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![that remains focused on the guiding principles of patient-centered care and translates
those aspirations into concrete terms that any organization can consistently implement.
The Always Events initiative is readily understood and enthusiastically endorsed by
patients, families, healthcare providers, and other stakeholders. It resonates across
industry and stakeholder lines and can be used in a multitude of ways to improve patient
experience, engage staff, and transform healthcare. It serves as a call to action for a
healthcare system that will consistently deliver patient-centered care to every patient,
every time, and it provides the necessary tools to make rapid action possible.
B. Unique Features of the Always Events® Initiative
There are many unique features of the Always Events initiative, including its positive focus,
open architecture, and community of organizations sharing resources.
Builds Relationships by Focusing on the
“[T]he concept of ‘Always Positive
Events’ for hospitals and Too often, healthcare improvement efforts focus
doctors is the medical exclusively on what is wrong with healthcare,
measurement equivalent of rather than how to build on what is already done
that popular management tool well and do it consistently. Always Events give
of ‘Always catch someone doing organizations the opportunity to reframe their
it right!’ Physicians are likely discussions of patient-centered care in a positive
to want to participate in intention-based manner that builds
discussions about these positive relationships between and among patients,
and important aspects of the families, and staff. The approach is similar to an
care experience.” “appreciative inquiry” process that highlights
what is working well and determines how to
Tom James, MD
learn from and expand upon that success to
Medical Director, National
promote consistent performance of the Always
Network Operations, Humana Inc.
Event with every patient, every time.
Open Architecture Enables Rapid Adaptation and Innovation
One of the many important decisions made during the development of the Always Events
initiative was the decision to maintain an open architecture for the program, rather than
creating a discrete list of Always Events. There were many factors supporting this decision.
Although a short list of clearly defined Always Events could, in theory, improve care, it
would be impossible to establish one prioritized list that would be relevant to all settings Page | 7](https://image.slidesharecdn.com/alwayseventsblueprintforaction11-2012-121212060708-phpapp02/75/Always-Events-Blueprint-for-Action-8-2048.jpg)
![build skills that not only will contribute to the success of the Always Events program, but to
the success of the organization. Yale-New Haven Hospital, for example, identified two staff
nurses as the project leaders for its Always Events initiative. As the principal investigator
Janet Parkosewich, DNSc, RN, CCRN, FAHA, noted, “For families to receive the level of care
we want, we have to give staff nurses these skills and experiences. . . . The project has helped
[the two nurses] to flourish as leaders. They are doing something they are passionate about
and are being given dedicated time in the schedule to do it. The Magnet program requires the
involvement of frontline staff in improvement work and this project demonstrates the
powerful impact that frontline nurses can have.”
For an Always Events project to be successful, leaders must model appropriate
behaviors. If the leaders in the organization are not behaving in a manner that is
consistent with the Always Event being implemented, staff will not engage in the project.
One Always Event initiative ran into challenges when the organizational leader questioned
the value of the project; not surprisingly, progress was slow without leadership support.
Leaders also help to put the right structure in place to support the project by building the
team as described in the team engagement section below.
Patient/Family Partnership: It is imperative that healthcare organizations directly
engage patients and families as active partners in all phases of the development and
implementation of an Always Event. This partnership can take many forms. Grantee
organizations with existing Patient and Family Advisory Councils and/or advisors
integrated into hospital operations involved those advisors in designing, implementing and
refining their programs. Organizations also sought patient and family involvement through
other formal and informal mechanisms such as focus groups, surveys, and interviews.
Incorporating patients and family members into planning is important, but the need for
involvement does not end there. Partnering with patients and family during
implementation of an Always Event is absolutely essential. Patients and families often have
very different interpretations of providers’ behavior than may be intended. For example,
one Always Events grantee who provided patients and family members with a paper tool to
record important information related to their discharge discovered that some patients
perceived the document as evidence of a lack of coordination rather than an initiative to
improve coordination of care, noting “Why do you need us to write things down – don’t you
know what we’re supposed to do?”. Patients and family members also identify opportunities
to improve communication and provide a realistic perspective on the way the event is
being implemented. One grantee discovered that patients did not understand the term
“handoffs,” and changed the language in patient materials to “change-of-shift bedside
report.” Another grantee found that although patients understood the language on the
questionnaire they were being provided while waiting for their outpatient visits, they were
not receiving any explanation from staff as to the purpose of the document. Page | 13](https://image.slidesharecdn.com/alwayseventsblueprintforaction11-2012-121212060708-phpapp02/75/Always-Events-Blueprint-for-Action-14-2048.jpg)
![the [A]lways [E]vent and provided the necessary knowledge, skills and attitude to fulfill the
expectations.” Always Events grantees used many types of education including online
learning, videos, simulation and role-playing, self-learning packets, and presentations.
Effective Always Events programs translate ideals into concrete behaviors for which
staff can be held accountable. Dartmouth-Hitchcock Medical Center for example, used the
acronym ALWAYS to break down patient-centered communication skills into six
observable behaviors. (A – Address and refer to patients by the name they choose, not
their disease; L – Let patients and families know who you are and your role in the patient’s
care; W – Welcome and respect those defined by the patient as ‘family’; A – Advocate for
patient and family involvement in decision making to the extent they choose; Y – Your
name badge: ensure patients can read it; S – Show patients and families the same respect
you would expect from them.)
In addition to describing “how” and “when” an Always Event will be implemented, it is
important to emphasize “why.” Patient stories can powerfully illustrate the why and
reconnect providers to their sense of mission of purpose. One grantee working on end-of-
life issues for neonates rallied staff around a powerful quote from a father, “Do clinicians
realize that we will never forget their names, their faces, and what they said to us about our
dying child?”
Education is a start, but it may not be enough to change staff behavior. Several Always
Events grantees identified “champions” or coaches who inspired and educated their
colleagues, led by example, and provided “peer-to-peer at the elbow support” and coaching
during implementation. Champions also must be supported in their roles. Some
organizations created formal written descriptions of the characteristics and
responsibilities of champions. Others convened the champions on a regular basis to
discuss how the Always Event was being implemented and to refine the program as
necessary.
Data Use/Performance Improvement: Prior to implementing a specified Always Event,
the organization should determine what metrics will be used to evaluate the program.
There may be baseline data available to compare performance before and after the Always
Event is implemented, which could affect project timing. In addition, some of the grantees
implemented Always Events on selected units and compared performance to similar
“control units” in which the Always Event was not implemented. It is important to have
these discussions prior to implementation so that the full range of evaluation options can
be discussed and appropriate tools developed before action is taken that forecloses certain
evaluation possibilities. Some of the grantees discovered mid-way through their projects
that the evaluation tools they had planned to use were not available, which limited their
ability to fully assess the impact of the Always Event. Page | 15](https://image.slidesharecdn.com/alwayseventsblueprintforaction11-2012-121212060708-phpapp02/75/Always-Events-Blueprint-for-Action-16-2048.jpg)
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Similar to Always Events Blueprint for Action
Always Events Blueprint for Action
- 1. Always Events® Blueprint forAction Improve the Patient Experience Engage Staff Transform Healthcare December 2012 © 2012 Picker Institute. All Rights Reserved.
