; Bev Johnson, President and CEO, Institute for Patient- and Family-Centered Care; Rosalyn Marshall, Nurse Manager, Medical College of Georgia; Steve Meisel, Patient Safety Officer, Fairview Health; Karen Tate, Family Advisor, Children’s Hospital of Philadelphia; Nancy DeZellar Walsh, Patient Experience Consultant; and Kristine White, Vice President, Innovation and Patient Affairs, Spectrum Health System. Finally, we thank Jane Roessner, Val Weber, and Don Goldmann for their critical review and editing of the paper. Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138 Telephone (617) 301-4800, or visit our website at www.IHI.org. Innovation Series 2011 Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care Authors: Barbara Balik, RN, EdD: Senior Faculty, IHI; Principal, Common Fire Healthcare Consulting Jim Conway, MS, FACHE: IHI Senior Fellow Lorri Zipperer, MA: Principal, Zipperer Project Management Joanne Watson, MD: Health Foundation/IHI Fellow 2008-2009; Consultant Endocrinologist/Clinical Director of Patient Experience, Taunton & Somerset NHS Foundation Trust 1 Innovation Series: Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care Executive Summary In response to growing interest from the hospital community in better understanding and improving the experience of patients and their families during hospitalization, the Institute for Healthcare Improvement (IHI) conducted an in-depth review of the research, studied exemplar organizations, and interviewed experts in the field. Our aim was to identify the primary and secondary drivers of exceptional patient and family inpatient hospital experience (defined as care that is patient centered, safe, effective, timely, efficient, and equitable), as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey’s “willingness to recommend” the hospital.1 The project’s multistakeholder team included patient and family members, patient and family advisors to health care organizations, IHI faculty, and experts in patient- and family-centered care. The project identified five primary drivers of exceptional patient and family inpatient hospital experience of care (each with associated secondary drivers, evidence, and exemplars): leadership; staff hearts and minds; respectful partnership; reliable care; and evidence-based care. Hospitals can use this framework to design their efforts to improve the patient and family experience — testing and implementing changes, weaving them into the fabric of daily work for everyone, and achieving outstanding results. This white paper compiles evidence and resources to support improvement of the experience of patients and their families during hospitalization.2,3 This work has informed the IHI Improvement Map,4 IHI initiatives such as Transforming Care at the Bedside,5 and presentations at the IHI National Forum, along with the improvement efforts of many hospitals. Although this paper draws primarily on experiences in the US, co-authors Conway and Watson have used this work in the UK and find the content highly transferable. Background Increased attention to the patient and family experience of inpatient hospital care stems from several sources. First, public reporting in the US of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)6 provides data on all hospitals’ performance and allows the public to compare organizations. Second, despite their efforts, many organizations have had trouble rapidly improving their patient and family experience results and sustaining the gains. Third, genuine and effective partnerships with patients at the clinical and organizational level are slow to develop, despite exemplars with proven results. Finally, many leaders struggle with integrating efforts to improve the patient experience into the strategic work of the hospital, treating these efforts instead as an array of good ideas. © 2011 Institute for Healthcare Improvement Innovation Series: Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care 2 In the face of one or more of these challenges, hospital leaders began asking IHI urgent questions, including: • How do we provide an exceptional patient and family experience? • There are so many pieces to patient- and family-centered care; how do we make sense of it all? • We have so many different projects underway; when will we start seeing real progress? • Does improving the patient and family experience actually make a difference in outcomes? In response, IHI initiated a 90-day research and development project to answer these and other questions. The R&D project included the following: • A multistakeholder project team, including patient and family members; • A review of the evidence by an expert librarian and inclusion of that evidence throughout the project to help inform the work; • Interviews with over 60 leaders experienced in measuring and improving hospitals’ patient and family experience; • Interviews with exemplar hospitals; • Consultations with expert organizations, including the Institute for Patient- and Family- Centered Care, the Picker Institute, and Planetree; and • A workgroup of organizations from IHI’s IMPACT Learning and Innovation Community to test and learn from proposed actions to accelerate improvement. The aim of the R&D project was to provide a concise summary and a clear framework (in the form of a driver diagram) of what it takes to achieve a culture of patient- and family-centered care and an exceptional experience for hospitalized patients and their families. To help hospitals make sense of the many aspects of improving the patient and family experience, this white paper includes: • A list of primary and secondary drivers that, taken together, will result in achieving the overall aim; • Exemplars from a variety of hospitals to help translate concept into action; • Tips on how to get started; and • Extensive references and a bibliography to provide further evidence, guidance, and applied examples. © 2011 Institute for Healthcare Improvement 3 Innovation Series: Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care Three themes emerged during the development of the driver diagram. 