Hourly Rounding Decreases Never Events

HCT engaged with a 275 bed not-for-profit Catholic health care provider to improve HCAHPS scores.  In addition to improving HCAHPS scores, this hospital experienced a significant decrease in falls.  Falls are one of Medicare’s Never Events and as of October 1, 2008, Medicare will no longer pay for this or any other serious medical errors that occur through the course of a hospital stay.  Medicare estimates the cost of a falls and trauma event at $33,894*.  Therefore, the work that HCT did with this hospital not only improved patient satisfaction, it had a significant financial impact as well as improving patient safety. 

HCT’s unique Hospital Transformation Intervention™ process was used in order to facilitate success with HCAHPS score improvement and decreased falls.  HCAHPS data analysis, direct staff observations, focus groups and staff, patients, and physicians interviews were used by HCT in order to perform a thorough assessment of this hospitals service culture. 

HCT compiled all the data and presented administration with an action plan to improve their HCAHPS scores.  As a first step, HCT recommended forming a Service Team of managers and staff members across all inpatient units in order to develop and implement specific initiatives.  Senior and nurse leader rounding, hourly rounding, scripting, education, and patient education materials are a few examples of the team’s initiatives.  The hospital had previously attempted to implement hourly rounding but did not experience the success that they had hoped for.  HCT was able to assist the hospital in re-invigorating and strengthening the hourly rounding initiative.  Areas that were rectified included:  the use of various methods of documenting the rounds, the multiple methods of rounding that were occurring from unit to unit, and lack of education with the nurses.  The team developed one documentation form to be used throughout the facility.   They standardized a process for performing hourly rounds that included the alternation of rounding between the RN and CNA.  Additionally, HCT conducted 40 hours of education reaching 290 staff members.  Education focused on how to properly conduct rounds, necessity of documentation and the benefits of hourly rounding to both the patients and staff.  

In addition to improving all HCAHPS domains by nearly 8%, this hospital was able to realize a 30% reduction in patient falls in a very short period of time.  Data from a baseline of Jan 08-April 08 was compared to the post implementation period of May 08 -Aug 08.  The potential financial impact is estimated at over $700,000 for this facility. 

This case study supports the research that has been conducted regarding the impact of hourly rounding on falls.  Research has demonstrated that falls can be reduced by as much as 50% through hourly rounding.  HCT can assist hospitals in transforming their culture so that falls are no longer considered just a fact of life in a hospital.  Additionally, they can help facilities protect their finances by decreasing their number of Never Events. 

* Source: CMS Fact Sheet: CMS Proposes List of HAC for FY 2009

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A 511 bed regional academic medical center requested a thorough assessment and recommendations for improvement from HCT Consulting in regards to their Emergency Department’s throughput times.  This Level 1 Trauma Center is the 2nd largest Emergency Department in their state and they average 8500 visits per month.
HCT assessed this hospital’s times by examining the three distinct phases of ED throughput: intake, throughput and output.  HCT collected data from each of these phases, closely studied and observed processes, and conducted interviews with leaders, physicians, staff and patients. Based on this information, HCT made recommendation for improvement that had significant impact with the hospitals throughput times. 

During the intake phase, HCT analyzed the ED department’s registration, triage and fast track processes.  Much data was collected in this phase:  average visits by hour of arrival, distribution of cases by Emergency Service Index (ESI), number of visits by hour based on the ESI, average check-in to Triage time, and average Triage to room time.  HCT made several recommendations based on their assessment: implementation of a quick registration process, relocation of triage, improvement in signage and the addition of a volunteer greeter to direct flow in the waiting room.  Additionally, several changes to their fast track process were recommended, such as: hours of operation, enhancements to office equipment and having a MD/RN combo in triage during peak times to perform Medical Screening Evaluations (MSE).

Much time was devoted to observing communication and teamwork during the throughput process.  Understanding the role of case management, as well as the other members of the team was gained during this time.  This facility had initiated many processes during this phase and HCT determined the effect that these multiple initiatives were having on the staff and their throughput times.  Of importance during this phase was the action of the staff and the process they followed when they became over capacity.  The relevant data collected during this phase was average room to provider time and average provider to bed request time.  Recommendations to enhance this phase included: implementation of a capacity alert policy, development of a method to measure success on implemented initiatives, streamline the number of initiatives being rolled out, a system to effectively evaluate initiatives as they are implemented, and a communication plan to make everyone aware of progress. 

