Ohio Hospitals Pursuing Patient-Centered Care: The Planetree Model
By Barbara G. Stiebeling RN, MSN, Quality Improvement Project Leader
The Centers for Medicare & Medicaid Services (CMS) has established the promotion of patient-centered care as one of its goals, consistent with that of the Institute of Medicine (IOM). A few hospitals in Ohio have made an extensive commitment to a model of care that supports a patient-centered approach, with a number of others actively considering adoption of such a model.
Founded in 1978 by a patient who experienced de-personalized hospital care, the Planetree model is a holistic approach to healthcare. Named after the tree Hippocrates sat under to teach his first medical students, the Planetree model encourages healing of mind, body and spirit.
In facilities where the model has been implemented, there has been a measurable increase in patient and staff satisfaction and a decrease in employee turnover. Core components include a focus on:
- Human interactions
- Compassion toward patients, families and staff
- Patients and families as active participants
- Architectural and interior design conducive to health and healing
- Homelike, barrier-free environments that support patient dignity and privacy
- Homelike amenities such as carpeting in the hallways, overhead music and computer Internet access per room
- Nutrition and nurturing aspects of food
- Healthy food choices in the cafeteria and vending machines
- Kitchens on the units to encourage families to prepare meals for patients
- Cooking demonstrations and classes provided by volunteers
- Room service meals comparable to hotels
- Empowering patients and families through education
- Customized packets of information
- Open chart policy where patients can read or write in their medical records
- Self-medication program for those able to administer their medication
- Consumer-friendly health resource centers
- Family, friends and social support
- Involvement of families/significant others whenever possible
- Care Partner Program teaches family members to care for patients, with volunteer care partners are available for patients who are alone
- Unrestricted visiting hours in all areas
- Touch
- Therapeutic full body or chair massage for patients and families
- Chair massage for staff
- Internships for massage therapists
- Training for family members in the Care Partner Program
- Spirituality
- Helping patients, families and staff connect with inner resources
- Chapels, gardens, meditation rooms
- Chaplains as vital members of the health care team.
- Healing arts
- Music, storytelling, clowns, and funny movies
- Artwork in patient rooms, treatment areas, etc.
- Volunteer artists who work with patients to create their own art
- Complementary therapies
- Aromatherapy has a calming effect on agitated and stressed patients and is being used during MRIs and with geropsychiatric patients.
- Pet therapy contributes to lowered blood pressure, elevated mood and increased social interactions
- Meditation, guided imagery, Reiki, acupuncture, yoga and others
- Healthy communities
- Working with schools, senior centers, churches and other organizations to expand the health of the surrounding communities
In Ohio, Forum Health was the first to adopt the Planetree model in 2002 and some form of the model is now used in all Forum Health facilities, including Northside Medical Center and Trumbull Memorial Hospital. One very successful program component is the chair massage for family members and visitors of patients in the intensive care units and surgery. The program, conducted under the direction of Norman Brown, Jr. BSAS, RRT, LMT, was implemented first at Northside Medical Center. Each participant completed a survey comparing how they felt before and after the massage. Due to the significant improvement experienced after massage, this program was expanded to the critical care and surgical waiting room areas of Trumbull Memorial Hospital. Anecdotal evidence confirms that this chair massage was a great help to families who were worried about loved ones.
Brown can’t say enough about how these programs have changed perceptions of the hospital by the community as well as employees. He has been active with the Planetree network, sharing ideas and mentoring other facilities as needed.
Alliance Community Hospital implemented this model in October 2002 as they built a new facility. According to Lin Sever, Executive Manager of Public Relations for the hospital, focus groups were convened and they were then able to incorporate not only the complementary therapies but many of the structural and environmental components of this model that were important to the community they serve.
Music, waterfalls, birds and fish highlight the entrance to the hospital. Waiting rooms have been designed as “comfort areas.” There is an outside rooftop garden adjacent to the obstetric, surgical and intensive care areas.
