The Antidote to Suffering How Compassionate Connected Care

The Antidote to Suffering: How Compassionate Connected Care Improves Safety, Quality, and Experience Christy Dempsey Chief Nursing Officer

Advancing the Industry Toward Transformation © 2018 Press Ganey Associates, Inc.

The Book • An Epidemic of Suffering • The Roots of Suffering • Quantifying Suffering • Compassionate Connected Care ™ • The Compassionate Connected Caregiver • Compassionate Connected Teams • The Compassionate Connected Organization • A Compassionate Connected Industry 3 © 2018 Press Ganey Associates, Inc.

A 360 Degree Perspective

A 360 Degree Perspective 5 © 2018 Press Ganey Associates, Inc.

A 360 Degree Perspective 6 © 2018 Press Ganey Associates, Inc.

A 360 Degree Perspective 7 © 2018 Press Ganey Associates, Inc.

The Roots of Suffering

Suffering is Inherent and Avoidable 9 © 2018 Press Ganey Associates, Inc.

What Do Patients Really Value? Confidence in the skill of the provider All Patients 15. 7% Recommendation Failure Rate 19% of patients Low: Confidence in Provider 74. 6% Fail to Recommend 14% of patients 81% of patients High: Confidence in Provider 1. 9% Fail to Recommend 5% of patients 8% of patients 72% of patients Team work Listening and Concern Low: Worked Together 90% Fail to Recommend 11. 4% of patients Low: Courtesy 92. 8% Fail High: Worked Together 28% Fail to Recommend 2. 5% of patients 0. 8% of patients 3. 4% of patients High: Courtesy 78. 2% Fail Low: Listens Carefully 45. 7% Fail High: Listens Carefully 24. 7% Fail Low: Worked Together 11% Fail to Recommend 2. 4% of patients Low: Concern for Worries 22. 3% Fail High Risk 5. 9% of patients High: Concern for Worries 6. 3% Fail High: Worked Together 1% Fail to Recommend 3% of patients Low: Concern for Worries 5. 6% Fail 68. 4% of patients High: Concern for Worries 0. 6% Fail Low Risk 10 © 2018 Press Ganey Associates, Inc.

Drivers of Likelihood to Recommend - Inpatient Teamwork S AFCourtesy Nurse ETY Room Cleanliness 11 © 2018 Press Ganey Associates, Inc.

What is Correlated with Likelihood to Recommend? 12 © 2018 Press Ganey Associates, Inc.

Higher Patient Experience Reliability Scores Link to Higher Quality (quintiles of performance) 13 © 2018 Press Ganey Associates, Inc.

Compassionate Connected Care™

Compassionate Connected Care ™ Empathy Courtesy Inform Personalize Privacy Caring Behaviors Choice Service Recovery Discharge Prep Clinical Skill Pain Control Environment Clinical Operational Excellence Efficiency Culture Wait Amenities Teamwork 15 © 2018 Press Ganey Associates, Inc.

Compassionate Connected Care ™ Themes ▪ Acknowledge Suffering We should acknowledge that our patients are suffering, and show them that we understand. ▪ Body Language Matters Non-verbal communication skills are as important as the words we use. ▪ Anxiety is Suffering Anxiety and uncertainty are negative outcomes that must be addressed. ▪ Coordinate Care We should show patients that their care is coordinated and continuous, and that “we” are always there for them. ▪ Autonomy Reduces Suffering Autonomy helps preserve dignity for patients ▪ Caring Transcends Diagnosis Real caring goes beyond delivery of medical interventions to the patient 16 © 2018 Press Ganey Associates, Inc.

