Point-of-Care Technology Improves Rounding at Baylor Scott & White

Added on Dec 15, 2016

Point-of-Care Technology Improves Rounding at Baylor Scott & White
By Diana Mahoney
Industry Edge December 2016

When the patient experience team at Texas-based Baylor Scott & White Health realized the organization’s rounding efforts were being hindered by time-consuming, manual tasks and variation across care sites, they looked to point-of-care (POC) surveying for a real-time solution.

Working closely with IT and leaders from across the system, the group designed an electronic rounding platform that enabled the immediate collection and reporting of patient experience data to support service recovery interventions, process improvement initiatives and employee recognition.

A pilot test of the platform initiated at various sites across the BSWH system in March 2015 resulted in a streamlined workflow, standardized rounding tactics and improved performance on specific Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions, according to Shon Tackett, process improvement consultant for the health system, who, along with Maggi Savo, director of patient experience, described the development and implementation of the electronic rounding platform at the 2016 Press Ganey National Client Conference.

For example, scores on two key HCAHPS communication domains— Communication about Medicines and Nurse Communication—improved substantially in the pilot sites that focused the POC survey questions on these areas. In one of the hospitals, top-box performance on Communication about Medicines increased from 65.7% pre-implementation to 68.7% six months post-implementation and, in the most recent quarter for which the data were available, to 78.4%. Similarly, top-box performance on the Nurses Listen Carefully to You item in the Nurse Communication domain increased from 81.8% to 85.6% at six months, and then to 89%.

With the technology, “rounding becomes more purposeful and less task-driven,” Savo explained. “For example, collecting real-time data allows staff to identify patient concerns and respond immediately, either by addressing them at the time they are identified or escalating them to a care provider before the patient leaves the facility.” The goal is not only to address issues quickly, she said, but also to communicate to the patient that the issue is being addressed, reassuring patients that their voice is being heard and that what they have to say matters.

Setting the Stage

The impact of hourly rounding on the patient experience is well-established. Recent research from the Institute for Innovation, for example, showed that patients who report that nurses and staff rounded hourly during their hospital stay gave higher evaluations of care in all areas across both Press Ganey and HCAHPS survey items. Importantly, they were 29% more likely to rate the hospital as a 9 or 10 on a 10-point scale and 27% more likely to give a top-box score for Likelihood to Recommend the hospital to friends and family—key indicators of patient loyalty. Further, the difference in mean scores between those who did and did not report hourly rounding exceeded 15 points for two individual survey items: “Response to concerns and complaints made during your stay” and “Promptness in responding to the call button.”

Purposeful nurse and leader rounding is not new to BSWH, which is the largest not-for-profit health system in Texas, documenting more than five million patient encounters annually across its 49 hospitals and more than 500 patient care sites. The best practice has been a long-standing, essential strategy in the health care system’s journey to STEEEP (Safe, Timely, Effective, Efficient, Equitable, Patient-Centered) care.

Yet multiple system-level barriers have kept the organization from realizing the full benefits of the practice, according to Tackett. Among the obstacles has been the fact that while each hospital has had an hourly rounding process, the processes have often varied by site. Hospitals have also been peppered with inefficiencies such as paper-based note taking and manual report creation, which impede workflow and the identification and resolution of patient issues.

Further, the lack of cross-site governance or a standardized method to document and track service recovery or process improvement needs has limited the ability of leaders to understand what works at each facility or to compare the effectiveness of practices between facilities or within units of the same facility, said Tackett.

In the face of these obstacles, “our hospitals have been asking for an electronic tool to capture, archive and report on data to improve workflow and efficiency,” Tackett said. The effectiveness of such a tool on its own, however, would be limited without the necessary foundational support, he noted, adding, “The Office of Patient Experience felt that standardization and governance with such a tool was critical for the system to be successful.”

For this reason, the development team’s first step was to conduct a gap analysis to identify the chasm between the current rounding situation and the future state they wanted to reach. This required identifying the various rounding tools and processes being used across the system, determining the purpose for each tool and process, and mapping the purpose to specific service intervention and recovery objectives. “We identified how information was being gathered, how the data were being presented, who was using the data and possible outcomes to determine which tool or tools would help reach our objectives,” Tackett said. “We also attempted to determine the impact that various solutions would have on CAHPS scores.”

The team decided the POC/eRounding platform would best meet the system’s needs because of its ease of use and access to data in real time, Tackett said. Working with IT and site leaders, they designed a pilot test of the technology in seven of the BSWH hospitals with a mixture of inpatient, outpatient and emergency services.

The next step was to establish a governance committee to optimize use of the tool across sites and settings, and a governance process to define a core set of questions and manage custom surveys. The governance committee included nursing, administrative, hospitality and service excellence leaders from each pilot site and was supported by a liaison from the Office of Patient Experience to create a foundation for the tool and recommendations for implementation.

The governance committee developed the structure of the survey, which included a core set of five questions for each area, two to three unique identifier questions (e.g., patient room and caregiver name) and two custom questions based on each site’s individual objectives. During the trial, hospitals were allowed to update or replace questions based on feedback from nurses and hospital leaders, and the governance committee met regularly to discuss usage, problems and survey results.

The core set of questions enabled leaders to make between-site comparisons and facility-level trending assessments, Savo said. The core questions included the following.