ED Output has several components.  HCT investigated the multiple reasons for delays in this phase of the process.  The roles of Patient Flow Coordinator, Bed Control and nursing in the ED and on the inpatient units were all closely evaluated.  Since the availability of beds in the inpatient units greatly affected delay times, HCT analyzed the delays in discharge for inpatients.  The metrics measured during this phase included: average provider to bed request time, average bed request time to discharge and average provider to discharge.  The evaluation of this phase resulted in several recommendations: redesign of the roles for Patient Flow Coordinator, Hospitalist, and ED Case Manager, enhancement to the bed control process, establish parameters for Academic Medical staff for inpatient discharges, update hallway bed policy, enhancement of processes that determine isolation requirements, improvement to bed board meeting, new housekeeping pager system, adjustments to housekeeping staffing, daily huddles between unit based case managers and nursing,  education for nursing on DRGs, LOS and Case Management  roles and responsibilities, InterQual® education for case managers and creation of a Palliative Care Team. 

The hospital implemented many of HCT’s recommendations and quickly experienced many positive results.  Patient assigned bed times have improved with 60% of patients being assigned a bed in 30 minutes and 90% of patients being assigned a bed in one hour.  Boarder hours have decreased from 10.69 to 6 hours with a goal to move this to 4 hours. Left without being seen (LWBS) decreased from 11.65 % to 7%.   Many units have adopted the process of discharge by appointment which is having an effect of patients being discharged earlier in the day from inpatient units.   

HCT’s thorough assessment of the phases that contribute to ED throughput times and their recommendations led the way for this hospital’s improvement.  HCT has provided continued support to this hospital as they persevere in improving their ED processes, thereby providing better quality of care to their patients.

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Operating room (OR) efficiency is a measure of how well time and resources are used for their intended purposes. The best method for determining efficiency is to determine how well the OR is utilized. Recently a 479 bed, for-profit hospital felt they needed assistance with their OR efficiency as they felt their OR was underutilized and they were struggling with trying to improve on their own.

Highly experienced perioperative consultants used the Hospital Transformation Intervention™ process to dissect the OR’s preoperative, intraoperative, and postoperative processes. Hospital Transformation Intervention™ process is comprised of three distinct phases: assessment and detailed implementation planning, process redesign and staff training, and rapid cycle implementation and performance measurement.

During the assessment and implementation planning phase the consultants analyzed factors affecting utilization rates including: preadmission testing (PAT) process, predictability in scheduling and case times, turnover times, cancellation rates, use and accuracy of preference cards, number of add-ons available to fill gaps, sequencing of cases, utilization rates by time of day and Post Anesthesia Care Unit (PACU) admission delays. Once a thorough assessment was performed including direct staff observations and interviewing staff, patients, and physicians, the data was compiled, analyzed and presented to administration with an action plan. An OR efficiency team was formed in order to ensure buy-in from key stakeholders. This team was comprised of our consultants, physicians, staff nurses, PAT and PACU staff. The team developed the goal to improve OR efficiency and utilization through targeted initiatives such as: improve first case start times, improve collaboration between PAT, anesthesia, OR, and PACU, revise the PAT process, improve turnover times, and improve preference card use and updates.  

During the process redesign and staff training phase, the consultants worked in collaboration with team members to ensure that rapid cycle implementation took place with the initiatives. In addition, they attended the OR’s daily huddles to provide education and clarification about the new initiatives. We also use this time for a number of staff training workshops. The HCT educational offering include: Leadership Training, Lean Operations, Problem Solving, Meeting Facilitation, Fundamentals of Leadership, Teamwork, Basic Service Training, Service Recovery, and Pain Management.

Through the course of the implementation phase, consultants provided posters that provided visualization of the progress to ensure performance management. This helped to motivate improvement across the metrics. The consultants also developed a scorecard for the facility to use on an on-going basis.

The eight week process had many positive and immediate results. OR first case delays decreased from 23 minutes to 11 minutes. They experienced a 13% improvement in case cancellations. Most importantly, OR utilization increased 33%. The consultants led the way in developing the skills the staff need in order to continue improvement upon their early success.  

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A 160 bed for-profit health care provider sought assistance with their ED throughput times as they were averaging 200 diversion hours per month and an average of 6.1 patients per day leaving without being seen.  They also had concern with their average length of stay for both their admitted and discharged patients. 