Harm Job Role What Stress & Harm Do Providers Cope With? • • • • • Stress of clinical role - complexity, high stakes activities Sympathy overload - secondary traumatic stress of witnessing suffering Emotional labor of caregiving role Emotional labor of employee demands Stress of interruptions, multitasking and task switching Stress of pace of change in organization and larger industry Lack of education/support to prevent/address compassion fatigue Moral distress arising from inability to provide level of quality desired Lack of appreciation Lack of resources Communication break downs, lack of needed information Lack of trust in leadership Lack of respect Emotional abuse (bullying, humiliating, demeaning behaviors) Back or musculoskeletal injuries Unprotected exposure to blood-borne pathogens Physical violence Lack of safe refuge to report physical and psychological harm 17 Inherent Avoidable © 2018 Press Ganey Associates, Inc.

The Burden of Emotional Labor ▪ Emotional labor or ‘emotion work’ is an element of job that requires an employee to display required emotions toward customers or others. ▪ Creates an emotional cost embedded in the role. ▪ Requirement to not display (turn off) an emotion you are feeling – Stress, surprise, disgust, fear, uncertainty, sadness, grief ▪ Requirement to display an emotion you are not feeling – Deference, optimism, assurance, compassion ▪ Much of clinician training requires the turning off of felt emotions and then we compound that emotional work by asking to simultaneously turn on the positive emotional displays. 18 © 2018 Press Ganey Associates, Inc.

The Process of Emotional Labor ▪ Emotional labor or ‘emotion work’ is an element of job that requires an employee to display required emotions toward customers or others. ▪ Surface Acting - the process of displaying behaviors that would be congruent with the required emotion. – Associated with burnout ▪ Deep Acting - the process of creating an internal emotional state that is congruent with the required action. 19 © 2018 Press Ganey Associates, Inc.

Qualitative Interviews: Key Themes Unwavering focus on high quality, safe care Support huddles to improve communication and teamwork Create a culture of respect Leverage data and evidence to support decisions and practice Promote inter-professional rounds and team-building Utilize safe and appropriate staffing 20 © 2018 Press Ganey Associates, Inc.

Staffing and Work Environment

Staffing vs. Work Environment Total Staffing HPPD > 8 Hrs No Meal Break Intent to Remain Status of Nursing Job Satisfaction . 370** -. 193** . 784** . 763** Quality in General . 354** -. 229** . 682** . 779** Rate Hospital 0 -10 . 261** -. 218** . 330** . 678** Nurses Listen . 190** N. S. . 342** . 634** Prompt Response . 199** -. 158** . 392** . 609** Unassisted Falls -. 202** . 170** -. 248** -. 558** CLABSI -. 168** N. S. -. 142** -. 383** HAPU II -. 189** N. S. -. 202** -. 500** RN Perception Patient Experience Patient Outcomes 22 © 2018 Press Ganey Associates, Inc.

Patient Likelihood to Recommend (For Treatment) Mean Score Patient Loyalty and Nurse Loyalty Are in Sync Patient Likelihood to Recommend vs RN Likelihood to Recommend R 2 = 0, 2548 100 95 90 85 80 75 3, 7 3, 9 4, 1 4, 3 4, 5 4, 7 4, 9 5, 1 RN Likelihood to Recommend (For Employment) Mean Score 23 5, 5 © 2018 Press Ganey Associates, Inc.

Nurse Job Enjoyment Is Related to Patient Loyalty 99 Patient Likelihood to Recommend vs RN Job 30 percentile Enjoyment th Patient Likelihood to Recommend Mean Sore (the cliff) 94 Above 25 th Percentile for. . . 89 84 Higher Job Enjoyment Levels Low Job Enjoyment Levels 0 -9 10 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89 90 - 99 RN Job Enjoyment Score - Percentiles 24 © 2018 Press Ganey Associates, Inc.

The Impact of Staffing and Work Environment Fall Rate by Quartile of Work Environment Fall Rate 2. 65 Work Environment 25 © 2018 Press Ganey Associates, Inc.

Pressure Ulcer Rate The Impact of Staffing and Work Environment 1. 64 Work Environment 26 © 2018 Press Ganey Associates, Inc.

Safety and Surveillance

Safety and Job Enjoyment 4, 8 4, 57 4, 6 4, 4 4, 28 4, 25 4, 2 3, 94 4, 0 4, 14 4, 05 4, 00 3, 8 3, 6 3, 59 3, 4 3, 2 3, 0 1 2 3 Safety 4 Surveillance 28 © 2018 Press Ganey Associates, Inc.

