American Hospital Association (AHA)/
Health Research & Educational Trust (HRET)
Hospital Engagement Network (HEN)
Nebraska
National Improvement Leader Fellowship (ILF)
Objectives
Today you will learn how to
•
Engage the hearts and minds of patients,
family and staff
•
Differentiate numeric data from experiential
data
•
Leverage patient experience for improvement
•
Deepen understanding of how experience
Nebraska ILF Achievements
•
Number of Improvement Leader Fellows: 23
•
Number of HAB Templates*: 29
•
Number of IHI Open School Registrants: 12
•
Hospitals with highest number of OS modules
completed:
–
Saint Francis Memorial Hospital (3)
–
Harlan County Health System (3)
What is IHI Open School?
•
Online courses focused on
–
Improvement capability
–
Patient safety
–
Tripe aim for populations
–
Person- and family-centered care
–
Leadership
–
Quality, cost and value
•
12 month subscription
ENGAGING HEARTS AND MINDS OF
PATIENTS, FAMILY AND STAFF
Presented by:
Jane Taylor, Ed.D.
Improvement Advisor (IA)
Institute for Healthcare Improvement (IHI)
September 2014
Years 1 and 2, Fellows learned about:
• Deming’s System of Profound
Knowledge
• The Model for Improvement (three
fundamental questions) and PDSA cycles
• The Sequence of Improvement (from
testing to implementation to spread)
• Run and Control Charts (e.g. using
data to guide improvement)
• Designing Reliable Systems
Refreshers available through Open School and On-Demand Videos on IHI.org.
Month Topic March HAB April Leadership May PFE June HAB 2.0 July Teamwork August Coaching and
Capability Building September Experience Data October Always
Events/Reliability November Engaging the Front
Lines
Looking
How Can We Integrate Qualitative Data to
Deepen Our Understanding of Success in
Reducing HAB?
•
How have you used patient and family
feedback as it relates to reducing harm across
the board?
Fellowship Participation: Themes for
Using Qualitative Data
Junior Fellows Senior Fellows Champion Fellows
What are you
curious about?
Where might
you find
qualitative
data?
What are your
opportunities to
use qualitative
data to tell a
more complete
story when
combined with
quantitative
data?
What are your next
steps for
systematically
gathering qualitative
data for your HAB
projects and using
that data to guide
improvement?
Open School Module
Chat at Your Table
If you have taken any of the Open School
modules, share one thing you found useful.
Which module did you find most useful and
why?
Model for Improvement
13Improvement Guide. 2nd Edition, 2009
The Approach
1. What is qualitative data?
2. Why collect it?
3. How to use it?
4. Practice application
Definitions
Field
Uses
Social
Sciences
Understand cultures: ethnography,
anthropology, sociology.
Business
Marketing research and product or service
evaluation.
Healthcare
Person and family experience. Make
improvements, evaluate service; understand
safety culture, etc.
Research
and
Evaluation
Add to numeric data to evaluate and
understand effects, results, experiences.
Mixed methods emerge as useful model.
Turn and Talk…3 minutes
Take turns
How does your hospital use these?
•
Patient and family stories to promote safety
•
Seek input from family and patients that come
from more than survey data
•
Observation
If you do not use these now, how might they be
useful to HAB work?
USING QUALITATIVE DATA
17
Wednesday, September 3, 2014
Bev Johnson
The meaning of care.
