Notable Nursing: Update December 2012 - Special Edition
Transforming a Top Concern Into Triumphs: Nurse Executives Say Support, Process Key to Patient Experience
It’s an essential topic emphasized by the recently upheld Patient Protection and Affordable Care Act (PPACA): efforts dedicated to improving the patient experience will become transparent as results from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys lead to payments that began on October 1. This fact has been on the top of nurse executives’ minds nationwide, with a recent survey showing patient experience as their highest priority. Yet, nurse leaders at Cleveland Clinic are embraced this change with efforts committed to making a difference for patients and the nurses who care for them.
“There isn’t a blanket strategy mandate for improving patient experience scores,"says K. Kelly Hancock, MSN, RN, NE-BC, Executive Chief Nursing Officer. "Rather, we’ve seen success through execution of proven strategies that we target and measure, then use in combination with different process metrics to ensure consistent application. The key is standardization and sustainment of these efforts.”
The Nursing Institute’s patient experience efforts began over four years ago in tandem with the creation of Cleveland Clinic’s Office of Patient Experience. The element of having a dedicated charge for the cause has made a crucial difference in the steps taken to address HCAHPS survey scores and beyond. “We have a very strong partnership with our colleagues in Patient Experience,” explained Hancock. “It’s because of this and our consistent efforts that nurses are transforming care at the bedside.”
While frontline staff understand that improving the patient experience is theoretically the right thing to do, Hancock states the Hospital Value-Based Purchasing Program (HVBP) is making the connection critical. The HVBP Program – a component of the PPACA -- is projected to save the government an estimated $50 billion over the next decade through incentive payments for hospitals that deliver high quality care.
To communicate the importance of the HVBP Program, the Nursing Institute uses monthly Patient Experience Forums at its main campus. Driven by both physicians and nurses, the meetings highlight HCAHPS domains that staff are struggling with and provide insight for solutions.
For example, to address the issue of staff responsiveness, nursing staff within Cleveland Clinic Taussig Cancer Institute developed a systematic approach to answering call lights. This call-light protocol, along with implementation of purposeful hourly rounding, has resulted in pain scores in the 90th percentile or higher, and call-light use reduction of 50 percent.
Success in reducing call light responsiveness time is also being seen within Lutheran Hospital’s orthopaedic unit. The unit contributes to 65 percent of the hospital’s overall patient experience scores and has improved its staff responsiveness rating from the 12th percentile to the 69th in the last year.
“For Orthopaedic’s to move their rating by 57-plus points is huge. We credit this to the unit’s manager who guides with an ‘all hands on deck’ approach,” explained Lutheran Hospital’s Chief Nursing Officer, Denise J. Minor, DNP, MSN, RN, CNS, NEA-BC. “It’s more about awareness and giving the whole unit permission to react to the patient’s needs.”
The Nursing Institute also enhanced system-wide awareness by completing "90/90 Unit Assessments." With the goal of increasing performance scores into the 90th percentile in 90 days, the specific elements addressed within each unit include: Purposeful Hourly Rounding, Daily Manager Rounding on the Units, Call Light Management, Nurse Communication, Pain Management, Medication Communication, HUSH (Quiet at Night), and Physician Communication.
“The 90/90 initiative helps us generate reports and meet with leadership to address what they do well and what needs improvement,” says Hancock.
Understanding Equals Sustainability
Hancock admitted that making progress in patient experience scores has been challenging, with typical efforts taking a minimum of six to eight months to show results. “We try not to celebrate one big jump every month, but instead focus on sustaining improvements,” she says.
To do this, Delos M. Cosgrove, MD, President and Chief Executive Officer of Cleveland Clinic, leads Hancock and approximately 100 hospital executives on monthly Executive Leadership Patient Experience Rounds at main campus. By rounding on patients and front-line staff, executive leadership listens to patients’ concerns and addresses staff’s needs.
“Patients and staff are often very candid as to what they need to improve the overall experience,” Hancock says. “By debriefing after rounding and ensuring follow-up, we make sure that not only the patients’ needs are met, but resources are provided for staff to do their job.”