Safety and Intent to Stay 94, 0 88, 59 89, 0 83, 75 84, 0 79, 87 81, 10 80, 13 83, 50 82, 01 79, 0 74, 01 69, 0 64, 0 1 2 3 Safety 4 Surveillance 29 © 2018 Press Ganey Associates, Inc.

Safety and Meaningful Work Meaningful Contribution 4, 3 4, 22 4, 1 4, 05 4, 04 4, 0 3, 86 3, 97 3, 93 3, 90 3, 8 3, 7 3, 66 3, 5 3, 4 3, 3 1 2 3 Safety 4 Surveillance 30 © 2018 Press Ganey Associates, Inc.

Safety and Clinical Outcomes Pressure Ulcers Fall Rate 1, 7 1, 6 1, 9 1, 54 1, 51 1, 9 1, 86 1, 84 1, 5 1, 40 1, 38 1, 4 1, 8 1, 30 1, 3 1, 78 1, 76 1, 8 1, 2 1, 71 1, 19 1, 14 1, 7 1, 1 1, 65 1, 7 1, 62 1, 0 1, 6 0, 9 0, 8 1 2 Safety 3 1, 6 4 Surveillance 1 2 Safety 31 3 4 Surveillance © 2018 Press Ganey Associates, Inc.

Nurse Perceptions of Surveillance Capacity and RN Safety, and Patient Overall Ratings of the Hospital Overall Rating of Care Given At Hospital 92 91, 72 91, 5 91, 13 91 90, 5 90 89, 5 90, 81 90, 45 91, 43 91, 04 90, 78 90, 11 1 2 3 Safety 4 Surveillance 32 © 2018 Press Ganey Associates, Inc.

Safety, Surveillance, and Star Rating 3, 2 3, 11 3, 1 3 2, 91 2, 9 2, 78 2, 91 2, 86 2, 83 2, 79 2, 7 2, 6 2, 5 2, 4 1 2 3 Safety 4 Surveillance 33 © 2018 Press Ganey Associates, Inc.

Resilience

Resilience as a Mechanism to Move Your Tipping Point Resilience Capacity to Cope Engagement Burnout 35 © 2018 Press Ganey Associates, Inc.

Resilience • Does not mean that you are ‘good enough’ • Does not mean that you are ‘cut out for this’ • Does means you are persevering in an environment tipped toward overwhelming stress • Resilience is not the same as Engagement • Primary goal: prevent burnout & promote engagement • Secondary goal: promote resilience 36 © 2018 Press Ganey Associates, Inc.

Visualizing Resilience Activation Decompression 37 © 2018 Press Ganey Associates, Inc.

Resilience Key Drivers

Takeaways: Key Drivers Overall Managers Non-Managers Activation Decompression Alignment and pride: "I like the work I do. " Work-life balance: Personal perception of stress and organization’s respect of stress levels. Organizational infrastructure: Resource availability, Pride in the organization or teamwork, job security/compensation. Pride in own work and personal performance. 39 Manager relationships: Feeling heard, getting meaningful feedback, assigned clear tasks. © 2018 Press Ganey Associates, Inc.

Takeaways: Key Drivers by Generation(s) Activation Decompression Overall Alignment and pride: "I like the work I do. " Work-life balance: Personal perception of stress and organization’s respect of stress levels. Baby Boomers Pride in quality of care Ability to do my job – resources, staffing, respect Generation X Pride in organizational values other than “quality”: safety, diversity, and community contribution Manager/Organizational Relationship: Clear tasks, feeling heard, and having ideas considered. Millennials or Generation Y Clear assignments combined with meaningful tasks Clear assignments combined with respect 40 © 2018 Press Ganey Associates, Inc.

How Caregivers Experience Care 41 © 2018 Press Ganey Associates, Inc.

