Data Relationships Help Drive Transformational Change at Cohen Children’s

Added on Jun 20, 2019

data graphicCuriosity and Conversation about Data Relationships Help Drive Transformational Change at Cohen Children’s Medical Center
By Audrey Doyle

At Cohen Children’s Medical Center, improvements in the safety, quality, and experience of care are supported by data—and guided by curiosity.

“We’re curious about what’s beyond the data—what the relationships are between patient experience, quality and safety, and employee engagement, and the stories these relationships tell us,” said Carolyn Quinn, RN, Cohen Children’s Executive Director.

Using the data as a tool to help them uncover these relationships and stories gives Cohen Children’s leaders deep insights into the factors that play a role in the delivery of an optimal care experience to their pediatric patients. According to Quinn, these insights have led to the development of new strategies around patient safety and family engagement, eliminated silos among care teams, improved interpersonal relationships between clinicians and their patients and families, and transformed the way the organization delivers care.

The pediatric hospital of Northwell Health, Cohen Children’s Medical Center is a 206-bed children’s tertiary care facility located in New York City. According to Quinn, Cohen Children’s has been leveraging survey data to drive improvements in patient experience, safety, care quality, and workforce engagement for a number of years.

“Like many other hospitals and health systems, if our data showed us we had a unit that was struggling in one of those areas, we would come up with an action plan to correct what we thought might be causing the problem. Then we would take a look at the data again after the next survey cycle,” said Quinn, who spoke about the organization’s transformational journey at the 2019 Press Ganey Pediatrics Executive Summit last month.

However, this “react-and-act approach,” as Quinn described it, produced only temporary gains. “It was a one-dimensional, static approach to improvement, where leaders would focus on a single data point, make a judgment, create their own story about what was causing the low score, and base their improvement plan on that,” she said. “But data is multidimensional and is influenced by many attributes, so even if the improvement plan worked, it wasn’t always sustainable.”

About three years ago, Quinn and fellow senior leaders began taking what she calls a “more mindful approach” to improvement. “We put a pause on judgment, and instead started exploring how those attributes are interdependent and can influence each other,” she said.

To help unit leaders, clinicians, and staff understand the interdependencies between the attributes and how they may change over time, they began implementing integrated performance dashboards that are aligned with the children’s hospital, pediatric service line, and Northwell Health’s strategic plan. Each dashboard provides data on a unit’s patient experience, employee engagement, quality, and safety measures from the preceding and current years, along with the unit’s year-todate (YTD) threshold, goal, and stretch targets. The dashboard also depicts whether the unit’s performance is below its goal, is meeting its threshold, or is meeting/exceeding its goal, and it includes a line graph depicting a month-to-date trend analysis of the unit’s performance.

Nurse and physician leader dyads meet to discuss their performance as described on their unit dashboard displays. In addition to the monthly discussion, biannual executive report-outs occur with the senior leaders and the unit or department dyad leaders. “We discuss what is and isn’t working, and we ask them what support they need from us,” Quinn said. The senior leaders also help guide the thought process so that the unit leaders don’t react against the data, but instead, feel comfortable talking openly about what they think is driving or influencing it.

In this way, according to Quinn, it becomes very clear that they understand how, for example, a drop in nurse engagement can affect patient experience, or how a change designed to improve patient experience can improve safety. “We talk about the influences that the data points have on each other and what’s driving them, instead of just singling out and siloing to one specific data point,” Quinn said. “Then the leaders are able to consider the why—for example, why they are experiencing drift in engagement, why patient experience results aren’t as high as they were last year, or why there were more safety events in a particular quarter.”

Through these conversations, the team identifies sustainable improvement strategies that Quinn says they wouldn’t see otherwise. Two examples in particular stand out to Quinn.

The first example concerns a systemwide initiative that Northwell Health’s Office of Patient Experience launched over a year ago in response to survey scores and comments indicating that nighttime noise on inpatient units in Northwell hospitals was sometimes below best-practice standards. To minimize noise at night and help maintain a quiet and healing environment, facilities throughout the system adopted a noise reduction “Quiet at Night” program that included environment light and sound awareness practices, and asked staff, patients, and visitors to lower their voices and place their cell phones on vibrate between the hours of 9 p.m. and 6 a.m.

