Coupling Lean and Experience-Based Design for Measuring and Incorporating Patient Emotional Experience Into the Redesign of Health Care.

BACKGROUND AND OBJECTIVES: Incorporation of Lean into health care requires consideration of the patient and other customer experience of care as well as final health outcomes. We incorporate experience-based design (EBD) into our Lean management method to assess the experience of care, guide redesign of care processes, and assess the effectiveness of quality improvement on the care experience. Foundational to EBD is identification of "touch points," moments in the health care delivery process where a patient has a strong positive or negative emotional response that has the potential to alter the way patients feel about their overall care experience. METHODS: EBD proceeds sequentially from qualitative assessment of customer experience and touch points (through observations and interviews); semiquantitatively assessing the experience across many patients (through EBD questionnaires); engaging in codesign with patients (through improvement teams and events); and reassessing the care experience after improvement (through follow-up EBD questionnaires). The use of project-specific (EBD) emotion word questionnaires enables assessment of change over time. These EBD questionnaires are developed ad hoc for each care improvement effort, to reflect the specific high emotion touch points patients identify for that care process, and therefore pose unique validity and reliability challenges. We have previously validated a set of emotion words that form the library from which questionnaire designers select the relevant emotion word choices. In addition, to assess consistency of measurement in the absence of any improvement, we performed a repeated-measures study deploying the same EBD questionnaire to different groups of patients, separated by a 60-day interval in the absence of any quality improvement work. RESULTS: We apply EBD across the health care enterprise, including patients and family caregivers, as well as staff members. Examples where EBD has been incorporated into care redesign have included; outpatient care for pancreatic cancer patients; clinic visits in rheumatology; delirium care for hospital inpatients; and the orientation process for newly hired advanced practice providers. Our reliability data demonstrate that moderate differences in scores on the EBD questionnaire (up to 19 percentage points) may reflect random variability, but differences of greater magnitude reflect actual changes in the patient experience. CONCLUSIONS: In summary, experience-based design has promise as a methodology to incorporate patient experience within a Lean management structure. EBD can aid with health care redesign, defining the emotional touch points that are foundational to the experience of care, enabling targeting of quality improvement efforts, and assessing change.

Fresh and Savory: Integrating Teaching Kitchens with Shared Medical Appointments.

Objectives: In the fall of 2017, Fresh and Savory, a Culinary and Lifestyle Medicine Teaching Kitchen (TK) program proved systematically feasible as a Shared Medical Appointment (SMA). A portable TK complemented physician consultations, interactive didactic presentations, nutritious cooking, and mind-body exercises. A series of SMAs were launched to develop a system for physicians to address patients' nutritional and lifestyle needs. Interventions: MedStar Health implemented three TK SMA programs to improve patients culinary and lifestyle skills and improve relevant habits. Two cohorts were recruited from Internal Medicine and Cardiology (Internal Medicine/Cardiology I and II) and completed an 8-week program leveraging a culinary and lifestyle medicine curriculum. One cohort (Sports Performance) was held with young, elite athletes completing a 4-week program regarding athlete's nutrition and lifestyle. Feasibility was assessed through patient surveys, staff program operation assessments, and reimbursement. Results: Fifty-three unique patients attended SMA programs, 4-18 patients per weekly session; 223 appointments billed in 2018. E&M code 99213 was billed at $157 and reimbursed, on average, at $116 per patient encounter. During a 4- to 8-week SMA program, changes in patient vitals were statistically insignificant, yet habit changes showed clinical significance. Patients noted increased knowledge of plant-based meals, importance of sleep, and adding mindfulness and exercise to their weekly routine. Conclusions: This exploration investigated the feasibility to implement TK SMA programs at MedStar Health. Developing financial and operational infrastructure for TK SMAs requires financial, staffing, location, and population considerations. TK SMAs proved patient demand for opportunities to develop healthy behaviors. However, sufficient time is required to recruit patients. Vital signs may not acutely improve over an 8-week period, however, small habit changes may improve health outcomes longitudinally and additional exploration is required to assess longitudinal patient outcomes. Financially, SMAs suggest a sustainable and effective approach to integrative medicine in health care.

Understanding the System You Are in Is Key to Improving It.