- 2. Table of Contents I. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 II. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 III. Why Always Events®? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 IV. Using Always Events® to Transform Healthcare Organizations . . . . . . . . . . . . . . . . . . 9 V. Using Always Events® to Educate Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 VI. Using Always Events® to Transform the Healthcare System . . . . . . . . . . . . . . . . . . . . . 24 VII. The Future of the Always Events® Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Appendices: A. History of the Always Events® Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 B. National Steering Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 C. Always Events® Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Please note: Although the terms Always Events® and Always Experiences® are registered trademarks, the Picker Institute encourages organizations to freely use and adapt the concepts, tools, and practices created as part of the Always Events program. Organizations interested in publicly using the trademarked terms in connection with their own programs should contact the Institute for Healthcare Improvement (IHI) for additional information on permitted uses. Page | 1
- 3. I. Executive Summary Healthcare is being transformed from the outside. Health reform, public reporting, regulatory requirements, pay for performance, and other sea changes are challenging healthcare organizations to operate in new ways. In these complex times, many healthcare leaders and even more frontline staff are overwhelmed by competing priorities. To thrive in the new external environment, healthcare leaders need to recognize the central theme that aligns all of these forces and to engage their entire organization in doing the one thing that unites any priority – to put patients at the center of care, not only in name, but in practice. Although the intensifying external pressures for patient-centered care are relatively recent, patient-centered care itself is not new. Even Hippocrates advised, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” For more than a quarter century, the Picker Institute has worked to advance patient- centered care by helping healthcare providers see through the patient’s eyes. Over those years, the patient needs and preferences embodied in the Picker Principles for Patient- Centered Care have been remarkably consistent. Patients want to be treated with respect in a healthcare system that is easy to access and provides coordinated and integrated care. Patients want reliable, understandable information and education and to be able to communicate effectively with their providers at all times across the continuum. Patients want to be physically comfortable and emotionally supported and want to be able to involve loved ones in their care. Patients want transitions to be seamless. Not surprisingly, these patient values and priorities are at the heart of many of the external forces redesigning healthcare. Viewing care through the patients’ eyes and addressing these unmet needs is the right thing to do for patients. It is also the right thing to do for healthcare organizations and the committed professionals and staff who work for them. The evidence validates that patient- centered care is an essential foundation for achieving other organizational goals, such as improving quality and safety, enhancing clinical outcomes, reducing readmissions, and promoting financial viability and the quality of life in the workplace. It can be done and it must be done. This Blueprint for Action provides a reliable roadmap to assist healthcare organizations in making rapid, dramatic advances in patient-centered care using Always Events for the Optimal Patient Experience. Always Events refer to aspects of the patient experience that are so important to patients and families that healthcare providers should always get them right. The Blueprint is not just aspirational, it is Page | 2
- 4. intensely practical, anddistills the lessons of organizations that have successfully implemented Always Events in their organizations. These organizations have used the Always Events concept to address some of the most vexing challenges in healthcare today, such as improving communication, providing consistent transitions, partnering effectively with patients and families, and improving patient safety. Their results and the lessons they have learned pave the way for other organizations to apply Always Events to their organizational challenges. The companion Always Events Solutions Book contains a snapshot of several successful Always Events projects, results and available tools, which already have been implemented and are available to be adapted and applied in any organization. The Always Events program is not only a useful tool for healthcare providers, but for patients/families, medical educators and other stakeholders as well. This Blueprint describes how anyone with an interest in improving healthcare can use Always Events. Section III describes the features of the Always Events initiative that make it a uniquely valuable improvement tool. Section IV provides guidance for healthcare organizations interested in using Always Events to improve the patient experience and connects the foundational elements of successful patient-centered organizations (leadership, patient/family partnership, team engagement, effective data use and performance improvement) to each phase of an Always Events initiative. Section V provides guidance to healthcare educators in using Always Events to train new healthcare providers. Section VI provides guidance to other stakeholders interested in using Always Events as a lever to transform healthcare. Section VII discusses the future of the Always Events initiative after the Picker Institute ceases operations and transitions the program to the Institute for Healthcare Improvement. Always Events put the patient at the center of the redesign of the healthcare system and provide a concrete roadmap for healthcare leaders, medical educators, and other stakeholders to rapidly meet long-standing patient needs. The initiative rebuilds healthcare from the inside out by refocusing and strengthening the core focus on patient needs. Always Events help to ensure not only better care for patients, but more joy for providers, no matter what external changes may be on the horizon. Page | 3
- 5. II. Introduction For nearly three decades, the Picker Institute has worked to advance patient-centered care by helping healthcare Picker Institute providers see through the patient’s eyes. As the Picker Principles of Patient- Institute’s programs have evolved, its mission has Centered Care remained consistent – to advance excellence in patient- centered care though education, research, and the Respect for patients’ dissemination of best practice. values, preferences and expressed needs Over the years, patient-centered care also has evolved from being perceived as a luxury to an essential aspect of Coordination and healthcare quality. Patient-centered care is now integration of care recognized by national policymakers as one of the six Information, pillars of a high quality healthcare system. In a recent communication and survey of healthcare leaders, 85% indicated that they had education invested additional time and resources over the past 12 months to improve the patient experience.i More than Physical comfort 40% of those leaders said their primary motivation for Emotional support and investing time and resources to improve patient alleviation of fear and experience scores was because those scores help the anxiety organization to “determine whether we are doing what’s right for the patient” rather than to respond to Involvement of family competitive or value-based purchasing pressures. and friends Continuity and Despite the recognition of the relationship between transition patient experience and quality and the intensified focus of both policymakers and providers on patient experience, Access to care patient needs are still not being met on a consistent basis. Although the healthcare environment has changed over the decades, patients’ desires and frustrations have remained remarkably consistent. Patients have been clear about what they want and need and their wishes are codified in the Picker Institute principles of patient-centered care. Principles are important, but not enough. Principles provide a guiding star on a journey toward a more patient-centered healthcare system but they don’t provide the tools to make the journey successfully. The Picker Institute recognized this need to pair principles with practical resources and has developed many tools to help providers see through patients’ eyes, including patient experience surveys designed to ensure that patient voices are Page | 4
- 6. consistently captured andused. The Picker survey, along with other tools, laid the foundation for the Consumer Assessment of Healthcare Providers and Systems surveys, which are now widely used in a variety of healthcare settings to invite perspectives from thousands of patients daily. The HCAHPS survey alone is administered to more than 25,000 recently hospitalized patients per day in the United States and is completed by more than 7500 of those patients per day, representing more than 7% of all hospitalized patients.ii Capturing patients’ perspectives is an important step, but it hasn’t been enough to dramatically improve patient-centered care. Recent HCAHPS data highlights the significant gaps that exist between the Picker principles and the reality of hospital care. Patients desire coordination of care but 38% indicate they don’t always receive information about the purpose of their new medications and possible side effects -- critically important information for self-management of their conditions.iii Patients want physical comfort, but only 79% of patients in even the best performing hospitals nationwide (95th percentile) indicate that their pain is always well controlled and that hospital staff always do everything they can to help manage the patient’s pain.iv Patients desire family and friends to be present and involved in their care, but it took an April 2010 Presidential memorandum to the Department of Health and Human Services requesting that the Department promulgate rules on “respecting the rights of hospital patients to receive visitors” and the subsequent CMS regulationsv to make this a reality in most hospitals. In many organizations, family and friends are still perceived as unwelcome interruptions, rather than partners in their care. Although these HCAHPS statistics reflects patients’ hospital experiences, patients report similar frustrations in all healthcare settings.vi What the healthcare system needs is leadership and what leaders need is a blueprint that explains how to translate patient-centered ideals into concrete patient-centered practices. The Picker Institute launched the Always Events initiative in 2009 to develop such a blueprint and to rapidly catalyze advancements in patient-centered care. Always Events are those aspects of the patient experience that are so important to patients and families that healthcare providers must perform them consistently for every patient, every time. Through research and consultation with patients, families, providers, and experts, including IHI, the Picker Institute developed and refined the program and ultimately issued a Request for Proposals inviting healthcare organizations to define and implement Always Events. More than 80 healthcare organizations answered the call. Twenty-one received small matching grants (less than $50,000) to implement their Always Events. More than two dozen medical educators also built Always Events into their graduate medical education grant programs. The grantee organizations have used the Always Events concept to Page | 5
