ProvenCare

by Glenn D Steele

  New professional appearance standards eventually will cover all healers, including physicians. Those with the same job title will be dressed in the same color. Environmental services workers already wear navy. Uniforms for licensed practical nurses will be rolled out next.

  The first impression of our healers is determined not only by tone and expertise but also by appearance and demeanor. The identical attire helps bring order to the complexity of our environment, offers a calming effect, and visually demonstrates professionalism.

  Bedside Shift Report, Hourly Rounding, and Whiteboards

  We are implementing a bundle of nursing best practices simultaneously at all Geisinger hospitals; three of the components are bedside shift report, nurse hourly rounding, and communication boards (whiteboards).

  At all hospitals, we’ve changed the handoff process so that discussions occur at patients’ bedsides, where nurses coming on and off shift discuss the status of the patient’s care and include the patient and/or family in the discussion. For decades, traditional nursing shift report took place in a conference room, at the nurse’s station, or even in the hall or via tape-recorded message.

  Bedside shift report involves patients in their care and leads to a higher level of safety.2 Any inaccurate or incomplete information is corrected on the spot by the patient or family members. Nurses look at IVs and examine wounds together, double-checking that everything is correct. In semiprivate rooms, we take precautions to safeguard privacy and not share protected health information.

  Hourly rounding is an evidence-based intervention in which nurses purposefully visit a patient about every hour to check the “Five Ps”: pain, potty, position, PO3, and placement. The series of questions includes “Are you having any pain? Can I assist you to the bathroom while I’m here? Are you comfortable? Would you like a drink or fresh ice? Do you have everything you need within your reach?” Nurses are scripted to say that someone will be back in about an hour, but if something is needed urgently before, the patient should ring the call bell. They also conduct an environmental sweep, ensuring that there are no safety issues such as tripping hazards. Hourly rounding generates trust and establishes caring through presence and partnering with patients. Further, it demonstrates Geisinger’s promise to patients and their families to anticipate and meet their needs. Hourly rounding decreases falls, reduces pressure ulcers, and improves patient satisfaction, and it also enhances nursing satisfaction owing to fewer call bells and less distance walked each day.4

  Whiteboards have been installed in every inpatient room systemwide. The information noted on this important communication tool is highly standardized and updated at shift change. The boards identify the patient’s doctor, nurse, nursing assistant, and unit operations manager; outline the patient’s plan of care for the day; show the patient’s phone number and anticipated discharge date; note the last time the patient had pain medication; record the patient’s fall risk; and indicate whether the patient needs assistance getting out of bed and whether one or two assistants are needed based upon steadiness and mobility.

  For all three best practices, we measure patient perceptions through Press Ganey surveys. In 2015, Geisinger added custom survey questions, asking whether nurses came in to check about every hour and whether we checked frequently enough. In addition, nurse managers round on every patient to check that hourly rounding and bedside shift reports are occurring and that whiteboards are updated, validating with patients in real time that the practices are taking place. Training occurs on all aspects of the bundle, and every nurse is evaluated annually on the practices, which are considered a nursing competency.

  Calls the Night Before Surgery and Patient Rounding on Demand

  Geisinger is implementing new physician processes to enhance inpatient satisfaction. For example, the surgeon, as captain of the ship, calls patients the night before surgery (or on Friday before a Monday appointment) to go over last-minute questions, reinforce pre-op quality measures such as cleansing the surgical site, and convey anxiety-reducing messages, such as she will be getting a good night’s rest, is confident that the procedure will go well, and will see the patient before he undergoes anesthesia.

  Not only do the calls contribute to increased quality surgical outcomes, they enhance engagement, with patients anecdotally demonstrating a significant amount of appreciation for the contact showing that the surgeon sincerely cares. Challenges have included not reaching patients and missing their returned calls, rehashing questions already covered during pre-op visits, and allocating time for the calls when a large number of patients are scheduled the next day.

  The idea of surgeons calling patients stemmed from an Orthopaedics Institute faculty meeting focused on increasing patient satisfaction. Forms of individual outreach were discussed, including calling the night before, and the surgeons were encouraged to try it and see what happened. Some jumped right in, while others initially said, “Forget it.” The concept was promoted to other surgeons, and it’s becoming a routine part of the day.

  In addition, the patient’s family members are consulted about a time window during which they would prefer the physician to round on their loved one. This is caring and efficient for patients and their families and helps build effective partnerships with their healers. We’ve done similarly with food service, offering an à la carte menu available by phone request, like hotel room service.

  Transition to Home Care

  Geisinger has improved the process for making the transition to home after hospitalization, anticipating patient and family needs in that stressful time. Our 70 nurse case managers, termed health navigators, focus on transition of care from hospital to home or nursing home. Representing a partnership between our healers and Geisinger Health Plan, the navigators are notified about every admission, identify patients with chronic conditions, and put strategies in place to prevent readmission for pneumonia, heart failure, cellulitis, and urinary tract infection.