TMAbout Us
8303 Campus 320 Beds
•
Emergency, Medical, Surgical and Rehabilitation
•
1
stHospital in Nebraska to Obtain Magnet Status
•
Perform more surgeries than any other hospital in the area
707 N 190
thPlaza 116 beds
•
Opened in June 2010
•
Provide Women’s Services (Obstetrical/Surgery)
•
Emergency & Neonatal Intensive Care Unit (NICU)
Qualitative Data Use
Prior to the Building of Women’s Hospital
•
Steering committee
•
Operations Committee
•
Women’s Advisory Council - Community Women
•
Patient/Family one on one interviews
•
Mock Up Rooms
•
Staff review of Plans
Since Opening –
Performed NICU Focus Groups
Qualitative Data Use
Include in the daily staffing meeting, daily
administrative report, monthly leadership
meetings with patient safety concerns
Example from a daily staffing
meeting/administrative report:
Need to reinforce use of ETHOL protocol with
scale. Some providers not familiar with scale
Qualitative Data Use
Patient Safety Case presentation by key personal
at the Performance Improvement Meeting (which
includes board members)
Example: 97 year old female cared for by family
•
Admitted for medical care – on Fall precautions
•
Assisted to bathroom by staff member
•
Lowered to the floor
•
Fractured pelvis
Qualitative Data Use
Patient/Family Involvement of Hospital Committees
Member on
•
Patient Rights & Ethics Committee
•
NICHE (Nurses Improving Care for Healthsystem Elders)
•
Palliative Care
Began the process coordinated thru Volunteer Services
•
Recruitment
•
Orientation
•
Expectations
Qualitative Data Use
Monthly leadership forum meetings conclude
with patient stories
•
Managers read letters that they have received
from patients on exceptional care –
•
Energizes the group to hear about success
stories & what can they take back to their
units
Learnings
•
Staff Remember Stories
•
Using patient specifics makes the data real -
having a description of the patient with what
occurs has a larger impact than giving a rate
•
Gives the data a Name to relate too
•
Patient/Family provide valuable input to the
process
•
Sharing the positive stories confirms the mission
of the organization
Planning
Organization Core Value –
Patient Centered, Patient Driven – Patients are our first
priority.
1. Developing a patient/family advisory council for the
cancer center patients goal first meeting in November
•
Coordinating thru volunteer services
•
Application process - have 20 applicants & plan for 10
2. Add members to other hospital committees
By November add a member to the Pain Management
Committee
Summary
Qualitative Data emphasis the importance of
Human Input
“Qualitative inquiry cultivates the most
useful of all human capacities – the
capacity to learn from others.”
“
There is no burden of proof. There is only
the world to experience and understand.
Shed the burden of proof to lighten the
load for the journey of experience.”
Purpose of Experience Based
Data or Information
Qualitative data provides insight into:
–
Experiences
–
Perspectives
–
Feelings
–
Understanding from the inside-out
In order to improve understanding, to develop
changes for testing and finally, to take action.
Practical Applications for
HEN Work
Use feedback from patients, family and staff to
enhance improvement.
Convert this data into actionable change
•
Inform better action
Purpose
Qualitative
Develop hypothesis
Seeks to explains how
and why
Looks for meaning
Quantitative
Develop hypothesis
Test hypothesis
Seek to understand
what happened
The “Study” of PDSA is
reflective
Qualitative Data Sources
•
Observation
•
Interviews
•
Documents
•
Autobiography
•
Focus groups
•
Stories
Data Collection
•
Audio and video recordings
•
Transcriptions
•
Field notes
•
Researcher journal: insights,
questions, notes
•
Documents: feedback cards, letters,
Lovelace Medical Center
Video
Through the Patient’s Eyes
•
The Eight Picker Principles of Patient-Centered
Care originated with the Seven Dimensions of
Patient-Centered Care, whose development was traced in the
1993 groundbreaking book Through the Patient’s Eyes.
•
Using a wide range of focus groups—recently
discharged patients, family members, physicians and
non-physician hospital staff—combined with a review
of pertinent literature, researchers from Harvard
Medical School, on behalf of Picker Institute and The
Commonwealth Fund, defined seven primary
The Eight Principles of Patient
Centered Care - Picker Institute
•
Respect for patients’ values, preferences and
expressed needs
•
Coordination and integration of care
•
Information, communication and education
•
Physical comfort
•
Emotional support and alleviation of fear and
anxiety
•
Involvement of family and friends
•
Access
My nurse of the moment (R.N.) came in at about one o’clock to wrap my leg from the knee down in a hot towel and insulator. As a first step, she turned on the hot water in the sink, as she needed hot water for the towel (some nurses uses the microwave for this purpose). She then departed, saying “I’ll be right back”. A social worker dropped in about a half-hour later. I asked her if she would mind turning off the hot water. She did. In another half-hour, the nurse came back to put on the hot towel, turned on the hot water, and completed the job.
Dr. X ordered from the pharmacy (in the hospital) a paste for the itch
caused by the sore leg. The pharmacy was out of one of the ingredients: must order it from the wholesaler, and can not make up the paste until Monday. I need it tonight. On prodding from Dr. X, the pharmacy sent someone out to a drug store to fetch the missing ingredient. The paste came up that evening.