Private rooms are spacious and have three distinct areas. The patient area is central with hospital equipment hidden behind works of art. The family area provides comfortable furniture including couches for sleepovers, and the nursing area contains technical equipment necessary for the patient’s stay. Visiting hours have been abolished to favor 24-hour access to the patient. This not only allows for optimal patient comfort, but many teaching opportunities for both patient and family.
In additional to these structural components, the hospital provides many complementary therapies including massage, Reiki and aromatherapy. Their pet therapy program is a favorite and includes a celebrity Chihuahua.
For more information on the Planetree model, please visit: http://www.planetree.org/
Abstraction/Validation Updates
By Karen Gallagher, RN, Quality Improvement Project Leader
The following changes in abstraction will be made starting with July 2006 discharges. It is critical that you use the appropriate specification manual for each quarter.
AMI
Contraindication to Beta Blocker (BB) at discharge: MD/NP/PA documentation of a BB hold or discontinuation during the hospitalization constitutes a clearly implied reason for not prescribing a BB at discharge.
Heart Failure
With cases where there is conflicting documentation in reference to the same, most recent test, and there are one or more numeric ejection fractions (EFs) in combination with one or more narrative descriptions of left ventricular systolic dysfunction (LVSF), take the numeric EF over narrative LVSF description(s).
Pneumonia
In order to be included in the pneumonia (PN) population, each case will have a working diagnosis of PN and documentation of a chest x-ray or CT scan that indicates PN within 24 hours prior to hospital arrival or anytime during the hospitalization. The ED physician’s documentation would take precedence over a radiologist’s interpretation of a chest x-ray even if the radiologist’s report was in place prior to admission.
Influenza vaccination status: Allowable value = 6: Vaccine not available to hospital, due to shortage of vaccine [ONLY if there has been an official memo from the Centers for Medicare & Medicaid Services (CMS) or the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)].
Comfort Measures Only: Inclusions = DNR Comfort Care (verbiage comfort care)
Exclusions = DNR CC (if the term CC is not defined in the medical record)
A “direct admit” is a patient who is admitted from their usual place of residence (home, nursing home, assisted living center, etc.) directly to a floor/unit through an order of their physician. A “direct admit” is not a patient who was seen in the emergency department.
SCIP Infection
SIP-3 has been revised to allow for CABG and other Cardiac Surgery procedures to discontinue ATBs “within 48 hours” instead of “within 24 hours.”
AMI and Pneumonia
Arrival date, time: Face sheet is no longer an acceptable source.
Only acceptable sources are:
Any ED documentation
Nursing admission assessment/admitting note
Observation record
Procedure notes
Vital signs graphic record
Transfer from another ED: This will no longer exclude the case from PN 2, PN4, & PN 7 measures
Pneumonia and SCIP Infection
Antibiotic (ATB) date, route, time, name: a new approach: Collect only three doses of each ATB from hospital admission through post-op. If an abstractor chooses to abstract EACH dose, that is acceptable.
ATB received, prior to arrival: Listed as “current” or “home meds” should be concluded as taken within 24 hours unless there is documentation to support otherwise. (The intent of this measure has not changed; this is a clarification.)
* * *
Dates to Remember (Dates are approximate)
May 15, 2006—Deadline for Data Submission to Clinical Warehouse 4Q05
May 30, 2006—Validation chart request of 4Q05
June 2006—Hospital Compare Web site release of 3Q05
June 30, 2006—Validation charts due of 4Q05
July 2006—Hospital Quality Alliance (HQA) Preview Report 4Q05
August 15, 2006—Deadline for Data Submission to Clinical Warehouse 1Q06
Web-Based Training Modules Focus on Quality improvement
By Betty Pilous, RN, MHSA, CPHQ, Director, Community Based Services
Healthcare providers can now access a diverse collection of healthcare improvement learning resources, featuring six Web-based, highly interactive training modules. The modules, which were developed by the Healthcare Improvement Skills Center (HISC) Collaborative, are located at http://improvementskills.org.
The modules provide a sound introduction to quality improvement in healthcare and should prove of particular benefit to those new to the field. For those experienced in quality improvement activities, the modules offer a way to fill gaps in knowledge and skills and provide tools, links, and citations. The modules are designed to support healthcare professionals who desire to make systematic improvement in the quality of care they provide to their patients.
