Project: Patient Satisfaction With Pain Management

EP33g, Lean Six Sigma-Patient Satisfaction with Pain Management Presentation to Master Black Belt.
pdf
Project: Patient Satisfaction with Pain Management
Name of Green Belt(s): Donna Grochow & Maurice

Espinoza
Name of Champion: Karen Grimley & Zeev Kain, MD
Date: March 6, 2012

1
EP33g, Lean Six Sigma-Patient Satisfaction with Pain Management Presentation to Master Black Belt.pdf
DEFINE
Problem Statement
• What is the problem? Low patient satisfaction with pain management has
been identified as an organizational problem.
• How do we know it is a problem? The baseline patient satisfaction scores
aggregated at the organizational level for satisfaction with pain
management are at the 26th percentile when compared nationally.
• What data to we have on baseline performance? National comparative
data from the HCAHPS Patient Satisfaction survey is available at the
organizational and unit level. Additionally, nursing has been involved in a
multi-center research problem sponsored by the National Database of
Nursing Quality Indicators which has resulted in data regarding pain
management.
• What “pain” does it cause? (impact to patient and/or bottom line): 74%
of other benchmarked facilities receive better scores from the patient in
regards to pain management, causing the patient to perceive less than
optimal care was provided which can lead to poor satisfaction scores, poor
publically reported data, decreased reimbursement, and a potential
increase in length of stay.
2
DEFINE
Why is this important?

• Include Voice of the Customer (VOC): Patients are not
satisfied with the pain management that is provided.
• Why this, why now? (“Burning Platform”): Scores have been

low for a long time, Publically reported, Reimbursement
issues, Quality of care issues, Affects Magnet Status
• What will happen if we don’t fix this? Potential loss of

patients to other providers, Decrease revenue, Increase
length of stay, loss of magnet designation, etc.
3
DEFINE
Stakeholder Analysis-Template
Insert your Stakeholder analysis here….
Stakeholder Analysis
Stakeholder(s) Level of Influence Interest in project 2 Current Level of Support Strategy
Likert 1 - 5
Very supportive = 5 Slightly
Supportive =4 Neutral = 3 Slightly
High = 3 Medium = 2 Low = 1 Gain = 3 Neutral = 2 Loss = 1 Resistant =2 Very Resistant = 1
Name and Title could they determine project success? do they perceive a gain or loss? how supportive are they currently? how can we engage their support?
Dr. Kain 3 3 5
Karen Grimley 3 3 5
Nursing Staff 3 3 4
MD Staff 3 2 3 Educate, Support from Peers
4
DEFINE
Project Charter
Project Name: Patient Satisfaction with Pain Champion: Karen Grimley & Zeev Kain, MD
Management
Belt: Donna Grochow & Maurice Espinoza Master Black Belt: Laura Winner/Henry Alvarez
Problem Statement: Project Goal:
The current patient satisfaction scores aggregated at the organizational To improve the perceptual experience of patients with pain
level for satisfaction with pain management are at the 26th percentile when management to the 50th percentile on selected units.
compared nationally. Four units are <10th percentile. To increase the mean of the 3 Path Y statements to the benchmark
mean and/or 50th Percentile.
Project Y / Path-Y: Scope:
Project Y: Patient satisfaction scores with pain management. Limited to these areas with current satisfaction scores <10th
Path-Y: Mean percent of patients with positive response to the statement percentile: CCU, DH 32, Tower 4, & 5
“My Healthcare team involved me in the decisions about controlling my
pain”.
Path-Y: Mean percent of patients with positive response to the statement
“My nurse suggested approaches to help manage my pain”.
Path-Y: Mean percent of patients with positive response to the statement
“My nurse believed my reports about my pain”.
Team Members: Benefits:

Nursing: Physician: Improved patient pain satisfaction scores
Donna Grochow S. Liao, MD Decreased length of stay
Maurice Espinoza I. De Alba MD Improved physiological and psychological healing
Charlene Miranda-Wood Patient Relations: Decreased rate of readmission
Khaled Al Eid Carla Camarillo Decreased rate of outpatient visits
Victoria Malonzo Haley McCraney Timeline:
Van Le Pharmacy Define/Measure July-September 2011
Holly Wicklas Lan Zheng Analyze September-December 2011
Dan Bernsein Improve/Control January-March 2012
5
SIPOC
DEFINE 6
DEFINE
Early Waste Identification DOMOWIT

• Defects:
– Lack of communication between MD & RN regarding pain plan of care
– Lack of communication between RN & aide regarding pain plan of care
– Lack of communication between RN & patient regarding pain plan of care
– Lack of communication between aide & patient regarding pain plan of care
– Lack of communication between MD & patient regarding pain plan of care
• Over-processing
– RN often has to page and/or call MD multiple times for pain medication orders
– Patient often unaware of when pain medication is available and has to repeatedly ask nurse
• Motion
– RN or aide has to answer patient’s call light to answer question about when next pain medication is due
• Over-production:
• Waiting
– Adequate/correct pain medication not given timely, patient has to request pain medication
• Inventory
• Transportation
7
DEFINE
Voice of Customer
Patients
Nursing
Physicians
Pharmacists
8
DEFINE
Voice of Customer
• What We Currently Have Available:
– Patient Satisfaction Data (HCAHPS)
– National Database of Nursing Quality Indicators (NDNQI):
• Participated in research study to identify issues with pain management
• All eligible medical-surgical patients were surveyed on 1 day in April 2011.
• Baseline data available for review
• Repeat survey pending in November
• Next Steps:
– Interview patients 1 day per week x 3 weeks using pre-designed
survey tool
– Focus groups with key stakeholders: MDs, nurses, pharmacist, etc.
9
DEFINE
Voice of Customer (VOC): Patient
23 English speaking patients interviewed on DH32, 4T, 5T & MICU
The following lists the questions that the patients were asked to answer along with the
responses.
Questions # of Yes Responses %

1. Did you expect you would have pain while in the hospital? 18 78%
2. When the staff came into your room, did they ask about your
pain often enough? 20 87%
3. Do you understand the pain scale? 23 100%
4. Are you comfortable talking about our pain with the staff? 23 100%
5. Does the staff inform you of the plan to manage your pain
so you understand? 18 78%
6. When you were in pain, did the staff act as fast as you expected? 19 83%
7. Do you believe the staff do everything they can to manage your pain? 18 78%
8. Do you notice any difference in your pain management day to day? 6 26%
→ 22% of the patients did not expect to have pain.

→ 22% of the patients were not informed about plan to manage pain
→ 26% of the patients noticed differences in the management of pain from day to day
paste
10
DEFINE
Voice of Customer (VOC): Patient
23 speaking patients interviewed on DH32, 4T, 5T & MICU
The following lists the questions that the patients were asked to answer along with the
responses.
Questions UC Mean Benchmark 50th Percentile

1. My nurse believed my report of pain 5.61 5.68
2. I had pain medication available when I needed it. 5.41 5.56
3. My nurse suggested approaches to manage my pain. 3.73 3.67
4. My nurse discussed side effects of pain meds with me 3.54 3.63
5. The pain medications worked well to control my pain 4.89 5
6. My healthcare team involved me in decisions about
pain control 4.8 4.94
7. Patients constantly experiencing pain in the past 2 hours 14.6 4.17
8. % of relief from pain treatments or medication provided 68.62 70
→ Our scores were < 50th percentile in almost all categories
paste
11
DEFINE
Voice of Customer (VOC): RN
Focus groups were held with staff from DH32, 4T, 5T & MICU. The focus group consisted of a written survey and verbal
roundtable discussion
The following themes affecting pain management were identified from the focus groups:
Themes
1. Communication
2. Knowledge/Education
3. Process
3. Patient Condition
4. Influence of Supervisors
5. Equipment
6. Complementary Therapy
paste
12
DEFINE
Voice of Customer (VOC): RN
Focus groups were held with staff from DH32, 4T, 5T & MICU. The focus group consisted of a written survey and verbal
roundtable discussion
The following themes affecting pain management were identified from the focus groups:
120 100
100 80
80
Percent
60
60
40
40
20 20
0 0
n n ss n rs t py
ti o tio c e itio ir o en r a
nic a uca
Pr
o
o nd pe ip
m
he
u Ed C u u T
m nt fS Eq ry
m e/ e o ta
Co
g ti ce en
l ed Pa n m
e i
now flu pl
K In m
Co
paste
13
MEASURE
Baseline Process Map
14
MEASURE
Baseline Data for Y-Template