HCT’s Hospital Transformation Intervention™ process was used to address these particular areas of concern for the hospital.  Initially a thorough assessment was performed by evaluating the hospital’s ED data, performing direct staff observations, and interviewing staff, patients, and physicians.  The data was compiled, analyzed and presented to administration with an action plan to impact the hospital’s throughput scores.  An ED throughput team was formed in order to ensure buy-in from key stakeholders.  This team was comprised of HCT consultants with ED expertise, physicians, staff nurses, registration, bed control and ancillary managers.  The team developed the goal to implement initiatives that would reduce patients’ time in ED beds with the aim of creating more capacity to accommodate new patients faster. 

In order to accomplish their goal, HCT examined causes for delays throughout their ED system: intake, throughput and output.  During the intake process they examined their registration and triage processes.  Working side by side with consultants, rapid cycle implementation took place with several initiatives such as, short triage form and bedside registration.  Metrics, such as bed to physician time and bed to discharge, were examined as a part of developing initiatives to address throughput.  Key initiatives were launched to address bottlenecks with physicians and streamline ancillary processes.    Initial bed request time to patient exit time was examined to develop processes to address bed control procedures.  Changes in practice included faxed nurse report and bed control bypass as well as diversion teams. 

Throughout the process staff was trained in leadership and patient satisfaction including: Lean Operations, Problem Solving, Meeting Facilitation, Fundamentals of Leadership, Teamwork, Service Recovery, and Pain Management.

The eight week process had many positive and immediate results.  Hours on diversion went from 200 to 0.  ALOS for ED patients went from 210 minutes to 171 minutes.  ALOS for admitted patients went from 456 minutes to 268 minutes.  Lastly, the average number of patients leaving without being seen per day decreased from 6.1 to 2.9.  These results have sustained and in many cases have improved over time with limited sustainability sipport.

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HCT Consulting was approached by a 350 bed, full-service, for-profit healthcare provider with the desire to totally revamp their case management department.  The provider felt they were not staffed appropriately and were operating like a case management department “out of the 1980’s”. 
The initial objectives discussed were:

•  Provide breakthrough analysis and deep analytical support to selected initiatives:
• Introduce expertise, approaches and specific knowledge in selected areas while accelerating implementation in key areas;
• Provide day-to-day program management support; and
• Achieve and sustain the performance impact in the areas of case management (department structure and operations), Medicare LOS and interdisciplinary interactions.

We used our unique Hospital Transformation Intervention TM process to conduct the assessment, process redesign & staff training as well as implementation and performance measurement.  
The assessment phase consisted of observations, shadowing, interviews and data analysis. The targeted areas were departmental infrastructure, education, barriers to discharge and technology.  Also, as a part of the assessment, we were asked to interview potential candidates for the interim Case Management department director position and to conduct an objective performance rating of all case managers and social workers in the department. 
The redesign & staff training phase consisted of brainstorming sessions which included case managers, social workers and nursing.  A product of this phase was a Collaborative Action Plan that was immediately implemented. In addition, a needs assessment was conducted to identify training and other educational gaps of the department. 

The newly developed action plan was put into place under the guidance of the HCT consultants.  Some key initiatives for departmental infrastructure included:

• Identification of new case management director;
• Transition to unit based assignments;
• Delineation of case manager and social workers roles and responsibilities;
• Engagement of a proactive physician leader;
• Establishment of an ED case manager; and
•  Creation of a new departmental escalation policy. 

Key initiatives for education included:

• Lining up in-services for case management department to be conducted as “lunch and learns”;
• Education of unit secretaries and HIM on importance of correct discharge dispositions;
• Ongoing nursing education;
• Community education which included meetings with nursing homes, SNFs and LTACHS; and
• Utilizing the Physician Leadership Director to conduct ongoing physician educational sessions.

To tackle some of the barriers to discharge, the tactics included;

• Establishing multidisciplinary daily huddles;
• Helping case managers and social workers to re-prioritize their day;
• Restructuring the complex case review meetings;
• Working closely with Hospitalists to establish responsibility and accountability for medical staff; and
• Implementing a concurrent coding process.

In the area of technology the focus was:

• Researching automated case management systems (including discharge planning); and
• Establishing access for all the case managers to KePro I- Exchange and setting the expectation for daily tracking for Medicaid approvals. 