Each module is free of charge and takes about an hour to complete. However, if you require documentation in the form of a continuing medical education or nursing continuing education credit certificate, a $10.00/module fee will be assessed.
The module topics are as follows:
- Describe the presenting quality issue
- Begin to identify possible systems failures associated with the problem
- Describe the overall goals of an improvement effort in clear and concise terms
- Select the situations where a team approach is preferable to an individual approach
- Build a team by involving the right people
- Organize and manage the meeting process to make good use of team members’ skills
- Identify systems failures associated with the problem
- Use evidence and benchmarks to evaluate the current situation
- Reduce the problem to manageable components
- Use basic quality improvement tools and skills to identify sources of unwanted variation in a process
- Collect, aggregate, analyze, and display data
- Use tools to develop, display, and select an intervention
- Develop and evaluate plans for a test of change
- Select measures with which to examine the results of change
- Display and analyze data in time series graphs
- Determine when a change in data over time is likely to be due to chance and when it is not
Module 6: Reconsider or Extend Improvement Efforts
- Reassess the change process and adopt new implementation methods if necessary
- Identify the likelihood that an innovation will be adopted in their organization
- Work with opinion leaders to facilitate change
- Use appropriate communications methods to support improvement efforts
Quality of Care and High Performance: Two Perspectives
By Mona Wendell, RN, BA, MBA, Quality Improvement Project Leader
Patients’ expectations for quality of care include receiving all of the care required to manage an acute episode and appropriate preventive care to enhance their quality of life. Hospitals recognize that quality of care is dependent on high performance that translates to positive patient outcomes. The narrow focus of these two groups--patients and hospitals--should make it easier to accomplish the defined objective: to administer the pneumococcal and/or the influenza vaccine to eligible persons.
Standing orders
Every day hospitals have competing priorities for their time, focus, and resources. Hospitals are finding that a systematic approach to care by way of standing orders for pneumococcal and influenza vaccine helps to ensure that every person receives the right care every time. Ohio’s General Assembly recently enacted legislation (3721.041 and 3727.19) that requires nursing homes and hospitals to offer residents and patients influenza and pneumococcal vaccinations unless a physician has determined that vaccination is medically inappropriate. Standing orders must be a structure approved by the medical staff, hospital administration and the governing board.
In addition to the Ohio Revised Code law, immunization for pneumonia and influenza is supported through the Federal Register 42 CFR Parts 482,483, and 484; Joint Regulatory Statement (The State Medical Board of Ohio, the Ohio Board of Pharmacy and the Ohio Board of Nursing, Rule 4729-5-01(K) and (L)(1)(2) O.A.C.and The Ohio Board of Health Recommendation.
Southeastern Ohio Regional Medical Center in Cambridge recently implemented standing orders, and their experience demonstrates that standing orders do work. After evaluating their wavering compliance scores with pneumonia and influenza vaccination screening, Southeastern Ohio Medical Center decided to institute a formal course of action to tighten the gaps. By taking an interdisciplinary approach to process improvement, the medical center developed a policy and protocol to increase compliance. Over the course of one year, Southeastern Ohio Medical Center raised its pneumococcal vaccination screening score by 16 percent and its influenza vaccination screening score by 27 percent.
The standards for immunization practices provide a concise, convenient summary of the most desirable immunization practices. These standards have been widely endorsed by major professional organizations. Everyone should strive to follow them not only to meet the CMS/JCAHO standard and the requirements of the new Ohio law, but also to save lives, minimize hospitalizations and reduce costs.
Surgical Care Improvement Project (SCIP) Lessons Learned and Shared by a Pilot Hospital
By Lynn Mistovich RN, Quality Improvement Project Leader
Ohio has the distinction of being a national leader in the Surgical Care Improvement Project because of the work done by eight hospitals during the SCIP pilot. Each of these hospitals shared their expertise during the development and implementation of many components of SCIP. Their work now benefits hospitals across the nation.