- 7. address some ofthe most vexing challenges in healthcare today, such as improving communication, providing consistent transitions, partnering effectively with patients and families, and improving patient safety. Their results, tools, and the lessons they have learned and shared pave the way for other organizations to apply Always Events to their organizational challenges. This Always Events® Blueprint for Action provides a reliable roadmap to assist healthcare organizations in using Always Events as a transformational tool to make rapid, dramatic advances in patient-centered care. The companion Always Events® Solutions Book contains a snapshot of several successful Always Events projects, results and available tools, which are ready to be adapted and applied in any healthcare organization. The Solutions Book and all referenced tools are currently available online at http://alwaysevents.pickerinstitute.org/ and the Picker Institute has arranged for the website to remain available even after the Institute ceases operations. Patients have been consistently asking for the same things for decades. It is time for healthcare “‘Always Events’ are the to change by truly putting patients at the center of bookend to never events. care and addressing these unmet needs. Always By articulating and making Events can provide a strategy and framework for never events visual, it this long-overdue transformation. galvanized people and created alignment around III. Why Always Events®? purpose. ‘Always Events’ serves the same purpose.” Patient-centered care is no longer optional. Payers incentivize it, regulatory requirements reinforce it, and patients are beginning to demand it. The pressure to not only produce excellent clinical outcomes, but to do so in a compassionate, personalized manner has never been greater, yet many organizations still struggle with how to transform good intentions into well-defined, consistently executed practices. With myriad consultants, programs, and improvement techniques competing for health care providers’ attention, it is reasonable to ask: “Why Always Events? What is unique about this strategy for advancing patient- centered care?” A. Picker Institute’s Rationale for Creating the Always Events® Program The Always Events initiative is a culmination of the Picker Institute’s many years of work to advance patient-centered care. With Always Events, the Institute has developed a program Page | 6
- 8. that remains focusedon the guiding principles of patient-centered care and translates those aspirations into concrete terms that any organization can consistently implement. The Always Events initiative is readily understood and enthusiastically endorsed by patients, families, healthcare providers, and other stakeholders. It resonates across industry and stakeholder lines and can be used in a multitude of ways to improve patient experience, engage staff, and transform healthcare. It serves as a call to action for a healthcare system that will consistently deliver patient-centered care to every patient, every time, and it provides the necessary tools to make rapid action possible. B. Unique Features of the Always Events® Initiative There are many unique features of the Always Events initiative, including its positive focus, open architecture, and community of organizations sharing resources. Builds Relationships by Focusing on the “[T]he concept of ‘Always Positive Events’ for hospitals and Too often, healthcare improvement efforts focus doctors is the medical exclusively on what is wrong with healthcare, measurement equivalent of rather than how to build on what is already done that popular management tool well and do it consistently. Always Events give of ‘Always catch someone doing organizations the opportunity to reframe their it right!’ Physicians are likely discussions of patient-centered care in a positive to want to participate in intention-based manner that builds discussions about these positive relationships between and among patients, and important aspects of the families, and staff. The approach is similar to an care experience.” “appreciative inquiry” process that highlights what is working well and determines how to Tom James, MD learn from and expand upon that success to Medical Director, National promote consistent performance of the Always Network Operations, Humana Inc. Event with every patient, every time. Open Architecture Enables Rapid Adaptation and Innovation One of the many important decisions made during the development of the Always Events initiative was the decision to maintain an open architecture for the program, rather than creating a discrete list of Always Events. There were many factors supporting this decision. Although a short list of clearly defined Always Events could, in theory, improve care, it would be impossible to establish one prioritized list that would be relevant to all settings Page | 7
- 9. and all patients.Allowing organizations to identify their own events promotes widespread engagement of patients, families, and staff in setting their own priorities. The open architecture allows organizations to identify the Always Events that are most relevant to them, facilitates innovation and implementation in a variety of settings, and ensures that the Always Events will remain relevant through rapid changes in healthcare. Growing Community of Organizations Freely Shares Practical Resources and Tools During the implementation of their Always Events programs, the Picker Institute worked with the Always Events grantees to gather their insights, resources, and tools, and to make that information readily available to any interested organization. No one should have to “reinvent the wheel” in advancing patient-centered care and because organizations learn not only from others’ successes, but from their challenges, the Picker Institute convened a monthly webinar series for grantees to share their insights. The webinars are recorded and available online and all of the grantees’ tools and resources have been added to the Always Events Toolbox at http://alwaysevents.pickerinstitute.org/?page_id The Four Phases of an =882, where they are categorized by topic. A brief Always Events® Process summary of several grantees' projects and tools also is included in the companion document, The Phase 1: Identifying an Always Events® Solutions Book, which is also Always Event available in the Toolbox. Phase 2: Developing and The grantees’ work is an excellent starting point Implementing the Program and the toolbox can be considered not only a Phase 3: Evaluating the treasure trove of solutions, but an incubator for Program innovation. Organizations may adopt and adapt the Always Events already in the toolbox, or they Phase 4: Sustaining the may submit their own projects for recognition as Momentum Always Events and contribute new items to the toolbox. The recognition program is described in more detail on p. 19. Page | 8
- 10. IV. Using Always Events® to Transform Healthcare Organizations Although the Always Events initiative is only a few years old, it builds on key foundations about success in patient-centered care that the Picker Institute has identified through years of research, education, and innovation. Successful patient-centered organizations share several common traits, including patient-centered leadership, partnerships with patients and families, engagement of teams, and effective use of data for performance improvement. These four themes have resonated throughout the Picker Institute’s research, including in the 2007 report “Patient-Centered Care: What Does It Take”vii and in the 2009 case study analysis of High- Performing Patient and Family-Centered Academic Always Events® and Medical Centersviii. These themes also dominated the Always Experiences® 2008 Patient-Centered Care CEO Summit, in which visionary healthcare leaders described their strategies Always Events are the for achieving patient-centered care. The Always Events provider program embodies these core foundations of patient- actions/practices that centered care at all phases of the program from create an Always identifying an Always Event, to developing and Experience for implementing a program, evaluating the program, and patients/families. sustaining it. Opportunities to strengthen these foundations throughout each of the four phases are The events are measured described below and summarized in the chart on p. 21. by whether or not they occurred 100% of the time. Phase 1: Identifying an Always Event® The experiences are The first phase of an Always Events initiative is to measured by assessment identify an Always Event that is so important to tools such as CAHPS or patients and families that it is imperative that other validated feedback healthcare providers perform it consistently, every methods, which measure time. One way to approach the selection process is for the extent to which the an organization to think about the ideal experience for events are having the patients (the Always Experience®) and then to identify intended outcome of specific events or practices that would create the improving the patient’s desired experience (the Always Event®). During the experience of care. first phase, it is imperative that organizations begin to build solid foundations for the program by considering the key role of leadership, opportunities to partner with patients/families, how to engage the team, and Page | 9
- 11. strategies for effectivedata use and performance improvement. Consider Building on Others’ Tools Leadership: Leaders set the right Several Always Events grantees developed tone for identification of an Always programs that built on work previously Event, positioning the initiative as a completed by other organizations: positive way to enhance both the Henry Ford Health System adopted as an patient and staff experience, rather Always Event dementia screening of than as one more “flavor of the patients age 70 or over using an adapted month” to-do list item. Leaders National Institutes of Health (NIH) capitalize on the positive focus of cognitive assessment tool. the initiative to help restore a sense of passion and purpose. Planetree incorporated in its Always Events initiative the web-based How’s Leaders reinforce that the selected Your Health patient engagement tool Always Event is an organizational developed by Dartmouth. imperative that is important in its own right and that also is connected Iowa Health System incorporated videos to other organizational goals such as developed for Health Literacy Iowa as part quality, safety, and financial of its Always Use Teach-Back! Toolkit stability. Leaders provide the focus, resources, alignment with other initiatives, and commitment to sustain the effort despite the widespread distractions and disruptions endemic in healthcare organizations, such as frequent changes in staff. Leaders also play a key role in ensuring that the organization’s selected Always Events initiative is realistically designed and capable of being achieved within a defined time period. Tackling large core issues like patient-centered care can seem overwhelming if the issue is not broken down into achievable programs. Carefully defining the scope and scale of the Always Event, as well as defining measures of success, helps to keep the program from becoming too broad and diffuse to have an impact. Leaders also can encourage teams to think broadly about Always Event opportunities, including those that build on others’ tools. The grant selection process was predicated on demonstrable leadership commitment, but organizations working to develop their own Always Events should consider how to demonstrate such commitment to their staff in order to promote engagement and success. The leaders of the Always Events grantee organizations were required to provide a letter of commitment indicating that they would support the Always Event initiative in their organization, contribute resources in the form of matching funds, and consider expanding Page | 10