For the performance measurement phase we worked very closely with the Quality/Performance Improvement department as well as the IT department to establish an extensive dashboard on the facility’s shared drive, allowing the tracking and trending of measures as well as providing easier access by the Administrative team.
The hospital was able to make major changes in a short period of time with the potential of a significant financial impact.  The hard savings which were realized rapidly were part of the department FTE restructure and resulted in a savings of approximately $200,000. The at-risk reimbursement that was corrected by establishment of new processes will save the facility $950,000.  As a result of changing the delivery model for case management and implementation of initiatives the facility committed to reducing Medicare LOS by 0.5 days.  This results in a “soft” savings of between $415,000 and $975,000. The total financial impact for this engagement ends up between $1.5M and $2.1M.
This facility is serious about sustaining the progress they have made and continuing to build on that progress.  They are still actively implementing improvements and are working very closely with HCT to help ensure ongoing success.

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A 275+bed not-for-profit Catholic health care providercontracted with HCT Consulting in order to perform an assessment on their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and to implement an action plan based on that assessment. This hospital was concerned that their first publically reported HCAHPS scores were below their direct competitor’s in every domain of the survey by an average of 8%.

HCT used their unique Hospital Transformation Intervention™ process to address the goals of the hospital. Initially HCT performed a thorough assessment by evaluating the HCAHPS data, performing direct staff observations, and interviewing staff, patients, and physicians. HCT compiled all the data and presented administration with an action plan to raise their HCAHPS scores. Among the recommendations, HCT proposed forming a service team of managers and staff members across all inpatient units in order to develop and implement specific initiatives to address the HCAHPS service domains. To ensure symmetry with the Senior Leadership group, a steering committee composed of hospital senior leadership was formed to offer continuous guidance to the team. The service team developed targeted initiatives such as; senior leader rounding, nursing leader rounding, nursing hourly rounding, scripting, standardization of hourly rounding documentation, and improved patient education materials. HCT was intimately involved with the development and the implementation of every initiative and its consultants worked side by side with hospital staff in order to ensure success. Recognizing the importance of facility-wide training and communication, 20+ hours of classroom offerings were conducted reaching hundreds of employees.

In a very short period, the hospital has been very successful in raising their HCAHPS scores by using the Hospital Transformation Intervention™ process. Post implementation they have enjoyed a 4 point increase in willingness to recommend, a 9 point increase in communication with nurses, a 7 point increase in communication with doctors, a 1 point increase in explanation of new medications, a 17 point increase in responsiveness with staff, a 6 point increase in discharge information, a 13 point increase in pain management and a 7 point increase in quietness at night. On average, each domain increased by 7.64%.

Service has a direct connection to quality as evidenced by a 33% decrease in falls/month post implementation of hourly rounding. This decrease in falls amounts to a savings of $38,800/month based on a decrease of 2 falls/month at a cost of $19,400/fall*. The decrease in falls is not the only return on investment that the hospital will realize. While it is too early to measure the financial impact, research has shown that hourly rounding results in reduction in the rate of pressure ulcers by 50%. The additional cost per discharge for a pressure ulcer is $15,958**. Additionally, the hospital should experience an increase in growth as beds become available from a decrease in length of stay resulting from fewer never events. Growth will also occur through the positive word of mouth that will occur within the community.

HCT has worked very closely with the hospital in training the leaders in the skills they need for sustainability. This includes bi-weekly steering committee meeting, on-going education and orientation to new staff on customer service skills. HCT will maintain a close relationship through a post engagement contract in order to ensure the hospital’s momentum so that they can continue to see success on the HCAHPS survey and provide their patients with quality care.

* National Prevention Center for Injury Prevention and Control, Division of Unintentional Injury Prevention; May 2007

** AHRQ, 2005, “Payments for Adverse Events”

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FMQAI is an independent medical case review and healthcare quality improvement organization that partners with healthcare providers and practitioners to improve patient care and outcomes. FMQAI has provided technical assistance to hospitals to help them comply with Medicare billing and coding regulations since 1999 and has been a national leader in reducing unnecessary hospital admissions since 2003.

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In 2005, Good Samaritan Medical Center in West Palm Beach, Florida partnered with FMQAI, the state Quality
Improvement Organization (QIO), to participate in a project focusing on improving Appropriate Care Measures (ACMs). Specifically, Good Samaritan focused on improving care delivered to patients who are diagnosed with heart failure, pneumonia, or acute myocardial infarction. Good Samaritan aimed to improve care to these patient populations by ensuring the most effective and efficient processes were being utilized.

More info on Good Samaritan

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