Front-line ownership (FLO) is an approach to change that is consistent with what we know about complex adaptive systems (CAS), such as a healthcare organization. Traditional change approaches can fail because they are based in the "organization as a machine" metaphor of traditional, scientific management. Both metaphors have their application. It depends on how closely the work naturally resembles a predictable machine. Often, the drive for detailed standardization is a misguided effort to make a human CAS behave more like a machine, so that our traditional approaches to change will work. FLO is a more appropriate tool in a CAS, where shared agreement at the level of a few simple rules (minimum specifications) and allowing flexibility for adaptation within local context is more appropriate than detailed standardization. Because humans in a CAS maintain some control over their discretionary effort, change advocates desiring sustainable change must work with stakeholders to co-create cases for change that resonate with the values of those being asked to change. FLO facilitates the emergence of this level of understanding of shared values.

Experience-based design for integrating the patient care experience into healthcare improvement: Identifying a set of reliable emotion words.

BACKGROUND: Experience-based design is an emerging method used to capture the emotional content of patient and family member healthcare experiences, and can serve as the foundation for patient-centered healthcare improvement. However, a core tool-the experience-based design questionnaire-requires words with consistent emotional meaning. Our objective was to identify and evaluate an emotion word set reliably categorized across the demographic spectrum as expressing positive, negative, or neutral emotions for experience-based design improvement work. METHODS: We surveyed 407 patients, family members, and healthcare workers in 2011. Participants designated each of 67 potential emotion words as positive, neutral, or negative based on their emotional perception of the word. Overall agreement was assessed using the kappa statistic. Words were selected for retention in the final emotion word set based on 80% simple agreement on classification of meaning across subgroups. RESULTS: The participants were 47.9% (195/407) patients, 19.4% (33/407) family members and 32.7% (133/407) healthcare staff. Overall agreement adjusted for chance was moderate (k=0.55). However, agreement for positive (k=0.69) and negative emotions (k=0.68) was substantially higher, while agreement in the neutral category was low (k=0.11). There were 20 positive, 1 neutral, and 14 negative words retained for the final experience-based design emotion word set. CONCLUSIONS: We identified a reliable set of emotion words for experience questionnaires to serve as the foundation for patient-centered, experience-based redesign of healthcare. IMPLICATIONS: Incorporation of patient and family member perspectives in healthcare requires reliable tools to capture the emotional content of care touch points.

Evaluation and development of potentially better practices for staffing in neonatal intensive care units.

OBJECTIVE: Five NICUs that participate in the Vermont Oxford Network's Neonatal Intensive Care Quality Improvement Collaborative 2002 attempted to identify potentially better practices that would have a directly impact on nurse recruitment and retention. The group identified nurse recruitment and retention as an important initiative for many hospitals that face a nursing shortage. METHODS: The group analyzed information from hospital demographics, literature reviews, process analysis questionnaires, and site visits. RESULTS: The literature review, process analysis questionnaire, and benchmarking with magnet hospitals identified 5 drivers for retention and recruitment. The drivers evolved into 5 potentially better practices that cover orientation, recognition and rewards, work environment, nurse/physician collaboration, and nursing autonomy. The magnet hospitals, which are known to have the highest retention rate and the lowest turnover rate, have many of these potentially better practices in place. CONCLUSION: The 5 practices described herein have the potential to decrease nursing turnover in NICUs.

Implementation and case-study results of potentially better practices for staffing in neonatal intensive care units.

OBJECTIVE: Five NICUs that participate in the Vermont Oxford Network Quality Improvement Collaborative have implemented several potentially better practices in an attempt to decrease nurse turnover by 50%. These potentially better practices focus on orientation, rewards and recognition, healthy work environment, nurse-physician collaboration, and nursing autonomy. METHODS: Each unit implemented some or all of the potentially better practices. An Excel spreadsheet tool for tracking turnover rates was developed and used to measure the impact of the potentially better practices on retention. Rates were measured quarterly. RESULTS: After implementation of the potentially better practices, turnover rates fell at all of the NICUs ranging from 13% to 64%. CONCLUSIONS: Nurse retention is multifactorial. Implementation of the potentially better practices had a positive influence on nurse satisfaction but a varied impact on nurse retention. The impact of larger issues such as pay and staffing levels is significant and may not be influenced at the unit level.