“We believe quiet hospitals heal and a healthy environment is one that is sensitive to noise, so we thought that implementing a noise reduction initiative was fantastic. But our staff had questions about the time of day that we were being asked to do this,” Quinn said. “We’re a pediatric hospital, and our patients don’t typically sleep between the hours of 9 p.m. and 6 a.m. They sleep when they want to, and most of the time our younger patients sleep longer hours and nap during the day.”

To come up with a solution that could be implemented—and, importantly, that staff, families, and visitors would embrace—Quinn and her team needed to know how noisy the inpatient unit actually was during the day as well as at night. So, following a suggestion by the unit’s Collaborative Care Council Committee, they used sound monitoring equipment to measure the noise levels on the unit.

“We were really surprised by the initial results,” Quinn said. “Through the data, we realized the decibel level of the unit’s normal conversation was close to the decibel level of a vacuum cleaner most of the day.” Equally surprised were the unit leaders. “They thought, ‘Of course we’re quiet all the time’—until we showed them they weren’t,” Quinn said.

That realization helped to ignite conversations with staff around how best to reduce noise levels 24 hours a day, and why this would be important, not just for patient experience, but for family engagement, patient outcomes, and patient safety, as well. From these conversations, the team developed a number of noise reduction strategies.

For example, in addition to designating quiet time as “all the time,” they discuss noise reduction during patient- and family-centered rounds. They also ask family members who are staying with a sick child whether noise on the unit impeded their ability to get uninterrupted sleep. This shows that the hospital is sensitive to their needs, but it also alerts the staff that a family member to whom they may be providing important patient information may be too tired to retain that information. “Rested families are able to more readily participate in family- and patient-centered rounds with clearer minds to better understand education and clinical care plans,” Quinn said.

The team also provides parents and teenage patients with a quiet comfort kit, which includes an eye mask and ear buds. In addition, unit receptionists are scripted to engage with families in conversation designed to heighten awareness on minimizing noise, and a unit announcement is made in the evening suggesting bedside visitors join in supporting a quiet environment.

As a result of these efforts, according to Quinn, the unit went from a top box score of 23.1 in the “Quietness of hospital environment” question to a May 2019 YTD top box score of 50.7, with a high of 71.4 in the most recent month. “Responsiveness to call bell” also increased from a top box score of 50 to a May 2019 YTD top box score of 70.6.

The second example concerns central line associated bloodstream infection (CLABSI) reduction efforts that were implemented in the facility’s medical oncology unit. Cohen Children’s had begun a journey to safety, called “Commit to Zero,” through the Children’s Hospitals’ Solutions for Patient Safety Network. Through that initiative, Cohen Children’s adopted and augmented the care bundle that relies on partnerships with families, patients, and clinical teams to comply with CLABSI avoidance culture elements.

According to Quinn, transparent conversation about the unit’s safety data, along with partnerships with unit-based frontline staff and patients’ families, opened the door to curiosity and conversations about ways to reduce CLABSI rates and empower families to become involved in the effort.

To that end, among the changes made on the unit was the elimination of IV tubing extensions that allowed patients to ambulate longer distances. In addition, “family members are encouraged to support their child’s participation in appropriate medical play and sensitivity to oral contact of their medical devices,” Quinn said. As a result, although central line infections in this high-risk population were once considered impossible to avoid, Cohen Children’s oncology unit has had no central line infections from November 2018 through May 2019, which has had a positive impact not only on patient safety and patient outcomes, but on patient length of stay, as well.

In addition to these changes, housekeeping staff are encouraged to alert the nursing staff if they see that an IV pump is too low and its tubing is hitting the floor or is too close to the floor. This collaboration across hierarchical and functional silos sends the message that all staff members are partners in patient care, and has a positive impact on employee engagement, Quinn said, adding, “It was no surprise to see that the oncology unit’s Employee Engagement was Tier 1, at 4.44.”

While Cohen Children’s has always believed that accurate performance data is a highly valuable asset to have, as it can reveal how well the facility is meeting the needs of its patients and its workforce, Quinn stressed that data is most effective in bringing about transformational change when it’s used as a tool to help guide improvement efforts across safety, quality, patient experience, and workforce engagement.

“Data on its own wasn’t driving improvement for us,” she said. “It was only when we started taking a more transformational approach to looking at our data, and really giving ourselves permission to ask questions and have conversations about it—not in an emotional way, in a curious way—that we were able to reveal opportunities that would result in integrated, sustained improvement.”