Describe how baseline data was obtained…
•Baseline data from HCAHPS Composite.
Patient Satisfaction with Pain Managment

60
50
40
30 UC Irvine Percentile
HCAHPS 50th Percentile
20
10
0
Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11
15
MEASURE
Baseline Data for Path Y
Interventions Implemented February 21,2012

16
MEASURE
Baseline Data for Y-Template

Describe how baseline data was obtained…
•Baseline data from HCAHPS Composite.
17
MEASURE
Measure
Results from Brainstorming on ALL potential X’s …
18
MEASURE
Filter X’s FMEA

Filtering of X’s to vital few…
19
MEASURE
Filter X’s
20
MEASURE
Filter X’s
21
ANALYZE
Analyze
Which X’s are key?
5 Whys
Cause & Effect Analysis
22
ANALYZE
Cause & Effect Summary

• Multiple Inputs were originally identified in the SIPOC
• Common themes were identified via surveys and focus groups
• These were then rated within categories

– Patient Satisfaction with Pain Management
– RN Role in Pain Management
– MD Role in Pain Management
• The C & E methodology identified the top Inputs/themes with

scores as seen in the next slide
• The top ranked Inputs/themes guided the work for the

Improve phase
paste
23
Cause & Effect

ANALYZE
paste
24
Cause & Effect

ANALYZE
paste
25
ANALYZE
Analyze: 5 Whys of Pain
26
ANALYZE
Analyze: 5 Whys
27
ANALYZE
Analyze: 5 Whys
28
ANALYZE
Analyze: VOC-Nursing
Pareto Chart of C2
120 100
100 80
80
Percent
60
C3
60
40
40
20 20
0 0
C2 n n ss n rs t y
ti o tio ce itio r io en ap
ic a uc
a o nd e m er
un d Pr o up uip Th
m /E ntC f S Eq r y
m ge tie e
o ta
Co l ed Pa nc en
e im
ow flu pl
Kn In om
C
C3 47 29 28 8 4 3 2
Percent 38.8 24.0 23.1 6.6 3.3 2.5 1.7
Cum % 38.8 62.8 86.0 92.6 95.9 98.3 100.0
29
IMPROVE
Ease v. Impact
Based on key X’s identified, what improvements
were identified?
10 Pain Scale Poster

Perception of Pain Managment
Impact of Change on Patient
9 Pain Goal & Medication Poster
8 Huddle Education
7
Quick Education Sheet Campaign
6
Pain Score Dashboards
5
Pain Score Reports to MD
4
MD Pain Management Education
3
2 Communication Reminders to MD
1 Require Pain Consult for Chronic Pain

Patients
0 Pain Free Campaign-Lounges,
Workroom & Intranet
0 1 2 3 4 5 6 7 8 9 10
Improve Pain Resource Website Visibility
Ease of Implementation
30
IMPROVE
Interventions
What X’s were selected for modification?
Communication
Education
What are the Interventions and the key X’s they address?
Improved Communication:
Pain Scale Poster
Pain Goal & Medication Poster
Poster Campaign-Lounges & Workroom (Potentially)
Improve Pain Resource Website Visibility (Potentially)
Nursing Education
Huddle Education
Quick Education Sheet Developed
Pain Score Dashboards
MD Education
Pain Score Reports to MD
Communication Reminders to MD
Pilot interventions and collect data…
31
IMPROVE
Visual Pain Tools in Every Patient Room
32
IMPROVE
Ongoing Education-Example
33
CONTROL
Control Plan
→ Control Plan to keep Improvements in place

→ Reaction plan/feedback mechanism
34
CONTROL
Control Plan
→ Control Plan to keep Improvements in place

→ Reaction plan/feedback mechanism
35
Pain Management Scores-Prior to Improve Phase

4T 5T
CCU DH 32
CONTROL
36
Pain Management Scores-Prior to Improve Phase

CONTROL
37
→ Right after key interventions implemented, Audit Results CONTROL
Is the pain tool in the room?