Community Health Partners, a Catholic Healthcare Partners hospital in Lorain, has proven to be an outstanding leader, both during the pilot and into the 8th Statement of Work. Jane Jones, Director of Quality Systems; Denise Perry, Infection Control Practitioner; and a team of dedicated professionals have developed many SCIP interventions. Perry has presented Community Health Partners’ lessons learned at several meetings and was quick to respond when asked to share some of the hospital’s interventions with other Ohio hospitals:
Leadership commitment
“First and foremost, without the commitment from organizational, executive and corporate leadership, success will be much more difficult,” said Perry. “I can't tell you how easy it was for us because of that commitment that came all the way from the top. I think many give lip service to the ‘top-down theory’ of commitment but it’s the actions, the backing and the support given that really counts.”
A commitment to improve and achieve target goals was made and then strategies were implemented to make it happen. Some of the strategies that worked include:
- Using a committed team of healthcare workers consisting of all specialties impacted by the project (Surgery, Clinical Education, Quality, Infection Control, Critical Care, Cardiovascular OR), as well as “members” who participated when needed to make things happen (the Medical Director, the Chief of Staff, a Surgeon, an Anesthesiologist, a Pharmacist, and the manager of Medical Records).
- Implementing two methods of chart abstraction. One group committed to attending a weekly chart audit session. When questions arose, this group felt they got valued input from each other's expertise. The other group was unable to commit to a weekly meeting but committed to get "X" number of charts abstracted per cycle (their charts were set aside for them each cycle). The chart abstractors were limited to only those who had been trained enough to ensure consistency in the abstraction process.
- Implementing monthly meetings to receive updates from the project coordinator, reviewing any feedback from the data source, identifying any obvious issues gleaned during chart abstractions, and planning strategies.
Some of the improvement strategies that made a difference were:
- Review and revision of all pre-printed orders that have impact on the measures. This probably had the biggest impact on improving their rates.
- Development of policies (signed off by the Medical Affairs Dept.) to support some of the changes (for example, a signed policy under the Department of Medical Affairs stating that "all prophylactic preoperative antibiotics are to be administered within 60 minutes prior to incision," leaving the process up to the Surgery Department to ensure compliance).
- Development of a process that ensures the prophylactic antibiotics are administered in a timely fashion (for example, no one is to administer the prophylactic preoperative dose except for the designated group; circulating RN when patient actually arrives in the operating room or by anesthesia) as well as discontinued in a timely fashion (with policies to support automatic stop by pharmacy of post-op prophylactic doses within 24 hours or 48 hours for cardiac-timeframe.)
“Blame Free” + Accountability = Just Culture*
By Dawn Knopp, RN, BSN, CPHQ, Quality Improvement Project Leader
Problems or errors in complex systems are seldom the fault of individuals. They are more commonly the result of a fault in the system. Therefore, when problem solving focuses on the individual alone, the problem will most likely continue. When individual accountability and system changes occur together to foster patient safety, a “Just Culture” is established.
In a “Just Culture,” one finds open and fair communications and practices; an environment where learning is valued; and safe systems to protect patients, families and staff and management of behavioral choices to benefit the organization. The goal is to develop an environment where system designs and behavioral choices are implemented and monitored so that human errors can be identified and managed before they lead to adverse events.
Not perfect
Neither systems nor humans are perfect; therefore, we must design systems that take into account factors affecting both the system and human performance. Factors that affect system performance include: size, complexity, designs in place to reduce the rate of and effects of error or failures. Factors known to affect human performance include: too much or too little information, design of equipment/tools and job tasks, a match or mismatch of qualifications/skills, perception of risk, individual factors, environment/facilities, organizational factors, supervision and communication.In a just culture, human failures are categorized into three areas: human error, at-risk behavior and reckless behavior. Each type of behavior has a consequence for the person and is managed in a different way.
Human error is unintentional, such as a mistake. This inadvertent act(s) is a product of a design failure and is managed through forms of consolation—acts of pity, consoling, or empathy for someone who has made an unintentional “human error.”