Compassionate Connected Care ™ for the Care. Giver ▪ We should acknowledge the complexity and gravity of the work provided by caregivers ▪ It is the responsibility of management to provide support in the form of material, human, and emotional resources ▪ Teamwork is a vital component for success ▪ Empathy and trust must be fostered and modeled ▪ Caregivers' perception of a positive work/life balance reduces compassion fatigue ▪ Communication at all levels is foundational 42 © 2018 Press Ganey Associates, Inc.

The Institute of Medicine ▪ The IOM charges us all to achieve these competencies: • Provide patient centered care • Work in interdisciplinary teams • Employ evidence based practice • Apply quality improvement • Utilize informatics 43 © 2018 Press Ganey Associates, Inc.

Caregiver Best Practices ▪ 56 Seconds ▪ Round With Connection ▪ Narrate Care ▪ Offer Choice ▪ Talk About Pain ▪ Consistency ▪ Critical Thinking 44 © 2018 Press Ganey Associates, Inc.

Impact of Hourly Rounding on HCAHPS Domains National Database – Q 3 2018 § When patients are Rounded on Hourly, hospitals’ Top Box scores are higher across all HCAHPS domains. § Nationally, for Q 3 2018, Hourly Rounding had the greatest impact on “Communication About Pain“ and “Rate Hospital 010. ” Top Box by Received Date, n=78, 341 45 © 2018 Press Ganey Associates, Inc.

Impact of Bedside Shift Report on HCAHPS Domains National Database – Q 3 2018 46 § When patients participate in a Bedside Shift Report, hospitals’ Top Box scores are higher across all HCAHPS domains. § Nationally, for Q 3 2018, Bedside Shift Reports had the greatest impact on “Communication About Pain“ and “Communication Top Box by Received Date, n=40, 057 About Meds. ” © 2018 Press Ganey Associates, Inc.

Impact of Nurse Leader Rounding on HCAHPS Domains National Database – Q 3 2018 § When patients are Visited by Nursing Leadership, hospitals’ Top Box scores are higher across all HCAHPS domains. § Nationally, for Q 3 2018, Visited by Nursing Leadership had the greatest impact on “Rate Hospital 0 -10“ and “Recommend the Hospital. ” Top Box by Received Date, n=155, 841 47 © 2018 Press Ganey Associates, Inc.

When Best Practices are Consistent, Exemplary Results are Realized 84 74 61 57 49 s on e rg s iti ns Tr a ed m HR/L R ct or Co 12 re Qu Co Re 16 1 1 ie t ne ss in es s Cl ea nl tio un ica 1 : M 11 m m sp on siv ica un m m Co e rs Nu 16 12 n en es s tio d en m co Re Actu al Non e HR 34 16 12 60 46 28 13 m Ra sp Ho 6 57 54 Do 1 te 1 n 9 66 Ca 34 56 78 re 58 78 72 m 65 74 98 94 90 sc ha 89 99 97 93 in 85 94 Di 9799 96 92 Pa 96 48 © 2018 Press Ganey Associates, Inc.

Leadership • Personally affirming a culture of excellence • Focus on quality and safety • Identify and address performance issues • Perceive that excellence in service quality, and safety is a strategic advantage • Passion for quality, safety, and service • Authentic and hands on style 49 © 2018 Press Ganey Associates, Inc.

High Reliability = Consistency Is Key!! 50 © 2018 Press Ganey Associates, Inc.

Before You Go Been There. Done That. Nothing New. Heard It Before. BUT…… Are You Actually DOING It? Knowing what to do Tactics Strategy Culture Connection Consistent Application 100% of the people 100% of the time 51 Optimal Experience & Engagement Scores Lower turnover Loyalty Higher Reimbursement © 2018 Press Ganey Associates, Inc.

Why It’s Important

You Will Never Know…. How Important You Are 53 © 2018 Press Ganey Associates, Inc.

Thank You! Christy Dempsey, MSN MBA RN CNOR CENP FAAN SVP, Chief Nursing Officer cdempsey@pressganey. com