Patient misidentification in the neonatal intensive care unit: quantification of risk.

OBJECTIVE: To quantify the potential for misidentification among NICU patients resulting from similarities in patient names or hospital medical record numbers (MRNs). METHODS: A listing of all patients who received care in 1 NICU during 1 calendar year was obtained from the unit's electronic medical record system. A patient day was considered at risk for misidentification when the index patient shared a surname, similar-sounding surname, or similar MRN with another patient who was cared for in the NICU on that day. RESULTS: During the 1-year study period, 12186 days of patient care were provided to 1260 patients. The unit's average daily census was 33.4; the maximum census was 48. Not a single day was free of risk for patient misidentification. The mean number of patients who were at risk on any given day was 17 (range: 5-35), representing just over 50% of the average daily census. During the entire calendar year, the risk ranged from 20.6% to a high of 72.9% of the average daily census. The most common causes of misidentification risk were similar-appearing MRNs (44% of patient days). Identical surnames were present in 34% of patient days, and similar-sounding names were present in 9.7% of days. Twins and triplets contributed one third of patient days in the NICU. After these multiple births were excluded from analysis, 26.3% of patient days remained at risk for misidentification. Among singletons, the contribution to misidentification risk of similar-sounding surnames was relatively unchanged (9.1% of patient days), whereas that of similar MRNs and identical surnames decreased (17.6% and 1.0%, respectively). CONCLUSIONS: NICU patients are frequently at risk for misidentification errors as a result of similarities in standard identifiers. This risk persists even after exclusion of multiple births and is substantially higher than has been reported in other hospitalized populations.

Automating addiction treatment: enhancing the human experience and creating a fix for the future.

The country's system of providing treatment for people struggling with addiction requires a fundamental overhaul. To address these daunting problems, a group of experts from outside the addiction field met in an intensive retreat and envisioned a new future for addiction treatment that would use the latest available technology. Retreat leaders employed creative techniques to help free up thinking beyond incremental improvement ideas. Current and former addicts or alcoholics and family members also attended the retreat to provide the panelists with a real-world understanding of their lives. Through this process, the panelists generated eight idea categories that visualized future treatments for addiction using technology. They were: (1) Integrated System and Record; (2) Monitoring/Treatment; (3) Virtual Experiences; (4) Treatment Access and "One Stop Shop"; (5) Networks; (6) Tailored Media Campaigns; (7) Diagnostic Tools; and (8) Help for Family. Two stories illustrate how these ideas could help a heroin addict and an alcoholic. The sponsors plan another meeting to bring these visionary concepts closer to real application.

Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial.

OBJECTIVE: To test a multifaceted collaborative quality improvement intervention designed to promote evidence based surfactant treatment for preterm infants of 23-29 weeks' gestation. DESIGN: Cluster randomised controlled trial. SETTING AND PARTICIPANTS: 114 neonatal intensive care units (which treated 6039 infants of 23-29 weeks gestation born in 2001). MAIN OUTCOME MEASURES: Process of care measures: proportion of infants receiving first surfactant in the delivery room, proportion receiving first surfactant more than two hours after birth, and median time from birth to first dose of surfactant. Clinical outcomes: death before discharge home, and pneumothorax. INTERVENTION: Multifaceted collaborative quality improvement advice including audit and feedback, evidence reviews, an interactive training workshop, and ongoing faculty support via conference calls and email. RESULTS: Compared with those in control hospitals, infants in intervention hospitals were more likely to receive surfactant in the delivery room (adjusted odds ratio 5.38 (95% confidence interval 2.84 to 10.20)), were less likely to receive the first dose more than two hours after birth (adjusted odds ratio 0.35 (0.24 to 0.53)), and received the first dose of surfactant sooner after birth (median of 21 minutes v 78 minutes, P < 0.001). The intervention effect on timing of surfactant was larger for infants born in the participating hospitals than for infants transferred to a participating hospital after birth. There were no significant differences in mortality or pneumothorax. CONCLUSION: A multifaceted intervention including audit and feedback, evidence reviews, quality improvement training, and follow up support changed the behaviour of health professionals and promoted evidence based practice.

Timing of initial surfactant treatment for infants 23 to 29 weeks' gestation: is routine practice evidence based?