  • Have you been given assistance in a timely manner when you have requested it?
  • Is your room clean to your satisfaction?
  • Do you feel the staff are actively listening to your needs?
  • Has our team been keeping you informed of what is happening?
  • Please share with us how we can improve. (Type data in box.)

The custom questions allowed sites to tailor their rounding surveys to support local process improvement. For example, three of the seven pilot sites wanted to drive HCAHPS improvement efforts and used HCAHPS items related to communication as their custom questions, Savo said.

Ready, Set, Survey

Prior to implementation, each site underwent a readiness assessment based on a multisection implementation checklist consisting of technical requirements and survey setup and use requirements.

The technical section of the checklist addresses wireless network and hardware requirements, and the survey setup portion supports workflow compliance and identifies recipients and use expectations of the data, Tackett explained. “For example, some facilities wanted to identify who was rounding, while other facilities focused more on specific topics and reward and recognition opportunities.” The setup section also includes recommendations on custom survey questions, user roles and access rights, he said.

In collaboration with Press Ganey, the team also created a survey workbook that was customized to BSWH needs. The workbook identifies administrators and users, includes dropdown selection options, and tracks changes and updates to the survey structure.

Once all of the checklist items were completed, users in the initial trial sites received training through webinars and site visits. Multiple hardware options—tablets, workstations and in-room charting computers—were configured for the surveys, which were administered by nurses and leaders who entered the responses as part of their rounding interactions. Despite some inevitable technical roadblocks, such as poor wireless coverage in some areas, the overall response among pilot sites to electronic rounding was positive.

“All of the sites gained efficiencies in reporting, service recovery while patients are still on-site, and escalation of process problems,” Savo said. “Facility leaders have confidence in the results presented back to staff through the electronic platform, and they are able to use real-time information to guide performance improvement initiatives.”

The technology also supports staff recognition, which in turn increases engagement, according to Savo. “Top-performing nurses and ancillary staff can be individually identified for providing resolution or superior care on a real-time basis.”

Driving Measurable Improvement

As noted, the pilot sites that focused their electronic rounding questions on HCAHPS communication items saw meaningful and sustained improvements in those areas following implementation. Four hospitals used the Nurses Listen Carefully to You question in their survey, and all but one saw improvements in the percentage of top-box scores for this item from pre-implementation to the most recent quarter for which the data were available.

Rather than being intrusive, the technology enabled adjustments to the rounding process that focused on the relationship with patients, Savo said. “For example, the pre-populated questions allowed nurses to focus their rounding interactions on a few conversational topics.”

Each of the three hospitals that used a question from the HCAHPS Communication about Medicine domain saw their performance improve following implementation. “The tool allowed them to quickly identify patients who had questions about their medications and get the questions answered before they left,” said Savo.

Since the initial pilot implementation, use of the electronic rounding platform across BSWH has expanded to include 15 hospitals, nine specialty service lines and nine outpatient clinics. “Customized surveys have been developed to meet the needs of areas not covered by traditional patient rounding,” Tackett said. “Departments and specialized units such as hospitality services, transplant, oncology, geriatrics, palliative care, long-term acute care and skilled nursing facilities have begun using the tool as a means to gather real-time actionable input from patients and families,” he explained. “The data from these point-of-care surveys are used in daily staff huddles and leadership meetings to keep staff and leadership informed of issues and concerns in real time.”

Improvement Is an Ongoing Process

The pilot test has provided a number of takeaways for future implementation. Most importantly, according to Tackett, is that the tool alone does not drive process improvement. “Having an established, purposeful rounding protocol in place prior to implementation is critical,” he said. “The platform is adaptable to maturing rounding processes in each facility when rounding was already in place without the tool.”

Additionally, the team learned the following lessons.

  • Successful implementation happens locally. “Sites with local implementation resources and those that invested more time in setup were most satisfied with the tool,” Tackett said.
  • Device selection is important. The rounding platform can work on any Web-enabled device, and while multiple device types are currently in use at BSWH, staff prefer tablets when the wireless capacity supports them. “Tablets are more convenient for the staff and are not seen by patients as a distraction that hinders communication,” Tackett said. “Use of tablets requires a robust internal wireless network or access to external networks. Network connectivity issues will present challenges in data collection and may result in end-user discouragement and reduced tool usage.” Part of the pre-implementation checklist is to confirm wireless signal strength on all of the units that are rounding.
  • Establishing a governance structure provides a sense of credibility that decisions and recommendations are vetted and developed from established leaders. “Our governance committee includes physicians and nurses from both hospitals and clinics, and ancillary service line leadership,” Tackett explained. “A diverse governance committee also provides representation from different patient touchpoints to keep data significant to all involved in rounding, and governance by key stakeholders is needed to provide structure and establish standards to allow comparisons across sites.”
  • A core set of questions is essential to support standardization and comparison between units and facilities. “These questions are performance drivers that produce actionable data while keeping rounding based on meaningful conversations,” said Tackett.

Finally, Tackett stressed, don’t be afraid to push the envelope and expand use of the tool beyond patient rounding. At BSWH, custom surveys were developed for ancillary services, such as environmental and dietary departments, and surveys have been developed to verify grant requirements, such as resident scorecards, and to identify patient and family concerns in outpatient oncology services, outpatient radiology and palliative care.

With the right foundational support and adherence to established implementation processes, point-of-care surveying can be a real-time treasure.