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Time to Put Patients First

Gienna Shaw, for HealthLeaders Magazine, May 12, 2010
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How America's hospitals have lost touch with their top priority—and what healthcare leaders are doing to fix it.

At the core, healthcare has just one mission: caring for patients. And yet it still fails them along the entire spectrum of care. Americans can't understand why they must wait months for an appointment with a specialist. They continually hear horror stories about wrong-site surgeries and hospital-acquired infections. They have trouble getting their physicians, specialists, and alternative providers to talk to each other—let alone communicate effectively with them. And then they get a bill for it all that they can't understand.

While no universal fix has been found to address these and other challenges, some healthcare industry innovators are leading change.

They're putting in place programs and strategies to truly put the patient at the center of everything they do. They are making renewed efforts to move patient care to the bedside, coordinating healthcare among disparate providers, and changing how they hire and deploy staff. In the process, they've improved quality, outcomes, and patient safety. They've reduced length of stay, improved accessibility, reputation, profitability, and volume. And they've begun to address the seemingly never-ending list of complaints that the public has about the U.S. healthcare system.

The academic medical center: Calling all executives
Healthcare is a team sport that includes the patient and his or her family, says David T. Feinberg, MD, CEO of the UCLA Hospital System. You can't have good outcomes without engaging patients, without helping them to be compliant. Patient-centered care is not about high thread-count sheets, private rooms, spectacular views, or room service-style meals, he says. Patient-centered care is safe, compassionate care delivered with the highest quality and level of patient safety.

"Patient-centered care means care that I would want for myself and my family. To me, that's the ultimate standard," he says. "We put the patient in the center of everything we do."

UCLA employs a number of tactics to achieve patient-centeredness. For example, electronic boards on each floor show real-time data, including falls and that day's patient satisfaction scores. Every floor conducts Ritz-Carlton-style team huddles—three minutes during which the team communicates what they will be doing that day. The staff helps develop programs, too. One example: Staff and clinicians wear color-coded uniforms to help patients identify the role of anyone who enters their room.

Feinberg is also a big believer in rounding. He gives patients his card and tells them they can call him 24 hours a day, seven days a week. "I'm here to help you," he tells them. "You don't need another number at UCLA." Feinberg says at one time about a third of the executives and managers thought the approach was crazy, another third were on the fence, and the rest found it inspirational. Today, everyone is aligned with the UCLA philosophy. Although he doesn't mandate that other executives follow suit, the idea is catching on. Now, when Feinberg walks into a room, he often sees five business cards on the bedside table. "The department chairs race to the bedside if there's a complaint," he says.

Once, Feinberg says, he got a call in the middle of the night from a gang member the hospital treated for a gunshot wound that left him paralyzed. He couldn't pay the $11 to get his car out of the parking lot. Feinberg spoke to the parking supervisor and had the charge posted to his office so the man could get home. Another call came from a family member who was unhappy with a loved one's care.

"The next day we set up a multidisciplinary meeting to discuss the diagnosis and treatment plan. At the meeting were all the caregivers and all the family members," he says. He also often gets calls or e-mails from patients who can't understand their bills or think they found a mistake. He forwards those to finance, he says, but follows up and stays involved until the problem is resolved.

The nationwide network: Care without compromise
Lillee Gelinas, RN, MSN, FAAN, vice president and chief nursing officer at the Irving, TX-based VHA, Inc., says the concept of patient-centered care is misunderstood. "I believe that today the term 'patient experience' is confused with patient-centered care in a very big way," she says.

The patient experience is an embodiment of all of the issues that touch a patient in the hospital, such as the care and treatment of patients and their families and the environment, she says. But patient-centered care is much more than that. "If patient-centered care is what we do, then patient experience is the outcome."

Part of the reason hospitals devote resources to patient experience, she says, is that the government (HHS) is measuring it with HCAHPS, the Hospital Consumer Assessment of Healthcare Providers and Systems survey. That "drives us down a path where we have blinders on," Gelinas says. "Patient-centered care or patient-focused care . . . is married with patient experience, and we're spending time on patient experience because that's where we're going to get paid."

Unfortunately, HCAHPS asks a "very narrow" set of questions, she says. And patient experience is not necessarily a reflection of outstanding clinical intervention.

"At the end of the day, the demands of the consumer are going to trump everything," she says. Patients will demand and payers will reimburse for efficient and effective care.

"Many outcomes mirror an organization's culture. And moving to a healthy culture that includes the culture of safety and a culture of patient-centeredness has to be a precondition for an organization, not a priority," she says. "A priority can be budgeted out. A priority can, at the end of the day, fall to the cutting floor because of budget cuts. A precondition is a core value."

Nurses must have the time to deliver patient-centered, high-quality care, Gelinas says. That means getting nurses back to the bedside and spending more time on direct care, doing the lifesaving work that nurses were trained to do and that patients expect nurses to do. "If you don't have time at the bedside to drive the emotional connection, then we're not really driving patient-centered care." And that, in turn, will lead to better patient satisfaction scores. "If I'm not at the bedside, if I am not in a position of trust with you, why would I expect you to answer a survey that you had an outstanding patient experience?"

One of the tactics VHA is using at some of its 1,400 not-for-profit member hospitals is called the "RetuRN to Care" initiative. "We're trying to put FRED to bed," she says. "That's 'frantically running every day.'" Gelinas says nurses spend too much time on non-value-added tasks, such as "hunting and gathering" equipment, supplies, and pharmaceuticals, when they should be at the patient's bedside.

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