At-risk behavior is that which increases the chances of a negative outcome either because the risk is not recognized, or is mistakenly believed to be justified. This form of unintentional risk-taking is managed through coaching methods.
Reckless behavior is a conscious choice to perform in an unacceptable way. This type of intentional risk-taking and is best managed through disciplinary action.
For more information see www.justculture.org
* From: “Assuring that a Culture of Safety Allows for Individual Accountability,” (David Marx, JD, March 2006, Teleconference Part 1).
Hospitals Get New Resource for Preventing Medicare Payment Errors
By Christine Lerz, Health Data Analyst
There’s a new Internet resource for hospitals seeking to prevent Medicare payment errors and reduce their audit risk. HPMPResources.org provides compliance officers, utilization and health information management professionals and other staff with one-stop shopping for tools and information related to payment error prevention.
All of the materials on HPMPResources.org are available to hospitals free of charge as part of the Hospital Payment Monitoring Program (HPMP), the national initiative to measure, monitor and reduce the incidence of improper fee-for-service inpatient payments.
There’s something on this site for every hospital that wants to reduce their payment errors and audit risk. Some of the notable materials on HPMPResources.org include:
- HPMP Compliance Workbook. This exhaustively researched workbook provides crucial guidance, suggestions and tools for hospitals seeking to develop, update or strengthen their compliance programs, particularly for areas monitored by the Centers for Medicare & Medicaid Services (CMS). The workbook was specifically written to aid staff in identifying and improving hospital compliance program structures and processes that contribute to payment errors due to medically unnecessary services and inaccurate diagnosis-related group (DRG) assignment, admission screening criteria noncompliance and insufficient medical record documentation.
- Tools Compendium. Hospitals can download data collection/analysis tools, data dissemination tools, prompters, pathways/protocols, guidelines, presentations, articles/handouts and other materials to aid staff in improving processes and preventing payment errors.
- Online Training for the Program for Evaluating Payment Patterns Electronic Report (PEPPER). Through the link to www.pepperinfo.org, it’s never been easier to learn to use PEPPER, the electronic report that contains hospital-specific data for areas often associated with payment errors. This four-part series of Web-based training sessions on PEPPER is the perfect tutorial for staff wanting to reduce payment errors and decrease their hospital’s audit risk using PEPPER data. A total of six continuing education credits approved by the American Health Information Management Association are also available for three of the sessions.
The collection of materials on HPMPResources.org will only grow over time as hospitals and QIOs use the Web site to share tools and information they have developed individually. Hospitals can access all of these resources and more by visiting www.hpmpresources.org.
Ohio KePRO also offers the HPMP Compliance Workbook, Training for the Program for Evaluating Payment Patterns Electronic Report (PEPPER), and the PEPPER Users Guide all on an easy to use CD. For a copy of the CD, your hospital’s PEPPER, or any questions regarding PEPPER data including requests for PEPPER data case listings, contact Christine Lerz at Ohio KePRO at 216-447-9604 ext. 2220, or clerz@ohqio.sdps.org.
Electronic Health Records Utilized to Reduce Medical Errors
By Donna Moore, RN, MBA, Quality Improvement Project Leader
The Appalachian Regional Informatics Consortium (ARIC) is not your ordinary Regional Health Information Organization (RHIO). RHIOs provide a mechanism for healthcare providers to share secure clinical information about patients across settings with an objective of improving the quality of care. The mission statement of ARIC is “to improve access to medical information in rural Appalachian Ohio by developing a sustainable model for a comprehensive and shared advanced information system.” This model will “establish a formal organizational structure and a comprehensive technical plan for a shared medical information system to benefit primary and behavioral healthcare providers, biomedical researchers, and medical educators.” Most RHIOs are part of a larger, urban healthcare system. The ARIC is made up of individual providers and will be patient centered as opposed to the usual RHIO which is system centered.
