The hospital has been using Service Alerts on the Skylight Interactive Patient System through the patient in-room TV to help in the discharge process, interpreters, housekeeping, facilities, etc.   Patients are able to submit a request to the specific departments with a turnaround time of 30 minutes or less, without calling the nurse.  The ability for the alerts to go directly to the non-clinical departments has allowed the nurse to spend more time at the bedside.

Because of the success they were seeing with the Service Alert workflow in other departments, it was only natural that they contacted me to see if I could help solve the situation with the dirty food trays.

I met with the Housekeeping Manager and we decided to add the option “I need my tray picked up” to the Housekeeping Service Alert on the Skylight System.   Either the patient or the nurse could trigger the alert.  Since Housekeeping staff was on the floors, it made sense for them to receive the alert/page and be able to quickly go into the room and remove the dirty trays rather than waiting for someone in Food Services to come back up on the floor.

Interactive Patient Systems Service Alerts have been a win/win for patient satisfaction and hospital staff productivity.

Thanks to groups like The Beryl Institute, a rapidly growing and highly engaged “cult” (and that’s “cult” in the most positive sense of the term) is galvanizing around improving the patient experience and delivering the message to the public and healthcare industry at large.  Headed by Jason Wolf, PhD and Stacy Palmer, the Institute has defined the experience as: “The sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.”

In only its 3rd year, the Beryl Institute Patient Experience Conference has doubled in size every year—this year drawing over 400 people from four continents—with a wait list of nearly 100 people.  Top-notch keynotes included Fred Lee the author of “If Disney Ran Your Hospital” and Colleen Sweeney who brought the group to their feet with her emotional and energetic session on “The Patient Empathy Project.” Throughout the 3-day event, speakers, session leaders, and attendees were highly engaged (and well fed!)  sharing stories, proven practices and new ideas.

In addition to Beryl, there are a number of events like ANCC Magnet, AONE, Planetree and others that are focusing on ways to put the patient at the center of care. One of these events is Skylight’s  Annual Client Conference being held November 14-16 here in San Diego at the Hotel del Coronado.  This conference has grown to be a focal point of the highly active Skylight community that freely shares information about how to provide the best possible patient experience while improving clinical workflow.  Learn more about Skylight’s Client Conference.

So how do you avoid the penalty?  Start by learning what’s working.  Below is a list of innovative models involving readmission processes and practices:

• Project RED (Re-Engineering Discharge)
• BOOST (Better Outcomes for Older Adults through Safe Transitions)
• The Care Transition Program® by Dr. Eric Coleman
• The Traditional Care Model by Mary Naylor

One common theme central to all these (and others) models:  Engagement.

At Skylight, using our CareNavigator™ solution, we can help hospitals and caregivers engage patients inside and outside the four walls of the hospital.  A patient, let’s call her Michelle, is admitted into the hospital and is newly diagnosed with Congestive Heart Failure (CHF).  Using the TV as an engagement tool, we begin to educate Michelle about CHF, medications, the importance of diet and exercise, and what to expect when she gets home.

Prior to going home, something else happens:  Michelle is prescribed a Care Map.  This map will help navigate Michelle and her family during the critical days and weeks that follow.  At home, Michelle and her family can log onto CareNavigator and see her discharge instructions, watch prescribed health education and information about CHF and her new medications. Reminders are sent to help her make and keep appointments and practice daily weight management.  Finally, alerts are generated based on Michelle’s feedback and interaction.  The platform can alert caregivers about growing problems related to weight gain, shortness of breath, and medications.  This in turn directs caregivers to patients like Michelle who need further engagement to help prevent a possible readmission.

CareNavigator helps you coordinate care by engaging and guiding patients so the role of self-management is transformed into patient-centered care which is at the heart of reducing readmissions.

The HRRP is not connected to the Value-Based Purchasing Program (VBP) and is unlike the budget neutral VBP (low performing hospitals lose money and high performing hospitals are able to make money). The HRRP is only punitive.  This means that the HRRP will take funding away from hospitals while simultaneously asking them to implement costly measures to lower readmission rates.  Therefore, Congress appropriated funds for the Agency for Healthcare Research and Quality (AHRQ) to develop readmission reduction “practice recommendations.”

CMS’s current definitions will cause a financial penalty as it includes readmissions that are totally unrelated to the initial discharge and over which the hospital has little or no control.  In addition, readmissions are attributed to the discharging hospital even if the patient is readmitted to a different hospital.  It is important to note that 20-40% of readmitted patients are readmitted to a different facility from where the original admission occurred, representing a significant gap in hospitals understanding the true extent of upcoming penalties.