- 12. the initiative ifit was successful. It is important for organizations developing their own Always Events initiative to mirror this type of support. Staff need to know that leadership is behind the initiative and is willing to commit the resources necessary for it to succeed, including staff time and dollars. Staff also need to know that the commitment will be sustained over a long enough period of time for the initiative to become embedded in the organization. Many staff members have had the experience of beginning a program with great hope and enthusiasm, only to have those hopes dashed when the leaders’ priorities shift and the initiative is no longer perceived as important. Patient/Family Partnership: To be considered an Always Event, the event must meet four criteria identified by the Picker Institute. Each Always Event must be important, evidence-based, measurable, and affordable/sustainable. The first criterion, important, is dependent upon a strong partnership with patients and families. Healthcare organizations often think they know what patients want and need, but if they don’t ask, they will work to improve the wrong things or will “improve” them in ways that don’t address the key needs of patients and families. Doing things for patients and families is not enough. Patients and families must be key voices in driving the identification of Always Events. Important Patients and families have identified the experience as fundamental to their care. This specification is designed to ensure that any event that is selected and successfully implemented will have a meaningful impact on improving the patient experience. Evidence-based The experience is known to be related to the optimal care of and respect for the patient. Measurable The experience is specific enough that it is possible to accurately and reliably determine whether or not it occurred. This specification is necessary to ensure that Always Events® are not merely general aspirations, but are translated effectively into operations. Affordable/Sustainable The experience can be achieved and consistently sustained by any organization without substantial renovations, capital expenditures or the purchase of new equipment or technology. This specification acknowledges the financial challenges of many organizations and encourages organizations to focus on capitalizing upon the many opportunities to improve care that are based on changes in practice, not infusions of capital. Team Engagement: To identify an Always Event, leaders must engage staff at all levels in defining what important aspects of care they are willing to commit to providing consistently. Despite the overwhelming demands on staff, when the discussion is framed in terms of “Always,” it tends to be viewed by staff as positive and energizing. After all, as Picker Award winner Jim Conway expressed, patient-centered care is “what staff wants – it’s why they went into healthcare.”ix In the focus groups conducted during development of Page | 11
- 13. the Always Eventsinitiative, staff indicated that they found these discussions to be exciting and empowering, because they gave staff the opportunity to develop a shared vision of what was right in healthcare and to work to deliver that consistently, rather than continuing to focus on what is wrong. Engaging the team in identifying Always Events is also an effective way for leaders to “encourage employee commitment to patient- centeredness, instead of demanding compliance” and to “empower people at all levels of an organization to understand and advance the principles of patient-centered care,”x key lessons from Picker’s 2008 Patient-Centered Care CEO Summit. Data Use and Performance Improvement: Successful Always Events initiatives use data and performance improvement techniques in a variety of ways throughout all stages of the initiative. Data can be instrumental in helping organizations select among many potential Always Events identified by patients and staff. The Always Events grantees used data in their grant applications to explain why their proposed Always Events were important, and identified Always Experience metrics that would be used to measure the success of the program. In many cases, an examination of organizational data is what motivated the organization to apply for an Always Events grant because they saw an opportunity to improve the patient experience. Phase 2: Developing and Implementing the Program Identifying the Always Event is only the first step. Once an organization has identified an Always Event project, there are several key factors to position the project for success. Leadership: In addition to continuing to set the right tone, sustain the focus and commitment and provide the necessary resources, a key role for leaders during development and implementation of an Always Events initiative is to align the program with other organizational priorities. With so many items on healthcare providers’ “to- do” lists, only those things that are positioned as key priorities that contribute to multiple organizational objectives are likely to be consistently performed. Many grantees aligned their Always Events initiative with efforts to improve patient safety, using metrics such as the Agency for Healthcare Research and Quality’s patient safety culture survey or readmissions data to emphasize the connection. Leaders also have an instrumental role in setting the expectation that the Always Event initiative calls for 100% consistent performance of the event and designing the program to achieve this goal, rather than focusing on small incremental improvements in performance. Good leaders not only lead, they develop other leaders. As IHI noted in its 2011 report Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care, “leadership behavior at the executive, middle, and front-line levels is essential.” xi Leaders actively seek opportunities to develop staff members throughout the organization and Page | 12
- 14. build skills thatnot only will contribute to the success of the Always Events program, but to the success of the organization. Yale-New Haven Hospital, for example, identified two staff nurses as the project leaders for its Always Events initiative. As the principal investigator Janet Parkosewich, DNSc, RN, CCRN, FAHA, noted, “For families to receive the level of care we want, we have to give staff nurses these skills and experiences. . . . The project has helped [the two nurses] to flourish as leaders. They are doing something they are passionate about and are being given dedicated time in the schedule to do it. The Magnet program requires the involvement of frontline staff in improvement work and this project demonstrates the powerful impact that frontline nurses can have.” For an Always Events project to be successful, leaders must model appropriate behaviors. If the leaders in the organization are not behaving in a manner that is consistent with the Always Event being implemented, staff will not engage in the project. One Always Event initiative ran into challenges when the organizational leader questioned the value of the project; not surprisingly, progress was slow without leadership support. Leaders also help to put the right structure in place to support the project by building the team as described in the team engagement section below. Patient/Family Partnership: It is imperative that healthcare organizations directly engage patients and families as active partners in all phases of the development and implementation of an Always Event. This partnership can take many forms. Grantee organizations with existing Patient and Family Advisory Councils and/or advisors integrated into hospital operations involved those advisors in designing, implementing and refining their programs. Organizations also sought patient and family involvement through other formal and informal mechanisms such as focus groups, surveys, and interviews. Incorporating patients and family members into planning is important, but the need for involvement does not end there. Partnering with patients and family during implementation of an Always Event is absolutely essential. Patients and families often have very different interpretations of providers’ behavior than may be intended. For example, one Always Events grantee who provided patients and family members with a paper tool to record important information related to their discharge discovered that some patients perceived the document as evidence of a lack of coordination rather than an initiative to improve coordination of care, noting “Why do you need us to write things down – don’t you know what we’re supposed to do?”. Patients and family members also identify opportunities to improve communication and provide a realistic perspective on the way the event is being implemented. One grantee discovered that patients did not understand the term “handoffs,” and changed the language in patient materials to “change-of-shift bedside report.” Another grantee found that although patients understood the language on the questionnaire they were being provided while waiting for their outpatient visits, they were not receiving any explanation from staff as to the purpose of the document. Page | 13
- 15. In some granteeorganizations, patients and families not only participate in the design, implementation and refinement of the Always Events program, they are critical components of the program. Multiple grantees used patients as educators in their Always Events initiatives. The patient educators were responsible for presenting information to healthcare providers and, in some cases, were also responsible for observing and evaluating healthcare providers’ behaviors. Patients and family members are not only effective educators of healthcare providers, they also can be wonderful guides and mentors to other patients and families. The St. Jude Children’s Research Hospital’s Parent Mentor Always Events Program developed formal roles for parents who were willing to serve as mentors to other parents of children newly diagnosed with cancer. The policies and procedures of the program were carefully designed to support not only those mentored, but also the mentors themselves. Other grantees developed Always Events programs focused primarily on patient/family partnerships, such as the UCSF Partner with Me program that engages family members in partnering with staff to customize care provided to dementia patients based on detailed information provided by family members about the patient’s preferences and routines. Team Engagement: After the organization decides to pursue an Always Event, there are several logistical issues to consider. A team that will lead the implementation should be identified and should include members with a variety of perspectives and skills. Frontline staff participation is essential. A process and structure for the project also should be developed, such as a meeting schedule and division of responsibilities. Implementation of any new process requires a thorough and realistic understanding of the current process that can only be gained through inviting perspectives from all disciplines that will be impacted by the process. It is important not to leave physicians out of this process. One Always Events grantee discovered after implementation that the Always Events tool that had been developed by patients, families, and staff did not meet physicians’ needs. After the team has developed a shared understanding of the processes to be changed and the manner in which they would like to make those changes, the team must identify strategies to engage all staff members who will be involved in doing the work. Education of staff in the new behaviors and expectations is an important component of an Always Events project. As one organization noted “mandatory education . . . set the expectations for Page | 14
- 16. the [A]lways [E]ventand provided the necessary knowledge, skills and attitude to fulfill the expectations.” Always Events grantees used many types of education including online learning, videos, simulation and role-playing, self-learning packets, and presentations. Effective Always Events programs translate ideals into concrete behaviors for which staff can be held accountable. Dartmouth-Hitchcock Medical Center for example, used the acronym ALWAYS to break down patient-centered communication skills into six observable behaviors. (A – Address and refer to patients by the name they choose, not their disease; L – Let patients and families know who you are and your role in the patient’s care; W – Welcome and respect those defined by the patient as ‘family’; A – Advocate for patient and family involvement in decision making to the extent they choose; Y – Your name badge: ensure patients can read it; S – Show patients and families the same respect you would expect from them.) In addition to describing “how” and “when” an Always Event will be implemented, it is important to emphasize “why.” Patient stories can powerfully illustrate the why and reconnect providers to their sense of mission of purpose. One grantee working on end-of- life issues for neonates rallied staff around a powerful quote from a father, “Do clinicians realize that we will never forget their names, their faces, and what they said to us about our dying child?” Education is a start, but it may not be enough to change staff behavior. Several Always Events grantees identified “champions” or coaches who inspired and educated their colleagues, led by example, and provided “peer-to-peer at the elbow support” and coaching during implementation. Champions also must be supported in their roles. Some organizations created formal written descriptions of the characteristics and responsibilities of champions. Others convened the champions on a regular basis to discuss how the Always Event was being implemented and to refine the program as necessary. Data Use/Performance Improvement: Prior to implementing a specified Always Event, the organization should determine what metrics will be used to evaluate the program. There may be baseline data available to compare performance before and after the Always Event is implemented, which could affect project timing. In addition, some of the grantees implemented Always Events on selected units and compared performance to similar “control units” in which the Always Event was not implemented. It is important to have these discussions prior to implementation so that the full range of evaluation options can be discussed and appropriate tools developed before action is taken that forecloses certain evaluation possibilities. Some of the grantees discovered mid-way through their projects that the evaluation tools they had planned to use were not available, which limited their ability to fully assess the impact of the Always Event. Page | 15