The three counties from southeastern Ohio that are involved in the project are Hocking, Athens, and Vinton. Members of the ARIC include Ohio University College of Osteopathic Medicine (OU-COM), Alcohol, Drug Addiction & Mental Health Services 317 Board, Doctors Hospital of Nelsonville, Health Recovery Services, Inc., O’Bleness Memorial Hospital, Pine Hills Continuing Care Center, Southern Consortium for Children, Tri-County Mental Health & Counseling Services, Inc., and University Medical Associates. Ohio University supports the ARIC project through OU-COM as well as through the IT department. OU-COM is on the cutting-edge of electronic communication technology, using technical resources to create, preserve, and share knowledge. By partnering with hospitals and other healthcare services, ARIC encompasses physical and behavioral healthcare – an approach that replicates a rural healthcare community.
ARIC is taking into consideration the regional social and economic issues facing Appalachian Ohio. These issues include difficulty in recruiting and retaining primary care physicians, sharing of information between institutions and across disciplines, declining state and federal funding, limited specialty and allied health services, geographic isolation with limited transportation, and high rates of unemployment. However, there are strengths to build on which include a strong sense of family and community, the local cultural heritage, and traditional values. The ARIC supports the Appalachian Regional Commission belief that “A healthy population is vital to the economic and social development of the Appalachian Region. Health care should be comprehensive, affordable, and tailored to the specific needs of each community. Reducing health disparities will require a multifaceted approach, focusing on healthcare workforce, recruitment, infrastructure development, and improved access to healthcare.”
Focus on “whole” patient
ARIC recognizes the need to focus on the “whole” person, not just a clinical patient. Community healthcare protocols will be built to focus on quality care of the patient and, providing easier access to services. For example, a patient has an appointment with their PCP who refers them to a specialist. The specialist schedules the patient for outpatient surgery. In each setting, the same demographic and patient information is collected. A goal of ARIC is to have a mechanism to collect this information one time and have it disseminated to the patient’s other relevant providers, simplifying the process for all involved.
Prior to proceeding with the project, OU-COM and the healthcare partners developed two surveys, one for physicians and one for area residents. The findings indicate that both groups recognize the benefit of the electronic health record whose implementation would be facilitated by ARIC. Almost two-thirds of the physicians have a positive perception of the electronic health record. They want a system that is cost effective, efficient and easy to use. Over 90% of the public believes that quicker access to their medical history will improve the healthcare system. Also, 90% of the surveyed residents believe that the electronic health record will be as accurate or more accurate than the current paper records.
More information about the Appalachian Regional Informatics Consortium is available at https://www.oucom.ohio.edu/aric/.
Ohio KePRO offers a variety of free tools and interventions on health literacy and pneumococcal vaccination, the Physician Office Toolkit, mammography postcards, brochures, booklets, and more. View Shopping Bag>>
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Newsletter: Quality Matters (Spring 2006)
Acute Care Services Team
David A. Bitonte, DO, MBA, FAOCA
Rita Bowling, RN, MSN, MBA, CPHQ
Jennifer Bitterman, RHIA, MBA
Karen Gallagher, RN
Dawn Knopp, RN, BSN, CPHQ
Lynn Mistovich RN
Donna Moore, RN, MBA, CPHQ
Patricia Nelson, RN
Karl E. Peters
Rosann Pasko, MS
Liz Simpson
Barbara G. Stiebeling, RN, MSN
Mona D. Wendell, RN, BA, MBA
Medical Editor: David A. Bitonte, DO, MBA, FAOCA
Editor: Robert A. Feigenbaum, MS
Associate Editor: Barbara G. Stiebeling, RN, MSN
To Contact Us
E-Mail: hospital@ohqio.sdps.org
Provider QIC Line: 1.800.385.5080
Rock Run Center, Suite 100 · 5700 Lombardo Center Drive · Seven Hills, OH 44131 · www.ohiokepro.com
Ohio KePRO, the Medicare Quality Improvement Organization (QIO) for Ohio, is working with committed hospitals, nursing homes, home health agencies, and physicians throughout the state who are dedicated to the common goal of Continuous Quality Improvement for Medicare beneficiaries.
Publication No. 8031-OH-017-5/2006. This material was prepared by Ohio KePRO, the Medicare Quality Improvement Organization for Ohio, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
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