Some believe the current (Congressionally approved) financial penalty calculation is too harsh.  The sample scenario in the graph shows the actual versus hospital-preferred penalty calculations.

Financial penalties beginning in October 2012 are based on calculated baseline readmission rates using Medicare data from July 1, 2008 to June 30, 2011.  For the first year of the program, payment reductions will be capped at a maximum of 1% of net inpatient Medicare payments. The payment reduction rates will subsequently increase by one percent each year before being capped at 3% for fiscal year 2015 and beyond.

During my rounds I came across an elderly woman that was nervous about who I was and what I was doing in her room.  She appeared to have dementia and seemed disoriented.  I asked her a few questions to try to comfort her, but she continued to appear to be nervous and anxious.  So, I asked her if she wouldn’t mind if I showed her something on the TV and she agreed.  I brought up a relaxation video of a fish tank showing various forms of colorful fish swimming through the water. She was immediately drawn to the images of the fish swimming around and said, “Oh, isn’t that pretty!”  All of the tension and nervousness that I had seen earlier was instantly gone as she became absorbed by the world inside that fish tank. We talked about the different colors and how fast one of the fish darted across the screen. As I got up to leave, I let her know I would leave the fish on the TV and she continued to be drawn to the activity on the screen.

It was a small gesture, but knowing that she found some comfort in her world of confusion was rewarding. It wasn’t just me. It wasn’t just the system. It was the combination of a person having a tool available at the right time to bring someone comfort.

As I conduct orientation sessions to new caregivers about how they can use the Skylight system, I often relay this story to them. It hits a chord with many and I believe they understand how they too can use the system, in all of its capacity, as a tool to bring an improved experience to their patients.

These transitions, from home to hospital or hospital to home, are where negative events often occur:  missed appointments, not understanding medications, improper weight management, just to name a few.  This can lead to problems like missed surgeries, unprepared patients, and readmissions.  The annual Med PAC report to Congress continues to highlight a consistent statistic:  nearly 1 in 5 patients are readmitted within 30 days.  Most of these issues are deemed preventable with the majority of problems associated with the transition from one health care setting to the next.

At Skylight, we start with one simple premise:  identify and recognize all of the steps needed to coordinate care across the various providers.  We focus on the hospital’s vital role in the acute setting but include physicians and various pre/post-acute care providers and coaches who are equally instrumental in the ultimate outcome.  By bringing together everyone who is critical in the overall coordination of care, planned or unplanned, we can better understand the workflows and steps necessary to assist patients and families.  We then develop an interactive experience that can help guide and inform patients as they step through this well-defined process.

Ultimately the role of self-management is transformed into a patient-centered partnership with Skylight’s CareNavigator being a roadmap for the patient and a tool for the caregiver.  A well managed engaged patient is an opportunity; a poorly managed disengaged patient is a liability.

Robert Bessler, CEO and founder of Sound Physicians, suggested four reasonable techniques to improve patient satisfaction scores:

• Use checklists to make sure clinical process of care measures are met and documented.
• Manage quality measures in real-time to reduce fall-outs and drive interventions while the patient is still in the hospital. For example, a hospitalist nurse can round on patients in the afternoon rather than having patients mail in surveys after the fact.
• Provide patients a brochure explaining, at admission, who their care team is, with pictures of each of the caregivers.

• Use call center follow-up to improve care coordination, intervention and data management.

All of these recommendations make sense, but how are they going to be scaled in a manageable way by a hospital that already has overloaded clinical and operational staff?   One way is to use patient management tools such as an Interactive Patient System (IPS):

• Don’t just use checklists, bake the checklists into an IPS such as Skylight’s automated process of engaging the patient before, during and after the hospital stay so that busy clinicians don’t have to remember long lists.
• Manage quality measures in real time, while patients are still in the hospital – have the hospitalist nurse round only on the patients that have indicated they have an issue, not on all of them.
• Provide patients with information in a digestible format– a short illustrative video, not an over-copied brochure that won’t be read; and show pictures of the care team on their personal electronic white board on their TV.
• Use call centers, but don’t call all the patients all the time – use a patient and diagnosis-specific, calendar-driven system like Skylight’s unique CareNavigator Ambulatory solution to guide you to patients who are more at risk for re-admission and focus your communication efforts on them

Using technology like IPS can help hospitals to put in place sustainable and scalable change to dramatically improve HCAHPS scores and patient connection across the entire continuum of care.