OBJECTIVE: To describe the timing of initial surfactant treatment for high-risk preterm infants in routine practice and compare these findings with evidence from randomized trials and published guidelines. METHODS: Data from the Vermont Oxford Network Database for infants who were born from 1998 to 2000 and had birth weights 401 to 1500 g and gestational ages of 23 to 29 weeks were analyzed to determine the time after birth at which the initial dose of surfactant was administered. Multivariate models adjusting for clustering of cases within hospitals identified factors associated with surfactant administration and its timing. Evidence on surfactant timing from systematic reviews of randomized trials and from published guidelines was reviewed. RESULTS: A total of 47 608 eligible infants were cared for at 341 hospitals in North America that participated in the Vermont Oxford Network Database from 1998 to 2000. Seventy-nine percent of infants received surfactant treatment (77.6% in 1998, 79.4% in 1999, and 79.6% in 2000). Factors that increased the likelihood of surfactant treatment were outborn birth, lower gestational age, lower 1-minute Apgar score, male gender, white race, cesarean delivery, multiple birth, or birth later in the study period. The first dose of surfactant was administered at a median time after birth of 50 minutes (60 minutes in 1998, 51 minutes in 1999, and 42 minutes in 2000). Over the 3-year study period, inborn infants received their initial dose of surfactant earlier than outborn infants (median time: 43 minutes vs 79 minutes). Other factors associated with earlier administration of the initial surfactant dose were gestational age, lower 1-minute Apgar score, cesarean delivery, antenatal steroid treatment, multiple birth, and small size for gestational age. In 2000, 27% of infants received surfactant in the delivery room. There was wide variation among hospitals in the proportion of infants who received surfactant treatment in the delivery room (interquartile range: 0%-75%), in the median time of the initial surfactant dose (interquartile range: 20-90 minutes), and in the proportion of infants who received the first dose >2 hours after birth (interquartile range: 7%-34%). Six systematic reviews of randomized trials of surfactant timing were identified. No national guidelines addressing the timing of surfactant therapy were found. CONCLUSION: Although the time after birth at which the first dose of surfactant is administered to infants 23 to 29 weeks' gestation decreased from 1998 to 2000, in 2000 many infants still received delayed treatment, and delivery room surfactant administration was not routinely practiced at most units. We conclude that there is a gap between evidence from randomized controlled trials that supports prophylactic or early surfactant administration and what is actually done in routine practice at many units.

Voluntary anonymous reporting of medical errors for neonatal intensive care.

OBJECTIVES: Medical errors cause significant morbidity and mortality in hospitalized patients. Specialty-based, voluntary reporting of medical errors by health care providers is an important strategy that may enhance patient safety. We developed a voluntary, anonymous, Internet-based reporting system for medical errors in neonatal intensive care, evaluated its feasibility, and identified errors that affect high-risk neonates and their families. METHODS: Health professionals (n = 739) from 54 hospitals in the Vermont Oxford Network received access to a secure Internet site for anonymous reporting of errors, near-miss errors, and adverse events. Reports used free-text entry in phase 1 (17 months) and a structured form in phase 2 (10 months). The number and types of reported events and factors that contributed to the events were measured. RESULTS: Of 1230 reports--522 in phase 1 (17 months) and 708 in phase 2 (10 months)--the most frequent event categories were wrong medication, dose, schedule, or infusion rate (including nutritional agents and blood products; 47%); error in administration or method of using a treatment (14%); patient misidentification (11%); other system failure (9%); error or delay in diagnosis (7%); and error in the performance of an operation, procedure, or test (4%). The most frequent contributory factors were failure to follow policy or protocol (47%), inattention (27%), communications problem (22%), error in charting or documentation (13%), distraction (12%), inexperience (10%), labeling error (10%), and poor teamwork (9%). In 24 reports, family members assisted in discovery, contributed to the cause, or themselves were victims of the error. Serious patient harm was reported in 2% and minor harm in 25% of phase 2 events. CONCLUSIONS: Specialty-based, voluntary, anonymous Internet reporting by health care professionals identified a broad range of medical errors in neonatal intensive care and promoted multidisciplinary collaborative learning. Similar specialty-based systems have the potential to enhance patient safety in a variety of clinical settings.