Lutheran Hospital’s leadership ensures an understanding of HCAHPS and the ongoing importance the surveys play as well. “In the last year, our president, Brian Donley, MD, has been very transparent about what needs to happen by translating patient experience data and what it means to staff,” says Minor. “He takes the time to meet one-on-one with all levels of the hospital to communicate the importance of patient experience.”
“Whether through town hall meetings, staff meetings or larger educational forums, we help emphasize the importance of HCAHPS for the patient and as an organization overall,” Hancock says. “Our nurse communication scores have consistently demonstrated a very high percentile because of how they consistently support each other. I give all of the credit to our frontline staff.
Advancing Nurse Knowledge, Improving the Experience
The reality of the Affordable Care Act (ACA) is that an additional 32 million Americans will become eligible for health coverage, placing highly skilled nurses in great demand. While the Institute of Medicine's (IOM) landmark report on The Future of Nursing has called for advanced degrees to meet the increasing need, today’s “highly skilled” nurse will need more than clinical expertise to reach the ACA’s patient-centeredness care expectations.
Nursing education is focused more on clinical preparation, but there also should be an element of interpersonal skill instruction, according to Christine Szweda MS, BSN, RN, Senior Director, Nursing Education, Cleveland Clinic Nursing Institute.
“A nurse who is committed to bettering themselves is someone who is committed to the profession. The more they’re committed to the profession, the more they’re committed to the patient experience,” says Szweda. “Communication skills are essential, but we realize that these are not often innate.”
Scenarios Build Skills
Nursing Institute staff are building their communication skills through Cleveland Clinic’s Multidisciplinary Simulation Center. The 10,000-square-foot enhanced environment offers multidisciplinary scenarios with each including some form of communication training.
“In 2006, The Joint Commission identified breakdown in communication as a leading cause of sentinel events,"explains Leslie Simko MS, BSN, RN, Director of Nursing Education, Simulation. "As a result, an IOM recommendation is to establish interdisciplinary team training. This can be accomplished through simulation. All of our simulated scenarios utilize techniques that integrate protocols for patient hand-offs and interdisciplinary communications. We accomplish this by incorporating elements of knowledge sharing, closed-loop, and professional communication.”
Communication-skill development is enhanced at the Center’s monthly multidisciplinary "Mock Code." The primary participants are physician residents preparing for their ICU rotation, nurses from different practice areas, respiratory therapists, and patient care assistants. The team works together to manage a patient crisis situation.
“This environment creates communication challenges, much like working through a code in a real-life situation," Simko says. "During a patient care emergency, the nurse may be faced with working with an unfamiliar team of providers. The goal is for them to experience a crisis situation without the risk of harming a patient.”
By using formal debriefing that includes watching a video of the event, participants can observe and differentiate between effective and ineffective communication techniques. This provides an opportunity for the learner to reflect on their current communication style. Additionally, these events serve as a change agent for improved team communication, resulting in improved patient outcomes.
“Did the nurse repeat the order back to the physician? Was the order carried out and stated that it was completed in the end? This is where breaks in communication frequently occur, making a focus on closed-loop communication so important,” explains Simko. “Often, each person responding assumes the other is doing their job in a crisis. The interdisciplinary simulations reinforce the importance of clearly defining individuals' roles and responsibilities during a crisis.”
“Interestingly, when participants in the Mock Code simulation are asked what piece will be most valuable to take back with them, it is always a communication skill,” says Simko.
Reiterating Communication’s Significance
Nurses are more research savvy, but there is a need to emphasize the importance of the patient experience through ongoing communication – particularly in a difficult care situation, explains Amanda L. Corniello, MSN, RN, ACNS-BC, PCCN, Clinical Nurse Specialist, Cardiovascular and Thoracic Surgery Step-Down.
While newly hired nurses are educated on patient experience initiatives such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains during orientation, there are continual methods to emphasize its place in daily care. Through role-playing and feedback, the advanced practice nurse can help pinpoint specific communication barriers that are often overlooked.