It may seem unbelievable, but the same thing took place some days later. My nurse of the afternoon ordered from the pharmacy a refill for the paste. No problem, except that there would be a delay, as (again) the pharmacy would have to order from the wholesaler one of the ingredients. Tomorrow will be Saturday, next day Sunday, Monday a holiday. They would send up a substitute, which would be in the form of a lotion, not paste.
Lets try together
• Dr. X ordered from the pharmacy (in the hospital) a paste for the itch caused by the sore leg. The pharmacy was out of one of the ingredients: must order it from the
wholesaler, and can not make up the paste until Monday. I need it tonight. On prodding from Dr. X, the pharmacy sent someone out to a drug store to fetch the missing
ingredient. The paste came up that evening. • It may seem unbelievable, but the
same thing took place some days later. My nurse of the afternoon ordered from the pharmacy a refill for the paste. No problem, except that there would be a delay, as (again) the pharmacy would have to order from the wholesaler one of the ingredients.
Tomorrow will be Saturday, next day Sunday, Monday a holiday. They would send up a substitute, which would be in the form of a lotion, not paste.
•
Coordination and
integration of clinical care
•
Coordination and
integration of ancillary and
support services
•
Coordination and
integration of front-line
patient care
_______________________And if we continued
reading . . . How would
you categorize, the sheet
changing item?
Exercise: Let’s Analyze
Some Data
•
Review Picker themes – your handouts
•
Sort data handout into themes
–
Use the margins of the page to assign a theme
•
Use handouts – clinical office practice
Now What?
•
Sort into categories
–
Select a particularly illustrative quote or two to
represent the theme when you share your
findings
–
Use quantitative data to augment and support
•
Assess problem
•
Assign improvements
•
Continue to collect and sort data: note
whether and how the “piles” change
Group Reflection
•
How can you make this a practical part of your
improvement work?
•
How can you use qualitative data to
understand if you are improving?
How to Use Patient Stories and Experiences
Fillmore County Hospital
Shari Michl RN
Director of Quality
About Us
•
20 bed CAH in Geneva, Nebraska
•
Fillmore County population approximately 6,000
•
Full range of services, including ER, OB, Skilled Care
•
Very active specialty clinic with over 20 different
specialists serving our patients
•
Employ a full time orthopedic surgeon whose
primary focus is total joint replacement
•
Active integration of behavioral health services
throughout the hospital
How We Use Qualitative Data
Patient safety data is presented as a narrative, not just in
numbers.
Comments from our Patient Experience surveys are shared in
our quarterly newsletter “Quality Matters.”
All staff are encouraged to share stories of patient
experiences at our morning huddle.
We use stories to give life to the data- and to help us see
things through our patient’s eyes.
The Power of Storytelling
What we have learned---
Numbers, graphs and pie charts are
meaningless to most staff
If you can tell a story about a specific patient, it
connects with caregivers
To make change happen, we have to start with their
hearts and the minds will follow.
Next Steps??
•
Patient and Family Advisory Council. . .
Looking forward to using what I have learned
today!
“If we are to engage with them — that is, make an emotional commitment to them — we might start by listening to them more and judging them, and the choices they have made, less. We need to build a health care system that meets their needs and values, not one that just reflects our own.”
quote from article by Alan Weil
Use of Stories
•
Other applications of experience data
•
Staff
•
Patients
•
Family
•
Visitors
Planning Connecting Technology Education Media Research Learning Inspire
Patient
Narrative
Collection ApplicationPlanning
Finding the stories Framing the questions
Holding the interview Storage and retrieval
Connecting
Content areas Hearts and minds Healthcare improvement
Local feedback
Technology
Written, audio, video Editing Photography Determining Uses
Patient
Narrative
CollectionEducation Media
Research
Learning
Inspire
Purpose: To improve care
How: Generating dialogue within
teams; identifying needs; creating improvements, feedback outcomes (from discovery)
Campaign: Learning sessions, how
to guides, intranet dialogue.
Education Media
Research Learning
Inspire
Purpose: To provide motivational
reminders to frontline staff of ‘Why they do what they do’
How: Distribute for use on trust
intranets, newsletters and in team meetings and conferences
Campaign: Newsletters, e-bulletins,
intranet/websites.
Education
Media
Research Learning
Inspire Purpose: To see the patient as equal
to the treatment; enabling a focus on the patient and not just the outcomes.