- 17. Although healthcare organizationstend to rely heavily on quantitative information, qualitative information provides important insights into whether an Always Common Evaluation Event is having the intended effect of creating a positive Techniques Used in AE Always Experience and/or whether the methods used to Programs educate and engage providers in implementing the Patient/Family Experience Always Event are having the desired effect. Throughout Measures the development and implementation phase, the Always Event program should be refined based on this qualitative Readmissions feedback. One grantee for example, determined based on ED visits staff feedback that it would be more effective to offer staff Safety measures (e.g. a self-learning packet for the program, rather than using falls, medication other training methods. Maintaining open lines of adverse events) communication during the implementation phase will CAHPS survey results help to ensure that any suggestions or concerns raised by Patient and/or family survey results staff are addressed. Qualitative feedback Phase 3: Evaluating the Program Educational Intervention The Always Events grantees utilized a variety of Measures approaches to evaluate their programs. Evaluating Post intervention multiple aspects of the program, including the qualitative surveys and quantitative impact on the patient experience, as well Self-evaluations of as consistency in implementation, helps organizations to efficacy and attitudes, differentiate between effective and ineffective strategies pre and post and to refine and adapt the program as necessary. intervention Observational Leadership: During the evaluation phase, it is important evaluations of behavior for leaders to reinforce a culture of continuous in simulation organizational learning. There is much to learn from Qualitative feedback both successes and challenges and it is important that participants in an Always Events program feel Consistency Measures comfortable speaking candidly about what is working and Observations of what isn’t. Too often in healthcare organizations, the behavior in practice same mistakes are repeated over and over again because Chart review there is no opportunity to engage in a constructive Patient/family survey organizational dialogue about unsuccessful initiatives. questions assessing Recent research emphasizes the connection between performance of AE organizational learning/continuous improvement and Qualitative feedback patient experience in hospital settings. The researchers Page | 16
- 18. analyzed the relationshipsbetween hospitals’ performance on the AHRQ Patient Safety Culture Survey (SOPS) and the HCAHPS survey and found that “organizational learning/continuous improvement” (defined as a “learning culture in which mistakes lead to positive changes and changes are evaluated for effectiveness”) was the SOPS measure most strongly correlated with HCAHPS performance.xii Effective leaders are “always thinking in terms of change and constant renewal”ix and use the evaluation phase as an opportunity to learn and adapt. Leaders should set realistic expectations for the time required to successfully implement an initiative and to see the patient experience improvement reflected in data. Transforming the patient experience takes time, and organizations should not expect dramatic changes in broad patient experience metrics such as CAHPS to occur immediately. Setting unrealistic expectations for an immediate, substantial increase in scores tends to have the effect of demoralizing staff when that desired level of performance isn’t achieved in a short period of time, even if the data is improving. Leaders should take care not to confuse setting realistic expectations about the quantitative impact of the intervention on patient experience with setting the bar too low for implementation of the program. An Always Event by definition is something that should be performed 100% of the time and leaders should set the expectation that an Always Event initiative will be consistently implemented. Leaders should ensure that appropriate resources are made available for a credible evaluation of the Always Events initiative. Obtaining quantitative and qualitative feedback and analyzing that feedback is essential to evaluating whether the initiative is having the desired impact. Another important role that leaders can play in the evaluation phase of an Always Event initiative is to recognize and reward both effort and achievement. Leaders should acknowledge the time spent by team members on an initiative even if it doesn’t succeed in achieving its goals. Failure to acknowledge effort can demoralize staff who invest time in an initiative and make them less likely to be willing to work on patient experience improvement efforts in the future. Partnerships with Patients/Families: Patients and families have a key role to play in the evaluation phase of an Always Events initiative. Through both qualitative and quantitative feedback mechanisms, patients and families should be asked both whether the Always Event occurred and, if so, what impact the Always Event had on the patient experience. In some cases, grantees directly involved patients and family members in conducting more in- depth evaluations of staff actions, such as by observation and critique during simulations. Patients/families also should be part of the team reviewing and interpreting the qualitative and quantitative data gathered during the evaluation phase. Page | 17
- 19. Team Engagement: Justas patients and families are instrumental in evaluating an Always Event, so are staff members. Staff should be invited to share their perspectives on the Always Event. In particular, staff should be asked what needs to be in place to enable staff to consistently perform the Always Event for patients and what barriers, if any, are preventing them from achieving consistent performance. Staff also should be asked to evaluate the implementation process for the Always Event, such as whether the education and coaching strategies are effective. Data Use/Performance Improvement: In the evaluation phase, it is important to put the data in perspective. Staff members who have been enthusiastically participating in an Always Events initiative may be expecting to see big improvements in quantitative performance and may be disappointed by small incremental changes. When reporting data from the evaluation phase of an Always Events initiative, it is important to note any limitations on the data, such as small sample size or short time period. It is also helpful to integrate qualitative and quantitative data to gain a more complete perspective on an implemented Always Event. Thinking about the evaluation phase during phase 1 will help organizations identify the most appropriate metrics for their Always Events initiative. It may be that a new form of data collection is necessary to directly evaluate the impact of the program (e.g. a new survey question specifically targeted to the Always Event), rather than a broader measure (e.g. readmission rates). In evaluating the impact of an Always Events initiative, organizations should be careful to differentiate between the evaluation of consistency of implementation and evaluation of impact. If an intervention has not been consistently implemented, it will be difficult to evaluate what the impact of the intervention could have been if it had been consistently implemented. Phase 4: Sustaining the Momentum After an Always Events initiative has been successfully implemented, organizations must focus on how to ensure that the Always Event will continue to be consistently performed in the areas in which it has been implemented and evaluate whether to expand the initiative to other areas. Leadership: Successful Always Events should become a core part of the organization’s culture, rather than another “to do” list item that may or not be performed. Leaders help to communicate the bigger picture impact of the initiative and to continue to put it in the context of achieving the broader goals of improving the patient experience, as well as advancing quality and patient safety. As a leader from Anne Arundel Medical Center remarked about its SMART discharge protocol program, “We must emphasize that the SMART protocol is not only a piece of paper for notes and questions. It is a process that will change how we deliver care.” Page | 18
- 20. Leaders also helpto embed Always Events into organizational systems and processes that make it easier to consistently perform the Always Event. Several grantees, for example, incorporated their Always Events into their electronic medical record systems, which made it considerably easier for staff to follow the Always Event process, rather than using a separate paper system that wasn’t aligned with the electronic record. University of Minnesota Amplatz Children’s Hospital, for example, embedded its MyStory program in the electronic medical record. MyStory involves gathering information about each pediatric patient’s interests and preferences upon admission and making it available to every care provider so they can have meaningful, personalized interactions with each child. Any organization that has successfully implemented a program that meets Always Events criteria may choose to apply for official recognition as an Always Event and leaders can set achievement of recognition as a goal of their program. Achieving recognition as an Always Event is a cause for celebration and an opportunity to reenergize teams. The criteria for recognition developed by the Picker Institute focus on not only the specification of the event and evidence of positive outcomes, but also on ensuring that the appropriate Always Events foundational processes are in place to support Recognition Program continued success, including leadership, partnerships with patients and families, Includes consideration of: engagement of staff, and data use/performance improvement. In addition, applicant Always Event Criteria organizations must express an intention to Foundational Elements maintain performance of the Always Event. The Evaluation and Outcome opportunity to be acknowledged by a national Evidence of Institutional organization as a peer expert also reinforces the Commitment underlying expectation that the Always Event will Shared Resources and be sustained. Tools Partnerships with Patients/Families: Reinforcing the impact of the Always Event on the patient experience through patient stories can be a powerful way to maintain momentum. One grantee brought patients and family members who had experienced the Always Event to team meetings so they could directly convey to staff members the importance of the Event to their experience. Grantee organizations using patients and family members as an integral part of their Always Events implementation, such as faculty members, noted that sustainability required that they recruit additional patient and family participants, given the expanded role and increased time commitment. Page | 19