A Skylight client hospital here in California recently went live with Online Meal Ordering via integration with their dietary software. Skylight turned on the ability for patients to order meals through the in-room television at 10:00am. Typical with any new integration, members of Skylight’s Client Services team were onsite to train the nurses and dietary staff between 10am-2pm so they would be able to help patients order dinner that afternoon.

That morning, the Director of Nutritional and Guest Services made her rounds to a few of the patients letting them know someone would be in that afternoon to help them order dinner.  The dietary office began receiving meal orders through the Skylight system a few minutes later. As soon as patients knew they could order their meals through the TV, they navigated, on their own, to the “Order Meals” button on the Skylight main menu and placed their orders. When Skylight’s account management team arrived to train the staff, they were already giving great feedback on how intuitive the Skylight Interactive Patient System was to use.

Skylight was back onsite for a follow-up meeting two weeks later and heard the same story from various staff members who weren’t even involved in the integration – the success story had made its way around the hospital!  The nurses in the meeting were raving about what a huge patient satisfier the new feature has been! Not only do patients feel empowered but they are able to order exactly what they want, when they want it which is cutting down on food waste. Instead of the dietary office spending much of their time entering paper menu orders into a computer, they are spending more time at the bedside helping patients make the right meal choices and offering nutritional education.

“A client recently approached me to discuss their pain management program.  She had seen a Skylight competitor presentation where they recommended using their system to encourage patients to self-assess pain levels.  Their workflow is comprised of an initial alert sent to the patient about 60 minutes after pain medication administration.  The patient could respond to that alert with their pain level using the standard 0-10 scale.  The numbered response would automatically be documented into the electronic medical record.  If the patient did not respond at all, an alert would be sent to the nurse for follow up.”

As a clinical professional, I was troubled!  I asked her how she explained this blind workflow.   She admitted she could not explain it.  I further asked if she had reviewed the workflow with the Quality Outcomes department since multiple, unverified, unanswered documentations into the medical record, especially about pain management, would indicate care outside of accepted clinical standards.  And finally I asked if she had developed a policy and procedure for this and had it reviewed by hospital legal counsel.

We reviewed several possible scenarios that may occur using their proposed workflow:

• What happens to the patient who repeatedly and frequently reports high pain scores, which are now documented in the medical record and there is no clinical reassessment or worse, no intervention to mitigate the patient’s self-reported pain. Why would I want my patient disturbed after being given pain medication?  Hopefully they are resting, if not sleeping, at their target comfort level.
• Why would I want to disrupt my nursing workflow with a reminder that the patient did not respond to the post-pain med admin alert?  I should be following up with a visual bedside pain reassessment per standard of care.
• I also reminded her that practices which do not meet clinical standards of care are open to tort exposure and legal scrutiny.  Why would we want to invite that kind of clinical inspection when well documented regulatory requirements for pain management are not met?

Developing a comprehensive and coordinated pain management program can be made easier by assessing good practices.  From policies and procedures for the different types of pain, to clinician training, to assessment tools; thoughtful clinical practices can assist to provide a comprehensive approach to pain management that meets the intent of the standards and achieves positive outcomes for patients.

At most of the hospitals I’ve dealt with, changing the temperature in a patient room is a cumbersome process:  (1) the patient pushes the nurse call button, (2) the nurse responds to the call button, (3) the nurse forwards the request to the Facilities Department, and (4) Facilities actually adjusts the temperature setting for the room.  This process occurs many, many times a day; every day of the year.

Skylight recently provided patients at a hospital client in Arizona with the ability to directly adjust their room temperature through Skylight’s CareNavigator system that runs on the patient room TV.  With just a few simple clicks on the pillow speaker pendant guided by easy-to-follow graphics on the TV, the patient can adjust the room temperature up or down by 1-3 degrees.

The preliminary results during the initial 50 days were incredible.  209 patient rooms generated 76 temperature adjustments per day through the Skylight system.  During the same time period, the number of requests made the old-fashioned way (patient to nurse to Facilities) declined by more than 50%, generating a projected $10,000 annual labor savings in the Facilities Department, and freeing up precious nurse time that can be reallocated to value-added clinical activities.

The hospital also anticipates improved patient satisfaction levels, driven by both more comfortable room environments and the increased sense of empowerment felt by the patients.  Since the Skylight system is aware of all patient admissions and discharges through an interface to the hospital’s ADT system, energy costs can be reduced by turning up room temperatures in the summer and turning down room temperatures in the winter of unoccupied patient rooms.  Talk about your win-win-win!