How: to follow patients, to offer
education services
Campaign: Learning session, how to
guides, intranet dialogue
Education
Media
Research Learning
Inspire Purpose: To validate the Campaign;
Change a public mindset;
Endorse good work and draw attention to flaws in the system
How: Features in press/tv/web
Campaign: Press Releases, Case
Studies, Feature articles
Education Media Research Learning Inspire Application
1 story – 4 applications
One patient story has the potential to provide:
•
Learning – to improve care
•
Inspiration – to provide motivational reminders to
frontline staff
•
Education – enabling a focus on the patient, as
well as the outcomes
•
A media resource – drawing attention to good
work, including the lessons that are being learned
and implemented
Group Reflection
•
How can you make this a practical part of your
improvement work?
•
How can you use qualitative data to
understand if you are improving?
When You Do This Type of Work
Consider you are the data collection
instrument and how the following
influence what you pay attention to:
•
Your assumptions
•
Point of view
•
Relationship to the topic and people
When you share findings or create a story,
be as transparent as you can about your
perspective.
Next Steps: Pick One
1. “
Discovery Shopping”
• Observe a patient or familymember using a service.
• Shadow
• Take notes, photos without people
• What do you hear, feel, smell
• What is the flow of events?
• Where is it easy, difficult?
• Where are waits, delays, not knowing?
3. Conduct interview
of staff around HAC
improvement
2. Conduct interview
with patient or family
member
4. Conduct focus group
with a group of
patients or family; or
with staff
5. Develop a story and
practice telling it
Resources
•
Denzin, N. K., & Lincoln, Y. S. Handbook of qualitative
research (2nd ed.). Thousand Oaks, CA: Sage Publications,
(2005).
•
Glaser, B. & Strauss, A. The Discovery of Grounded Theory,
1967, 1999.
ISBN 1-884156-13-4
•
Glasser, B. Doing Grounded Theory, Sociology Press, 2008.
•
Morgan, D. Krueger, R. Focus Groups Kits, Sage, 1998.
•
Patton, M. Q.. Qualitative Evaluation and Research
Methods, Sage, 1990.
•
Van Maanen, J. (1988) Tales of the field: on writing
ethnography, Chicago: University of Chicago Press.
Resources
•
Video Intervention/Prevention Assessment (VIA),
–
a research method where child and adolescent patients
make video illness narratives to show and tell their
clinicians about their experience of illness.
–
To date, VIA has been used with children and
adolescents to study chronic health conditions ranging
from asthma and obesity to spina bifida and HIV.
www.viaproject.org
•
Getting Started in Video Ethnography: A Catalyst for Guiding.
www.innovations.ahrq.gov/...Agency for Healthcare Research
and Quality. Nov 6, 2013 - Getting Started in Video
Ethnography: A Catalyst for Guiding and Motivating. Kaiser
Permanente.
(R) J Taylor and V Crowe 63
Further Learning
•
Interviewing
–
Interview Guide: Using the Interview as a Source of Data,
Information, and Learning IHI Tool created by J Taylor
–
http://www.ihi.org/resources/Pages/Tools/InterviewGuideUsing
theinterviewasasourceofdatainformationandlearning.aspx
• Remember avoid GIGO!
•
Focus Groups
–
Focus Groups or The Focus Groups Kit
• R. Krueger and MA Casey
•
Wales Story Framework
–
Sarah Puntoni
(R) J Taylor and V Crowe 64
Further Learning
•
Qualitative Journals or Articles
–
Qualitative Health Research
– http://qhr.sagepub.com/
–
Grounded Theory Review
•
http://www.groundedtheoryreview.com/
•
Crowe & Bitterman (2009)
– Unprivatizing: A bridge to learning. The Grounded Theory Review, vol.8, no.1, pp. 31-52
(R) J Taylor and V Crowe 65
Further Learning
•
Ground Theory
– http://www.groundedtheory.com/
•
Experience Based Co-design
– Paul Bates (UK )
• Vermont Oxford Network • Article
– http://eprints.ucl.ac.uk/7150/
• Example
– Luton and Dunstable Hospital
– http://www.ldh.nhs.uk/Service_Development_03.htm
•
Research and Evaluation
– Qualitative Research and Evaluation Methods
FIELDWORK ACTION ITEMS
AND CLOSING
Presented by: Sarah Bender, MSPH
Program Manager, AHA/HRET HEN