- 21. Team Engagement: Regularongoing communication is a valuable strategy to keep staff engaged in an Always Events initiative on an ongoing basis. Anne Arundel Medical Center, for example, implemented a multi-faceted communication campaign that included posters, tip sheets, change of shift staff huddles, weekly champion meetings, audits, and individualized education, as well as weekly recognition of staff members. As noted above, incorporation of the Always Event into hospital systems and processes, including the electronic medical record, also reinforces the sustainability of the event. Communication should always invite dialogue. Continued responsiveness to any questions and concerns raised and ongoing refinement of the program based on staff feedback promotes long-term success. One grantee, for example, discovered that hospital staff felt a need for additional training beyond the materials included in the program and is exploring options to provide this guidance. Data Use/Performance Improvement: Continued monitoring and reporting of performance metrics will help to keep an organization focused on sustaining its Always Event. Although the evaluations may be scheduled to take place less frequently, continued evaluation ensures that the organization will be able to take action if performance becomes more variable or no longer is having the desired impact. Page | 20
- 22. Foundational Phase I: AE Phase 2: Developing and Implementing Phase III: Evaluation of an AE Phase IV: Sustaining the Element Identification an AE Initiative Momentum Leadership •Set positive tone •Align initiative with other organizational goals •Reinforce a culture of continuous •Transition from a program to an organizational learning integral part of the organization •Emphasize importance •Identify leaders at all levels and incorporate opportunities for leadership development •Learn from both successes and failures •Communicate big picture impact •Provide focus, resources, sustained commitment •Model appropriate behaviors •Set realistic expectations •Embed in organizational systems and processes •Define scope and scale •Put the right structure in place •Provide resources to conduct a credible evaluation •Apply for recognition as an •Consider building on Always Event® others’ tools •Recognize and reward both effort and achievement Patient/ • Ask patients/ families to • Include patients and family members on the project • Include patients/family in evaluation • Continue to use patient/family Family identify what is most team to design, refine, and evaluate the program process stories to motivate the team important Partnership • Develop new roles for patients/family in • Consider qualitative and quantitative • Bring patients/families affected • Validate that proposed implementing the program (e.g. as faculty, mentors, feedback by the Always Event to team Always Event addresses etc.) and provide support for those roles meetings or all staff meetings unmet need • Consider using patients/family as direct observational evaluators • Expand role of patient/family and recruit more participants • Involve patients/family in interpreting the data Team • Involve staff at all levels • Create a process/structure for the project • Include multidisciplinary staff in the • Communicate on a regular basis evaluation process through a variety of channels Engagement • Reconnect to purpose • Build an interdisciplinary team • Consider qualitative and quantitative • Build Always Event into • Incorporate real-world experience from all feedback technology disciplines, not an idealized process • Explore staff needs and implementation • Invite dialogue • Provide targeted education, role modeling, support barriers and coaching • Modify program based on • Evaluate impact of educational feedback • Translate ideals into concrete, accountable behaviors interventions on changing attitudes and • Use patient/family stories to motivate and inspire behavior • Identify peer champions Data Use/ • Use data to identify and • Select meaningful metrics • Report meaningful information • Continue monitoring and prioritize opportunities for reporting implementation and Performance • Collect baseline data • Acknowledge the limitations of the improvement impact metrics Improvement metrics • Develop evaluation tools • Begin to identify metrics • Integrate qualitative and quantitative to evaluate program • Collect qualitative and quantitative information metrics • Respond to suggestions/concerns raised during • Measure consistency of implementation and adapt the program as necessary implementation, as well as impact
- 23. V. Using Always Events® to Educate Providers In addition to being used by organizational providers to improve the patient experience, Always Events are also being used to train more humanistic, patient-centered physicians. Since 2005, the Picker Institute has partnered with the Arnold P. Gold Foundation, a nonprofit organization dedicated to the advancement of humanism in medicine. The Gold Foundation has developed criteria to advance humanistic, patient-centered physician behaviors that perfectly complement the Picker Institute principles of patient-centered care stated on p. 4. The Picker Institute and Gold Foundation conduct an annual Graduate Medical Education (GME) challenge grant program designed to support research and development of innovative projects and best practices in the education of future practicing physicians. Since 2010, each GME grantee has incorporated one or more Always Events into their educational initiatives. To date, nineteen GME grantees have completed their Always Events initiatives and five additional GME grantees have committed to implement an The Arnold P. Gold Foundation Always Event as part of the 2012-2013 grant Criteria to Advance Humanistic, cycle. Patient-Centered Care The Always Events embedded by the GME Shows respect for the patient’s grantees in their programs are wide-ranging and viewpoint address many aspects of patient-centered Displays effective and empathetic communication and coordination between communication and listening physicians, patients, and families. The GME skills grantees have produced a wide range of tools and Demonstrates sensitivity in resources that are available for any organization working with patients and family to adapt and use, which can be accessed online in members of diverse cultural and the GME toolbox social backgrounds http://cgp.pickerinstitute.org/?page_id=1230. Is sensitive to and effectively The applicability of the innovative approaches identifies emotional and implemented by the GME grantees is not limited psychological concerns of to formal graduate medical education for patients and family members physicians. The techniques and strategies used to Engenders trust and confidence develop patient-centered physicians can be used Adheres to professional and by any organization that is training healthcare ethical standards providers, including in facility orientation Displays compassion and respect programs. throughout the patient interaction Page | 22
- 24. The educational strategiescommonly used by the GME grantees include: (1) teaching health care professionals patient-centered behaviors and techniques; (2) providing opportunities for health care professionals to learn about patient and family perspectives, often by directly engaging patients and family members as the teachers; (3) providing opportunities for patients and families to provide direct feedback to individual professionals about their performance; and (4) helping professionals to develop a deeper understanding of their own perspectives and behaviors that will help them to maintain compassion and empathy throughout their careers. The Picker Institute encourages organizations to always consider incorporating these strategies in professional education. Teach patient-centered behaviors: Too often, organizations expect behavior that they don’t teach. Patient-centered skills aren’t intuitive for all healthcare professionals, but they are teachable skills. All healthcare providers should have opportunities to develop the competencies they need to be more patient-centered. Several of the GME grantees focused on developing professionals’ skills in patient-centered communication, such as how to share bad news, promote informed patient choice, disclose medical errors and have conversations about end-of-life decisionmaking. Others focused on improving processes such as rounding and discharge. Provide opportunities for healthcare providers to learn about patient and family perspectives, preferably directly from patients and family members themselves: In addition to teaching providers patient-centered skills, GME grantees provide physicians with opportunities to learn about how care is experienced by patients and families. New York Presbyterian, for example, developed a program for its housestaff that consisted of rigorous analysis of “the voice of the patient” as expressed in survey comments and in focus groups, followed by pilot workshops and an intensive workshop designed around the themes identified in the data analysis and simulated encounters. One result of the program was the acronym POTHOLES to facilitate patient-centered care in any situation (Pay attention; Orient patients and families; Test understanding; Humanism – be kind; On-time care; Let patients explain; Expectations – what should patients expect?). Many GME grantees have incorporated opportunities for patients and families to interact directly with healthcare providers in the educational process, such as by serving as faculty. Mount Sinai School of Medicine’s Project PARIS (Parents and Residents in Session), is a program that teaches residents about what it is like to be a parent of a hospitalized child by pairing parents of previously hospitalized children with pediatric residents in 1:1 meetings facilitated by a faculty member. Providing opportunities to deepen understanding of parent experiences is particularly important since, as noted by parent advisory council members in a focus group conducted during development of the Always Event program, many residents do not yet have children and find it hard to understand parents’ needs. Page | 23
- 25. Provide opportunities forpatients and families to provide direct feedback to individual professionals about their performance: An additional strategy used by some GME grantees is to include opportunities for patients and families to provide direct feedback to individual professionals about their performance, either in simulated encounters or based on actual practice. University of Maryland School of Medicine’s program, for example, helps residents learn how to partner more effectively with patients on medication regimens, and provides patients with the opportunity to evaluate the resident’s performance using a targeted questionnaire. Help providers understand themselves: Some GME grantees incorporate opportunities for providers to reflect on their own experiences, such as through reflective blogging and journaling. These strategies are designed to give providers tools they can use throughout their professional lives to provide better care for their patients, while caring for themselves. Some grantees also incorporate self-evaluations into their programs, such as pre- and post- self-efficacy assessments, so providers can understand what skills they feel comfortable with and where they may need some additional coaching and support. V. Using Always Events® to Transform the Healthcare System To date, the Always Events initiative has focused on strategies for health care provider organizations to develop and implement innovative approaches for achieving Always Events. But for the Always Events strategy to realize maximum impact it should ideally achieve alignment with key external drivers of system change. These drivers fall into two major categories: 1) policy drivers such as public reporting, value-based purchasing, and accreditation; and 2) public engagement drivers that harness the latent but growing power of consumer-driven demand for an optimal patient and family experience. A. Policy Drivers Public Reporting Always Events measures are critical for motivating and monitoring improvement within organizations, but they can also be used for holding organizations accountable for achieving Always Events and related results through public reporting. Ideally, such measurement and reporting should be based on the best available scientific evidence, and standardized to enable fair and accurate comparisons within and across organizations and practitioners. One highly relevant set of metrics for assessing many Always Events projects is the CAHPS family of patient experience surveys. Building on the foundation established with the original Picker Institute surveys, the evolving CAHPS suite of standardized instruments for assessing the patient experience now spans the continuum Page | 24