  When patients come home from surgery, a box is waiting for them at home containing the medical equipment they need and have ordered, from a shower stool to a bedside commode, accompanied by clear instructions for the new care setting.

  The idea for the boxes originated in the Orthopaedics Institute, where as part of preparation for total knee or hip replacement, patients participate in a program that manages expectations. They view a video and attend a class during which they learn the steps in total joint replacement, what to expect in the hospital, how their pain will be managed, the type of physical therapy they’ll require, and the level of care needed at home postsurgery.

  Also included is discussion regarding what equipment is helpful postoperatively, including a walker, knee brace, or ice therapy device. This allows patients to preorder such items so they are delivered before surgery, not two weeks later.

  Same-Day Appointments and Phones Answered by Human Beings

  Lack of healthcare access is not compassionate. When your third grader is drawing disturbing pictures with red yarn around his neck, when you’ve found a lump, or when your father falls in the bathroom and is bleeding, but doesn’t call you until the morning because he didn’t want to disturb you, you don’t want to go through an 800 number and wait six weeks for an appointment. Geisinger offers a warranty to patients that a person will answer the phone and that same-day appointments are available in any specialty, any day of the week.

  We have a twofold tactic for managing access. For primary care services, there are large blocks of volume, lots of clinicians, and always someone available with capacity for urgently needed care, and we make room.

  With specialists such as otolaryngologists or neurologists, it works differently. There always have been specialists on call overnight in the emergency department, so part of a specialist’s day now starts in the daytime, and when a need arises, there’s a system to make the physician available at night.

  We recently upgraded to a state-of-the-art phone system, answered by humans who use a script prompting
callers regarding whether they’d like to be seen that day. About 20 percent take us up on the offer.

  We have same-day appointments every day of the week, especially on the weekends, because it’s easier for patients who are working or going to school to see a doctor then. The goal is to create an awareness in our patients that we’re like a big-box store or a restaurant: you know we’re open, and we’re ready and happy to serve you.

  Notes Pushed to the Patient

  Geisinger collaborated in the development of OpenNotes and was one of three original study sites in 2010. Today, more than 1,400 of our team members routinely share notes with more than 300,000 outpatients, inpatients, and emergency-department patients. Since the inception of OpenNotes, we’ve pioneered an evolution: OurNotes for patient activation to enhance the patient/provider relationship.

  OurNotes not only documents the visit but also pushes the note to the patient and employs an agenda, a previsit application that creates a patient-generated problem list. OurNotes also enables us to communicate more effectively what our healers are thinking, to tell a real story that makes sense in language a layperson can understand.

  Via e-mail link, OurNotes pushes to patients not only lab results and medication lists but the entire note from the most recent and all prior visits. This improves patients’ compliance and helps them better understand their medical reports and be more involved in their health decisions. Patients use the agenda application to prepare for a visit, prioritizing what they want to cover. The note cannot be closed until the healer addresses the concerns identified by the patient when creating the agenda.

  In the first large-scale study of its kind, our researchers confirmed that patient access via a web portal to doctors’ notes is associated with increased adherence to a medication regimen, improving overall health while reducing use of healthcare services, leading to a lower overall cost of care.5

  A Redesigned Bill

  The way we pay for healthcare is irritating, confusing, and unintelligible to consumers. Everyone understands the other things they pay for in life, such as a mortgage, a restaurant meal, or groceries—all of these the common individual can explain. But few can explain health insurance coverage and medical billing.

  Having a health insurer as part of our system, Geisinger is uniquely qualified to make revolutionary improvements in this area. Geisinger and Geisinger Health Plan work hand in hand to understand what patients want on their statements and explanations of benefits (EOBs). We’ve found that what matters to patients isn’t what insurance covers, but what they owe.

  In 2005, we were among the first to develop a combined statement, the document we use to bill patients. It contains charges for all providers and delivers information regarding what is expected of patients, their options for payment, and alternatives for financial assistance if needed. (See Figure 12.2.)

  FIGURE 12.2 Geisinger Patient Statement

  Geisinger doesn’t send statements to patients until their insurance has satisfied the bills. We tell patients their liability and give them options for paying in full or over time. We are one of the few health systems in the nation to have EOBs correlate to the patient statement; most systems send out estimated bills. We ensure that the EOB and statement match and that they are simple for patients to understand.

  We’re improving this statement with clearer, more familiar wording about the services provided to help the patient better connect with what occurred at the visit. We also are spelling out more plainly how much insurance paid and the patient’s obligation.

  We are exploring how better to convey what insurance covered to help dispel misunderstanding between insurance coverage and insurance benefits paid. We also are working on guaranteeing a price estimate for when we counsel patients in advance regarding how much a service will cost.