“We’re able to bring an evidence-based approach to the bedside, supporting the importance of communication skills,” says Corniello. “This approach promotes best practice concepts and encourages nurses to include evidence-based responsiveness efforts into their practice, such as engaging the patient during bedside report and purposeful hourly rounding. In the end, patients have their needs met more proactively while increasing nurse-patient communication.”
A Foundation for Patient Experience: Nursing and Leadership Partner for Success
Building a sound foundation is always the first step that Cleveland Clinic’s Office of Patient Experience takes when it sets out to develop a successful patient-centered initiative by partnering with more than 11,000 nurses.
To proactively address the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey domains, while remaining supportive of the nurses’ role in achieving high ratings, the Office of Patient Experience focuses on three essential groups: processes, people and patients. In addition, it is the support of Cleveland Clinic leadership that enables the current progress and success.
“Our CEO Dr. Cosgrove and leaders from each of our hospitals ensure that patient experience is at the center of everything we do,” says Executive Director Mary Linda Rivera, RN, ND.
Building a Successful Foundation
“Nurses have a significant impact on all patient experience measures. Because of this, we make sure our mission stays consistent with the Nursing Institute and the challenges it faces,” says Rivera. “One of our mantras is that we can’t make any patient experience initiative feel like it is one more added task for Nursing. We try very hard to integrate our strategies into what they’re already doing.”
An example of how this objective guidance has aided the overall process is seen in how Cleveland Clinic approached the HCAHPS domain of medication communication. By partnering with the Quality & Patient Safety Institute, Rivera and her colleagues added medication education as part of the Nursing Institute’s teach-back method already in place. Through “Ask 3/Teach 3,” patients are educated and then asked the name of their medication, why they need to take it and what the possible side effects are.
“Instead of bringing forward an initiative to Nursing from Quality and a separate initiative from Patient Experience, we try to integrate as much of our efforts as possible,” Rivera says. “It’s not one more protocol – it’s how we do our work.”
While challenges for integrating patient experience into any organization can be daunting, the primary focus should always be creating a culture that tends to the patient’s needs as a whole, according to Rivera.
“You can put tons of work around expediting a process, but if you don’t have the proper culture, it’s not going to have an impact,” Rivera says. “For whatever you’re trying to improve, you have to make sure you have a service excellence based culture. Your leadership’s support and commitment should build around that and engage your patients in those solutions.”
To help establish a local culture that supports service excellence and a focus on putting patients first, the Office of Patient Experience teaches nurses to “Communicate with H.E.A.R.T.TM” through a service excellence training program that provides practical tools for all patient, family and caregiver interactions. In addition, all Cleveland Clinic caregivers have participated in “Cleveland Clinic Experience,” a half-day session that focuses on enhancing and transforming culture to improve the patient and caregiver experience.
Combined with the Nursing Institute’s professional practice model, implementing programs that teach nurses to make connections with their patients has had a substantial effect on patient satisfaction scores. Initiatives such as Purposeful Hourly Rounding helps nurses address patient concerns and requests in a timely manner, allowing nurses to manage patient care and their own time more efficiently. Cleveland Clinic has also implemented “No Pass Zones” so all caregivers can respond to a call light and quickly address patients’ needs.
“Rounding with a Purpose is another best practice that’s making an ongoing impact," explains Rivera. "While you can put in place a model that requires a nurse to round on each patient every hour, we’ve proven that it’s engaging the patient and developing a relationship each time that makes a difference.”
“Patients like to know someone is watching over them. Rounding with a Purpose not only fulfills call light requests, but also demonstrates our nurses’ availability and their commitment to building a relationship with their patients,” says Rivera.
Involved and informed patients are more likely to be satisfied with their care and have better long-term outcomes. “It is our obligation as caregivers to educate them so they feel empowered to be actively involved in their own care,” says Rivera.
To be successful with any initiative, it is necessary to have the proper combination of leadership support, a collaborative nursing partnership, an engaged patient population and proper leveraging of local culture to build on service excellence. “With the right elements in place, we can make significant improvement in the patient experience,” says Rivera.