1. An integrated system is key to achieving the aim of an excellent patient and family experience of inpatient hospital care. Interviewed leaders and experts were unable to separate efforts to improve the patient experience from efforts to improve quality and safety; they saw the two as integrated and mutually reinforcing. For example, excellent partnerships with patients contribute to safer care, and safer care results in better patient experiences. Patients and families view the experience of care in its entirety, not as separate components; thus clinical, relational, and environmental aspects of care all tie together. 2. Leadership behavior at the executive, middle, and front-line levels is essential to achieving exceptional results. Leadership commitment to creating an environment that nurtures and continuously improves the patient and family experience and results in positive outcomes is essential. When executives delegate improving the patient experience to caregiving teams, results are isolated and limited. Effective leaders demonstrate the components of IHI’s Framework for Leadership for Improvement: they have the will, ideas, and commitment to execution to achieve results.7 3. The path to achieving excellence in the patient and family experience includes a group of dynamic, positively reinforcing actions rather than a linear set of activities. For instance, effective leadership engages the hearts and minds of staff and providers, which in turn provides a foundation for respectful team communication and partnerships with patients and families, which in turn reinforces staff and provider engagement. Patient- and Family-Centered Care: History, Definition, and Current Status History and Definition References to “patient-centered care” date to the 1950s, and the concept of “patient-centered medicine” was introduced by Balint and colleagues in 1970.8 The Picker Commonwealth Program for Patient-Centered Care and the Picker Institute began research in 1988, identifying eight essential dimensions of patient-centered care and measures of patient experience for each dimension. Dimensions included access; respect for patients’ values and preferences; coordination of care; information, communication, and education; physical comfort; emotional support; involvement of friends and family; and preparation for discharge and transitions in care.9 In 2001, the Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century,10 included patient centeredness as one of its six overarching aims for improvement. “Patient experience” is a measure of patient centeredness.11 © 2011 Institute for Healthcare Improvement Innovation Series: Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care 4 There are several definitions of “patient- and family-centered care.” Although they vary slightly, the definitions offered by the Picker Institute,12 the Institute for Patient- and Family-Centered Care,13 and Planetree14 share common elements (see Table 1). Table 1. Definitions of Patient- and Family-Centered Care The Picker Institute • Patient- and family-centered care is defined as “improving health care through the eyes of the patient.” • A ll patients deserve high-quality health care and patient views and experiences are integral to improvement efforts. • Patient-centered care includes the following principles: ❍ Effective treatment delivered by staff you can trust; ❍ Involvement in decisions and respect for patients’ preferences; ❍ Fast access to reliable health care advice; ❍ Clear, comprehensible information and support for self-care; ❍ Physical comfort and a clean, safe environment; ❍ Empathy and emotional support; ❍ Involvement of family and friends; and ❍ Continuity of care and smooth transitions. Institute for Patient- and Family-Centered Care Patient- and family-centered care has these characteristics: • People are treated with dignity and respect; • H ealth care providers communicate and share complete and unbiased information with patients and families in ways that are affirming and useful; • P atients and family members build on their strengths by participating in experiences that enhance control and independence; and • C ollaboration among patients, family members, and providers occurs in policy and program development and professional education, as well as in the delivery of care. Planetree Patient- and family-centered care includes the following components: • Human interaction; • Family, friends, and social support; • Information and education; • Nutritional and nurturing aspects of food; • Architectural and interior design; • Arts and entertainment; • Spirituality; • Human touch; • Complementary therapies; and • Healthy communities. © 2011 Institute for Healthcare Improvement 5 Innovation Series: Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care Whether drawing on these definitions or others, organizations should craft a definition of patient- and family-centered care that meets their unique needs and mission. The definition provides the focus for all work to improve the patient and family experience. It should be clear, compelling, precise, and concise. It is not a slogan but an authentic statement of the organization’s beliefs and