  The U.S. Department of Health and Human Services has invited Geisinger to collaborate with other vanguard health systems regarding development of national best practices in easy-to-understand medical provider bills and EOBs, with recommendations expected in 2017.

  STANDARDIZED CONTINUOUS SERVICE RECOVERY

  How do we handle situations such as these?

  • There’s a bad trauma incident tonight on I-80, and some of those with elective surgery tomorrow are being rescheduled.

  • An ICU doctor is “so amazing” that when his patients are ill, he sleeps in the room with them, giving up his personal life. Then he is cranky with others because he’s tired.

  • You show up for an appointment that was confirmed via telephone, but find out you’re not on the schedule until tomorrow.

  The opportunity is always there to be recovering, and our brand loyalty depends on it.

  Our 30,000 healers are trained to notice if something’s not right with a patient, to ask about it, and to do what it takes to make things right. Geisinger healers all are accountable, and leadership has their backs.

  We empower our staff to fix compelling, rational, and real problems within 24 hours, not requiring them to seek permission multiple levels up the organization. At our Geisinger Marworth Alcohol and Chemical Dependency Treatment Center, Gina Cicio, director of food and environmental services, learned that patients found their plastic-encased bed pillows uncomfortable and hot, making it difficult to sleep. Many patients there have sleep disorders, and the pillows were making their conditions worse. Ms. Cicio went to a local big-box store and bought 70 pillows for the patients.

  Walking through the Geisinger Medical Center lobby, Alison Mowery, nurse practitioner specializing in cardiovascular disease, discovered a tearful patient and her mother. Asking how she could help, Ms. Mowery learned that the patient had been in substantial pain for quite a while and had driven more than an hour to the hospital, expecting an MRI at 7:00 a.m. But the precertification hadn’t been completed, so the patient was turned away, and follow-up appointments that day had been cancelled. Finding the patient distraught and not knowing what to do, Ms. Mowery escorted her and her mother to neurology, where the grateful patient was seen, her case discussed, and the MRI rescheduled.

  We’re very hands-on in terms of training to recognize and deal with service recovery and empowering employees who have direct contact with patients, and we’ve created tool kits to make it easier for team members and patients to respond. For example, the checkout staff ask how the experience was today, and if there is a problem, they are authorized to remedy the situation on the spot.

  Like an airline giving you free miles or a ticket to atone for a mechanical delay or overbooking situation, if Geisinger doesn’t live up to its promise anywhere along the line, we compensate for the dissatisfaction by apologizing, providing parking and meal vouchers, and offering to refund all or part of the copay.

  Our patient advocacy team subsequently springs into action, ensuring that whatever occurred is relayed to the operations team. To ensure that it doesn’t happen next time, we’ve implemented back-end processes to close loops and effect change. The goal is to minimize the number of bad experiences through an environment of continuous improvement so that, over time, the need for remediation will be low.

  THE PROVENEXPERIENCE APP

  The concept of giving a refund certainly isn’t new; our innovation is ensuring it’s as clear and easy as requesting a refund from Amazon.com or Zappos.com, making it a one-touch process, promoting it, and in a sense entreating patients to request the refund.

  We developed a free, simple smartphone application for ProvenExperience to measure patient experience and offer a refund as part of our service recovery with our patients. It was built and rolled out in about three months, using a clinician-led team to ensure relevancy, with vital administrative support for project management, technical skills, subject matter expertise, and regulatory compliance.

  We piloted the app with bariatric and lumbar spine surgery patients, considered knowledgeable about technology and having substantial copays of $1,000 and $2,000, respectively. We learned that patients wanted to tell us th
eir stories about what went well and didn’t and to have a sliding scale for the refund request.

  Patients receive a one-page handout instructing them how to access the app and are encouraged via e-mail to respond one week after surgery. The app prompts, “Tell us about your experience,” triaging between “I’m happy” and “I’m unhappy.” Happy patients indicate with check boxes which aspects of their care were outstanding; unhappy patients are asked where the experience went wrong. The app records how the patient would like to proceed, either talking to us or sending a message, getting a copay refund, or submitting information about the experience. Patients without smartphones respond in more classic ways, on paper, by phone, or using our website.

  LESSONS LEARNED

  Geisinger is disrupting the entire healthcare service model, making it as customer-centric as the Ritz-Carlton, keeping prices down like Walmart, and knowing you as well as Amazon.com. ProvenExperience puts our money where our mouth is. We are writing refund checks, but they are valuable, because our patients are telling their friends and neighbors how we made it right.

  • Treat patients like family.

  • Lack of access is not compassionate.

  • Empower all employees to make it right, and have their backs.

  • Get leaders into the clinical areas frequently.

  • Don’t study innovations forever. Pilot, learn, and roll out.

  • If healthcare doesn’t disrupt itself, someone will do it to us.

  13