120
112
100
80
60
40
20
1 0
0
Yes No No Answer
→ Visual Pain Tool is present in room
→ DC % steady with both improvement in median order time & discharge leadtime
38
Is the staff RN utilizing the tool?

90
80 77
70
60
50
40
30
30
20
10 6
0
Yes No No Answer
→ Visual Pain Tool is being used by 68% of RNs
→ Education regarding tool was provided
39
Can the patient see the tool?

120
109
100
80
60
40
20
4
0
0
Yes No No Answer
→ Visual Pain Tool is visible to 96% of patients
40
Does the patient understand the tool?

100
93
90
80
70
60
50
40
30
18
20
10
2
0
Yes No No Answer
→ 82% of patients understand the tool
41
Does the patient like the tool?

100
90 88
80
70
60
50
40
30
20 16
9
10
0
Yes No No Answer
→ 78% of patients like the tool
42
Is the pain tool helping you and your nurse manage

your pain effectively?
80
72
70
60
50
40
30 26
20 15
10
0
Yes No No Answer
→ 64% of patients think pain tool is helping team to effectively manage pain
43
Opportunity for Spread

• Could other areas of the organization benefit
from a similar improvement effort?
Plan is to disseminate interventions to entire
organization once pilot is completed and any
needed changes are finalized.
44

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EP33g, Lean Six Sigma-Patient Satisfaction with Pain Management Presentation to Master Black Belt.

Project: Patient Satisfaction with Pain Management

Name of Green Belt(s): Donna Grochow & Maurice

Name of Champion: Karen Grimley & Zeev Kain, MD

Date: March 6, 2012

Why is this important?

• Why this, why now? (“Burning Platform”): Scores have been

• What will happen if we don’t fix this? Potential loss of

Team Members: Benefits:

Early Waste Identification DOMOWIT

Questions # of Yes Responses %

→ 22% of the patients did not expect to have pain.

Questions UC Mean Benchmark 50th Percentile

→ Our scores were < 50th percentile in almost all categories

Baseline Process Map

Baseline Data for Y-Template

Patient Satisfaction with Pain Managment

Interventions Implemented February 21,2012

Baseline Data for Y-Template

Filter X’s FMEA

Cause & Effect Summary

• These were then rated within categories

• The C & E methodology identified the top Inputs/themes with

• The top ranked Inputs/themes guided the work for the

Cause & Effect

Cause & Effect

Analyze: 5 Whys of Pain

10 Pain Scale Poster

9 Pain Goal & Medication Poster

1 Require Pain Consult for Chronic Pain

Visual Pain Tools in Every Patient Room

→ Control Plan to keep Improvements in place

→ Control Plan to keep Improvements in place

Pain Management Scores-Prior to Improve Phase

Pain Management Scores-Prior to Improve Phase

→ Right after key interventions implemented, Audit Results CONTROL

Is the pain tool in the room?

→ Visual Pain Tool is present in room

→ Right after key interventions implemented, Audit Results CONTROL

Is the staff RN utilizing the tool?

→ Visual Pain Tool is being used by 68% of RNs

→ Education regarding tool was provided

→ Right after key interventions implemented, Audit Results CONTROL

Can the patient see the tool?

→ Visual Pain Tool is visible to 96% of patients

→ Right after key interventions implemented, Audit Results CONTROL

Does the patient understand the tool?

→ 82% of patients understand the tool

→ Education regarding tool was provided

→ Right after key interventions implemented, Audit Results CONTROL

Does the patient like the tool?

→ 78% of patients like the tool

→ Right after key interventions implemented, Audit Results CONTROL

Is the pain tool helping you and your nurse manage

→ Education regarding tool was provided

Opportunity for Spread

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