NIC/Q 2000: establishing habits for improvement in neonatal intensive care units.

OBJECTIVES: The Vermont Oxford Network is a group of health professionals who are committed to improving the quality and safety of medical care for newborn infants and their families. Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/Q 2000) was the second in a series of multiorganization improvement collaboratives organized and administered by the Vermont Oxford Network. The objective of this collaborative was to make measurable improvements in the quality and safety of neonatal intensive care, develop new tools and resources for improvement specific to the neonatal intensive care unit setting, evaluate improvement progress, and disseminate the learning. METHODS: The 34 centers that participated in NIC/Q 2000 learned and applied 4 key habits for improvement: the habit for change, the habit for evidence-based practice, the habit for systems thinking, and the habit for collaborative learning. A plan-do-study-act method of rapid-cycle improvement was an integral part of the habit for change. Multidisciplinary teams from the participating centers worked closely together in face-to-face meetings, conference calls, and dedicated e-mail listservs under the guidance of trained facilitators and expert faculty. Focus groups formed around specific improvement topics used critical appraisal of the published literature, detailed process analysis, benchmarking, and round-robin site visits to identify potentially better practices (PBPs). RESULTS: The focus groups developed a total of 51 PBPs. Each focus group has developed a "resource kit" summarizing its work. Many of these PBPs have been tested and implemented at the participating centers using rapid-cycle improvement. The PBPs and descriptions of individual center PDSA cycles are available to participants on NICQ.org, the dedicated Internet site for the collaborative. CONCLUSIONS: Collaborative quality improvement based on the 4 key habits can assist multidisciplinary neonatal intensive care unit teams in identifying, testing, and successfully implementing change.

Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit.

PROBLEM: Need for improved sedation strategy for adults receiving ventilator support. DESIGN: Observational study of effect of introduction of guidelines to improve the doctors' and nurses' performance. The project was a prospective improvement and was part of a national quality improvement collaborative. BACKGROUND AND SETTING: A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours. KEY MEASURES FOR IMPROVEMENT: Reduction in patients' mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes. STRATEGIES FOR CHANGE: Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial. EFFECTS OF CHANGE: Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified. LESSONS LEARNT: Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.

Coaching and leadership for the diffusion of innovation in health care: a different type of multi-organization improvement collaborative.

BACKGROUND: Health care organizations have suffered a steady decrease in operating margins in recent years while facing increased competition and pressure to provide ever-higher levels of customer service, quality of care, and innovation in delivery methodologies. The ability to rapidly find and implement changes that will lead to strategic improvement is critical. To assist member organizations in dealing with these issues, VHA Upper Midwest launched the Coaching and Leadership Initiative (VHA-CLI) in January 1999. The initiative was intended to develop new methods of collaborating for organizational learning of best practices, with a focus on generalizable change and deliberate leadership supports for deployment, diffusion, and sustainability. The emphasis was on the spread of ideas for improvement into all relevant corners of the organization. STRUCTURE AND PROCESS OF THE COLLABORATIVE: The structure of the VHA-CLI collaborative involved four waves of demonstration teams during 2 years. Each meeting of the collaborative included an executive session, team learning sessions (concepts applied to their improvement projects), and planning for the 6-month action period following the meeting. An important feature of the collaborative is the way in which teams in the various waves overlapped. For example, the Wave 1 team for a given organization came to a learning session in January 1999. At the second collaborative meeting in June 1999, the Wave 1 teams reported on the progress in their pilot sites. This meeting was also the kick-off session for the Wave 2 teams, which could learn about organizational culture and the improvement model from the efforts of their colleagues on Wave 1. Wave 1 teams also learned about and planned for spreading their efforts to other sites beyond the pilot. The pattern of multiple teams stretching across two waves of activity was repeated at every meeting of the collaborative. SUCCESS: Each organization in the collaborative has achieved improved outcomes around its selected clinical topics. In total, 26 teams have made significant improvement in 17 different topic areas. In addition, each organization has been able to successfully spread tested improvements to other individuals, teams, or locations, and the improvement work has become easier and more rapid with each successive cycle. CONCLUSIONS: The learning process initiated by this project will continue for at least another year in the VHA Upper Midwest region and will be expanded as participating organizations in other regions enroll in the VHA's national effort.