- 26. of care, includinghealth plans, hospitals, medical groups, individual clinicians, in-center hemodialysis centers, nursing homes, home care services and assisted living facilities. The Centers for Medicare & Medicaid Services (CMS) publicly reports data from many of the CAHPS surveys on its website. Public reporting of HCAHPS has been underway since March 2008. A number of regional initiatives, such as the Aligning Forces for Quality and Chartered Value Exchange communities, are also publicly reporting these data to help consumers make informed choices about providers. A limited but growing body of evidence suggests that public reporting of quality measures creates strong incentives for organizations to improve their performance.xiii Public reporting of patient-centered AE measures, based on CAHPS and other appropriate metrics, could play a powerful role in stimulating organizational change, especially as these measures are incorporated into value-based purchasing. Value-Based Purchasing Public and private purchasers might consider how Always Events could be incorporated into value-based purchasing or pay-for-performance programs. It has been clearly demonstrated that when organizations like CMS or those administering pay-for- performance initiatives provide financial rewards for improved performance, organizations take notice. Adopting Always Events into an incentive scheme is a key strategy for elevating the attention paid by health care organizations to providing optimal patient-centered care. Since the inclusion of HCAHPS in Value-Based Purchasing (VBP) by CMS, a great deal of attention has focused on how to improve HCAHPS scores. With this increased attention, there have been steady improvements in these scores.xiv As health systems and primary care practices prepare for the use of CAHPS surveys for medical home recognition, Accountable Care Organization (ACO) evaluations, and more widespread incorporation of these surveys into pay-for-performance programs, interest in effective patient-centered quality improvement strategies can be expected to increase. Accreditation and Certification Accreditation and certification programs such as those sponsored by the National Committee for Quality Assurance (NCQA), the Joint Commission and the American Board of Medical Specialties (ABMS) have historically provided significant external incentives for health care organizations to improve. Increasingly, these programs are building measures of patient-centered care into their processes. Instituting Always Events as a requirement for certification would be another step toward validating patient-centered care as a key component of providing excellent care. Page | 25
- 27. B. Public EngagementDrivers There is enormous potential power of consumer and patient groups in raising public expectations of what the health care system should always be doing on behalf of patients and families. Patient and consumer advocacy organizations could lead or support activities aimed at raising awareness of “always events” demand for key practices that should always happen. Patients may simply take for granted that many of the fundamental things that are critical to their optimal care are already being done. It is important to raise the visibility of what patients should expect ahead of time instead of risking that they only learn of them following a negative experience. It is also critical to begin supporting patients and family members with the information and tools they need to successfully interact with the health care system, as true partners with their health care providers. Public engagement strategies must continue to be coupled with strategies to engage providers. As one expert representing the consumer perspective noted early in the development of the Always Events initiative, "Consumer engagement is only going to work if you have created a receptive environment for that behavior, and that only happens when you change provider behavior. In this sense, consumer engagement follows and complements changes in provider behavior." According to some industry thought leaders, patients and families are the single most important drivers of change in health care organizations. Strategies for educating and engaging patients to take a more active role in the care process will provide an important complement to the efforts of health care organizations to become more patient-centered. Involving patients and families as advocates for Always Events will lead to increased pressure for organizational responsiveness to the need for patient-centered care. Page | 26
- 28. VI. The Future of the Always Events® Initiative In early 2013, the Picker Institute will cease operations. The closure has been planned for several years and is cause for celebration of a job well-done, rather than concern for the future. Through a thoughtful and rigorous process, the Institute identified partners to carry on its work and is transferring the Always Events initiative to the Institute for Healthcare Improvement (IHI). IHI is an ideal partner to continue building on the momentum of the Always Events initiative. IHI shares the Picker Institute’s commitment not only to inspiring action, but to providing practical tools and resources to make rapid and dramatic advancements in patient-centered care possible. IHI will: maintain free, open access to all of the Always Events resources and tools; continue to adapt Harvey Picker had the vision to and expand upon those materials by inviting believe that a sharp and defined organizations to apply for recognition of their campaign for patient-centered programs as Always Events; promote a care could embed the concept learning network; and continue to engage and the values in medicine. members of the National Steering Committee in And by God, it has succeeded. guiding the program. Redesigning care to meet the needs of the patient wasn't even The Picker Institute envisioned the Always recognized as a problem when Events initiative as a mechanism for quality the Institute started. improvement that could rapidly transform the The Institute has since made healthcare system. The pioneering work of the that goal central to how health Always Events grantees and the addition of systems, insurers, the organizations with recognized Always Events government, and the public proves that this vision was correct. Always measure and define success. Events has the potential to be a force that The Institute has set the agenda unites the immense power of patients, families, and put us a remarkable providers, and other stakeholders to change distance down the road to our the way healthcare is delivered in this country. destination. What an The Picker Institute envisioned a future in extraordinary accomplishment. which using the Always Events framework to advance patient-centered care is itself an Atul Gawande, MD Always Event. With this Blueprint and the companion Solutions Book as a guide, the Picker Institute is confidently handing over the baton and inviting you, in the words of Harvey Picker, to “Carry On!” Page | 27
- 29. Appendix A: Historyof the Always Events® Initiative Learning from Leaders: Patients, Families, Providers and Experts When the Picker Institute Board began discussing “always events” in April 2009, it immediately recognized the need to seek the guidance of others who would be essential in helping to evaluate and refine the concept. The Picker Institute reached out to more than 150 individuals, including patients, families, frontline providers, measurement experts, thought leaders, and key stakeholder representatives. In addition, the Picker Institute reviewed both published research and unpublished research graciously shared by individuals and organizations contacted to explore the Always Events idea. In April 2010, the Picker Institute hosted a one-day summit on “Always Events® as a Proposed Strategy for Advancing Patient-Centered Care.” The summit provided an opportunity to further explore the potential of Always Events and the many directions this initiative could go, to begin to make some key decisions, and to identify partners. Notably, every participant enthusiastically supported moving Views from Focus Groups, forward with the Always Events program and Interviews and Always expressed interest in collaborating with the Events Grantees: Picker Institute to support its development. Communication Following the Summit, a National Steering “If you have communication Committee (NSC) was created to guide the . . . everything else will fall program. The commitment, expertise, and into place, because that’s passion of the NSC members for improving the the first starting point.” healthcare experience has been instrumental in stewarding the Always Events initiative from a Care Transitions seed of an idea into a powerful program effecting “Patients are vulnerable change in healthcare. The members of the from their diseases, but steering committee represent patients and they’re more vulnerable families, healthcare organizations, national from their transitions if you quality groups, researchers, and Picker Institute look at what really went partners. The list of NSC members is included in wrong.” Appendix B. Identification of Major Themes: Communication and Care Transitions Two overarching topics emerged as dominant themes throughout all of organizational phases of the Always Events initiative: 1) communication and 2) care transitions. Patients, families, providers, and experts alike agreed that success in these two areas was at the Page | 28
- 30. heart of patient-centeredcare. This qualitative feedback was supported by the data, which demonstrated both the importance of effective communication and care transitions to patients and highlighted the significant opportunities for improvement. Based on the strength of the qualitative and quantitative evidence, the NSC and the Picker Institute decided to initially focus the Always Events program in these two categories. Theme 1: Communication Communication encompasses the exchange and sharing of information among several key players of the healthcare team, including communications between patients/families and providers, as well as among providers collectively responsible for a patient’s care. Communication is a foundation of effective patient-provider partnerships. It is a theme constant in any interaction a patient may have with the healthcare system. Theme 2: Care Transitions Care transitions refer to the experiences of patients and their family members as they move from one provider or healthcare setting to another (e.g., from primary care doctor to specialist, from hospital to home, long-term care or rehabilitation facility, and from emergency department to inpatient unit). Transitional experiences are critical since they are often poorly handled and there is strong evidence they can be improved. This theme is applicable across care settings, and is an important element of coordination between the settings. Putting the Concept into Practice: Innovation and Implementation The series of exploratory interviews with thought leaders, focus groups with patients and frontline providers, the national leadership summit, and the creation of the NSC provided a solid foundation for the development and implementation of the Always Events concept. It was clear to all participants that the Always Events program was an innovative strategy with significant potential for galvanizing action to advance patient-centered care in the United States healthcare system and that the next step would be to determine how the concept could be successfully implemented in practice. In 2010, the Picker Institute began to invite healthcare organizations to define and implement Always Events through two grant programs. The forty grantee organizations that received resources through these programs to implement one or more Always Events are identified in Appendix C. Always Events Challenge Grant Program The Always Events Challenge Grant program invited organizations to demonstrate how Always Events could be implemented in practice. The Always Events Challenge Grant Request for Proposals was issued in October 2010 and drew an enthusiastic response from Page | 29