promises to patients and families, with the overall intent to engage patients and their families as full partners in care and in all decision making. IHI defines “family” as those individuals the patient chooses to call family, not those that caregivers define. Current Status Optimizing the patient and family experience has historically been viewed as a nice-to-have, but not a fundamental aspect of a health care organization’s attention. Despite nearly a half century of conversation, research, and application, realization of patient- and family-centered environments, systems, and experiences has been elusive. The Patient-Centered Care Improvement Guide, developed jointly by Planetree and the Picker Institute, captures and reports myths that have slowed progress (along with the evidence debunking them).15 Sample myths include the following: • There is no evidence to prove that patient- and family-centered care (PFCC) is effective. • Providing PFCC is too costly. • Providing PFCC will add more work for nurses; it will take too much time. • The first step to PFCC is new construction (or its companion myth: We will do PFCC and have better experience results as soon as we eliminate double patient rooms). • Patients’ access to the medical record violates confidentiality requirements. • We have won numerous quality awards, so we must be patient- and family-centered. • The patients will have unrealistic demands. • Families will interfere with care, creating delays, errors, and lapses in infection control. • Having patients and families at care team meetings will inhibit staff and providers from being open. Multiple forces, both “push” and “pull,” are changing the nature of patient- and family-centered care rapidly and dramatically. These forces are summarized in Table 2. © 2011 Institute for Healthcare Improvement Innovation Series: Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care 6 Table 2. Forces Impacting Patient- and Family-Centered Care “Push” Forces: “Pull” Forces: Making the Status Quo Uncomfortable Making the Future Attractive • Consumer movement: • O rganizing the health care system around the patient and family works for everyone. ❍ onsumers are saying to health care C professionals, “It isn’t yours alone to decide.” • O ptimizing the patient experience correlates with other outcomes, including clinical,16,17 ❍ Patient rights financial,18 and staff satisfaction. • Patient safety: • P atient activation and self-management is ❍ T he voices and faces of those who have been enhanced, achieving better chronic disease harmed by medical care are more visible to outcomes.19,20 Great stories and results are hospital boards and consumers. being generated internationally and in health ❍ gency for Healthcare Research and Quality A care organizations within the US, shaping a new consumer patient reporting system standard for performance. • Transparency demands • H ealth care providers and caregivers are seeking a better patient experience for those • Health care reform they serve and for their own families. • Accrediting organizations • A ARP, Consumer Reports, National Quality Forum, National Priorities Partnership, Picker Institute, Planetree, Institute for Patient- and Family- Centered Care, IHI, Lucian Leape Institute, World Health Organization — all working to advance consumer partnerships A growing body of evidence shows that improving the patient experience and developing partnerships with patients are linked to improved health outcomes. For example, evidence shows that patients who are more involved in their care are better able to manage complex chronic conditions,21,22,23 seek appropriate assistance, have reduced anxiety and stress,24 and have shorter lengths of stay in the hospital.25 In addition, the Centers for Medicare & Medicaid Services (CMS) has supported posting patient experience ratings on the Hospital Compare website26 and announced that future reimbursement will be impacted by a hospital’s ranking relative to its peers. This combination replaces the “nice-but-not-necessary” view of PFCC; hospital leaders now have performance requirements in patient and family experience equal to those in clinical quality, safety, and finance. Understanding the Exceptional Patient and Family Experience While extensive literature exists on the patient experience, organizations often struggle with where to begin the journey, what is the right sequencing, how to intensify progress when results are lagging, and which actions yield the best results when an abundance of recommendations exist. Evidence from the literature, successful organizations, and content experts offers a clear picture of essential actions for application, further testing, and, where appropriate, broader spread: © 2011 Institute for Healthcare Improvement 7 Innovation Series: Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care • Partnerships with patients and families are the foundation of excellence in PFCC. As noted by the Lucian Leape Institute of the National Patient Safety Foundation, “If health is on the table, the patient must be at the table, every table.”27 • An exceptional patient and family experience is the common ground for all six aims of quality care as defined by the Institute of Medicine in Crossing the Quality Chasm — care that is patient centered, safe, effective, timely, efficient, and equitable.28 • Patient- and family-centered care must be part of all settings of health and health care (inpatient, outpatient, extended care, and home care) and all levels (environment, organization, microsystem, and individual experience of care). (See
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