- 31. more than 80organizations proposing a wide range of projects in the two focus areas of communication and care transitions. After a rigorous evaluation process involving a distinguished group of external reviewers, including many NSC members, the Picker Institute Board awarded twenty-one matching grants totaling more than $900,000 to an outstanding group of organizations that are demonstrating a set of powerful, highly motivating, sustainable, and replicable examples of how the Always Events concept can be implemented in practice. Graduate Medical Education Challenge Grant Program In 2005, prior to the development of the Always Events initiative, the Picker Institute partnered with the Arnold P. Gold Foundation to sponsor a Graduate Medical Education Challenge Grant Program supporting the research and development of successful patient- centered care initiatives and best practices in the education of future practicing physicians. Beginning with the 2010-2011 grant cycle, all Graduate Medical Education grants also have included an Always Events component. To date, 19 exceptional GME grantees (ten in the 2010-2011 cycle, 9 in the 2011-2012 cycle) have been involved in demonstrating the power of Always Events in practice. GME grantees in the 2012-2013 cycle are continuing to incorporate Always Events into their program. The Picker Institute is deeply grateful for the contributions of the many individuals and organizations who contributed their time and expertise to the development of the Always Events program. Page | 30
- 32. Appendix B: NationalSteering Committee Co-chairs J. Mark Waxman, Esq., Chairman, Picker Institute Board of Directors Gail L. Warden, MHA, President Emeritus, Henry Ford Health System Patients and Families Beverley H. Johnson, President/CEO, Institute for Patient- and Family-Centered Care Debra Ness, President, National Partnership for Women & Families Mary Ann Brown Peugeot, CPA, PC, Chair, Vanderbilt Patient and Family Advisory Committee John Santa, MD, Director, Consumer Reports Health Ratings Center, Consumers Union Gerald M. Shea, Assistant to the President for Internal Affairs, AFL-CIO Healthcare Organizations Jennie Chin-Hansen, RN, MSN, FAAN, Chief Executive Officer, American Geriatrics Society Chris Condeelis, Senior Director of Quality and Professional Development, American Health Care Association Nancy Foster, PhD, Vice President, Quality and Patient Safety, American Hospital Association Susan Frampton, President, Planetree Thomas James III, MD, Corporate Medical Director, Humana Inc. Gregg S. Meyer, MD, Senior Vice President for Quality and Safety, Massachusetts General Hospital Ken Mizrach, Director, VA Medical Center, East Orange, New Jersey National Quality Groups Karen Adams, PhD., Vice President, National Priorities, National Quality Forum Barbara Balik, RN, EdD, Senior Faculty, Institute for Healthcare Improvement Katherine Browne, MBA, MHA, Deputy Director/COO, Aligning Forces for Quality, Center for Healthcare Quality, George Washington University Medical Center Peggy O’Kane, President, National Committee for Quality Assurance Jeff Selberg, MHA, Executive Vice President/COO, Institute for Healthcare Improvement Researchers Paul D. Cleary, PhD, Dean, Yale School of Public Health Eric A. Coleman, MD, MPH, Professor of Medicine/Director, Care Transitions Program, University of Colorado Jim Conway, IHI Senior Fellow, Harvard School of Public Health Picker Institute Board Sam Fleming, Treasurer and Secretary Lucile O. Hanscom, Executive Director Sir Donald Irvine, MD, FRCGP, FRCP, FMedSci, Former President, UK General Medical Council David C. Leach, MD, Former Executive Director, ACGME Stephen C. Schoenbaum, MD, Vice Chairman Picker Institute Partners Barbara Packer, Managing Director/COO, The Arnold P. Gold Foundation Dale Shaller, MPA, Principal, Shaller Consulting Group Carrie Brady, JD, MA, Independent Consultant Liaison Carolyn Clancy, MD, Director, Agency for Healthcare Research and Quality Page | 31
- 33. Appendix C: AlwaysEvents® Projects Always Events Challenge Grant Recipients American Academy of Pediatrics – Family Feedback – Always! Anne Arundel Health System – The SMART Discharge Protocol Cleveland Clinic – Unmet Expectations re: ICU Patient Outcomes: Identification and Management of At Risk Families Dartmouth-Hitchcock Medical Center – Implementation of a Set of Always Events that Will Increase Communication Exempla Saint Joseph Hospital – Comfort & Pain Relief Menu Health Care For All – Patients and Families Improving Hospital Discharge Healthcentric Advisors (formerly Quality Partners of Rhode Island) – Enhancing Medication Safety Through PictureRx Henry Ford Health System – Dementia Screening for Senior Patients Inova Health System – Developing a Patient-Centered Approach to Handoffs Iowa Health System – Always Use Teach Back! Lahey Clinic – Transitions of Care Partnership Project March of Dimes – Close to Me Massachusetts General Hospital – Always Know Your Caregiver/Always Responsive Northeast Valley Health Corporation – Team Up for Health Planetree – Same Page Transitional Care: Creating a Template for Optimal Transitions St. Jude Children’s Research Hospital – Parent Mentor Program University of California San Francisco – Improving Patient- and Family-Centered Care for Hospitalized Persons with Dementia University of Minnesota Amplatz Children’s Hospital – MyStory University of Pittsburgh Medical Center – Care Team Twittering and Guardian Angels Vanderbilt University Medical Center – Effective Communication and Collaboration with Patients and Families for Falls Prevention Yale-New Haven Children’s Hospital – Premature Life Transitions: A Patient- and Family-Centered End-of-Life Care Program for Neonates Recognized Always Event® Sharp Memorial Hospital – Safe Patient Mobilization Program Page | 32
- 34. Graduate Medical EducationChallenge Grant Recipients in 2010-2012 Incorporating Always Events Children’s National Medical Center – Caring for Children with Special Health Care Needs Dana Farber Cancer Institute – Teaching Patient- and Family-Centered Care in the Setting of Life-Threatening Illness Dartmouth-Hitchcock Medical Center – Integrating Patient and Family-Centered Care Principles into a Simulation-based Institutional Curriculum Geisinger Medical Center – Employing a Patient-Centered Approach to Develop a Medical Passport to Improve Transition and Educate Health Care Providers Hebrew SeniorLife/Beth Israel Deaconess Medical Center – “How Do You Have the Conversation?” A Curriculum for Residents Jacobi Medical Center – Experiential Learning of Patient/Family-Centered Care Johns Hopkins University – Development and Implementation of a Patient-Centered Discharge Curriculum Mount Sinai School of Medicine – Project PARIS: Parents and Residents In Session – The Next Generation New York Presbyterian Hospital – The Patient’s Voice: Institution-wide Training for Housestaff in Patient-Centered Care Riverside Methodist Hospital/OhioHealth Foundation – Teaching Disclosure: A Patient- Centered Simulation Training for the Crucial Conversation SUNY Upstate Medical University – Learning to Talk University Medical Center – The Native American Cultural Competency Curriculum University of California – Humanism in the Perioperative Environment University of California San Francisco/VA Medical Center San Francisco – Development of Interprofessional Team-based Observed Structured Clinical Examinations to Ensure Patient-Centeredness in Primary Care Teams University of Chicago - Engineering Patient Oriented Clinic Handoffs (EPOCH) Project University of Maryland School of Medicine – Empowering Patients to Optimize their Medication Regimens: A Multidisciplinary Approach University of Massachusetts Medical School – Home Medication Education and Support (HOMES): A Resident Module on Home Care in Children University of South Florida – Enhancing Medical Resident Cultural and Linguistic Competency Wake Forest University Baptist Medical Center – Improving Transitions of Care for Older Adults through Interdisciplinary Education for Medical Residents Page | 33
- 35. Endnotes iZeis, M. PatientExperience and HCAHPS: Little Consensus on a Top Priority, August 2012. http://www.healthleadersmedia.com/intelligence/detail.cfm?content_id=282893&year=2012(accessed October 2, 2012) HCAHPS Executive Insight, October 2011. hcahpsonline.org. Centers for Medicare & Medicaid Services, Baltimore, MD. ii http://www.hcahpsonline.org/Executive_Insight/Files/October2011HEI.pdf (accessed October 2, 2012) Summary of HCAHPS Survey Results (January 2011 – December 2011 Discharges). Centers for Medicare and Medicaid iii Services. http://www.hcahpsonline.org/ HCAHPS Percentiles October 2012 Public Report (January 2011 – December 2011 Discharges). Centers for Medicare and iv Medicaid Services. http://www.hcahpsonline.org/ v Department of Health and Human Services, Centers for Medicare and Medicaid Services, Final Rule: Medicare and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions of Participation to Ensure Visitation Rights for All Patients, Federal Register, volume 75, no. 223 (November 19, 2010). vi S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S. Health System Organization: A Call for New Directions, The Commonwealth Fund, August 2008. Shaller D. Patient-Centered Care: What Does It Take? The Commonwealth Fund. October 2007. Available at vii http://www.commonwealthfund.org/Publications/Fund-Reports/2007/Oct/Patient-Centered-Care--What-Does-It- Take.aspx (accessed October 2, 2012). Shaller D, Darby C. High-Performing Patient and Family-Centered Academic Medical Centers: Cross-Site Summary of Six viii Case Studies. The Picker Institute. July 2009. Available at http://pickerinstitute.org/profiles-of-medical-centers/ (accessed October 2, 2012) ix Conversations with Leaders: Jim Conway. Picker Institute. Available at http://pickerinstitute.org/a-conversation- with-jim-conway (Accessed October 2, 2012). x Conversations with Leaders: Gail Warden. Picker Institute. Available at http://pickerinstitute.org/conversations-with- leaders-gail-warden/ (Accessed October 2, 2012) Balik B, Conway J, Zipperer L, Watson J. Achieving an Exceptional Patient and Family Experience of Inpatient Hospital xi Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2011. (available on www.ihi.org) xii Sorra J et al, Exploring Relationships Between Patient Safety Culture and Patients’ Assessments of Hospital Care, J of Pat Safety, September 2012, 8 (3), p 131–139. Hibbard JH, Stockard J, Tusler M. Hospital Performance Reports: Impact on Quality, Market Share, And Reputation. xiii Health Affairs. Vol 24, Issue 4, 1150-1160. July/August 2005. Elliott MN, Lehrman WG, Goldstein EH, et al. Hospital survey shows improvements in patient experience. Health Aff. xiv 2010;29(11):2061-2067. The Always Events® Blueprint for Action was authored by Carrie Brady in collaboration with Dale Shaller of Shaller Consulting Group who together have been honored to serve as the Always Events Consulting Team since the program’s inception in 2009. The authors thank the Picker Institute, the National Steering Committee, and all of the organizations implementing Always Events for their leadership and demonstrated commitment to improving healthcare in partnership with patients and families. Page | 34
- 36. Picker Institute Lucile Hanscom, Executive Director 1.207.236.0157/1.888.680.7500 [email protected] http://pickerinstitute.org http://alwaysevents.pickerinstitute.org Picker Institute Board of Directors J. Mark Waxman, Esq., Chairman Stephen C. Schoenbaum, M.D., Vice Chairman Samuel Fleming, Treasurer and Secretary Sir Donald Irvine, MD, FRCGP, FRCP, F.Med.Sci David C. Leach, M.D., Former Executive Director, ACGME Gail L. Warden, MHA, President Emeritus, Henry Ford Health System Always Events Consulting Team Dale Shaller, MPA, Principal, Shaller Consulting Group [email protected] Carrie Brady, JD, MA, Independent Consultant [email protected] Picker Institute Staff Hannah Honor H., RN, BSN, Grants Coordinator, [email protected] Kathy Cassidy, Financial Director Carolyn Marsh, Communications Director © 2012 Picker Institute. All Rights Reserved.