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Improving the Patient Experience

 |  By cclark@healthleadersmedia.com  
   September 13, 2011

At Lehigh Valley Health Network’s two hospitals, teams are trying to improve patient experience scores, especially for one metric that for them seems the toughest: reducing noise levels around patients’ rooms.

“We’re the largest trauma center in Pennsylvania, with four helicopters coming in and out, and it’s pretty hard to overcome that,” says Anthony J. Ardire, MD, Lehigh’s senior vice president for quality and patient safety. “I don’t want to rationalize our scores, but that’s the reality.”

Lehigh, 60 miles northwest of Philadelphia, has replaced metal plates in the doors that banged whenever they opened or closed, stopped playing the Brahms’ “Lullaby” whenever a new baby was born at night, no longer uses the overhead pager to request wheelchairs be returned to the ED, and stopped 5-minute alerts when a trauma patient was incoming. Nurses now distribute earplugs so patients can get a better night’s sleep.

Teams also make sure patients realize the hospital’s trauma status translates to high-quality services in many specialty areas, so patients will even appreciate the helicopters’ noise.

Since taking those and many other steps, “We’ve moved our scores up some, and we’re closer to the national average,” Ardire says. “In fact, Lehigh improved its noise scores by 24% in both facilities from the second quarter to the third quarter.”

There’s a lot of money at stake. 

The Patient Protection and Affordable Care Act requires that Medicare reduce FY 2013 payments for about 3,500 acute care hospitals by 1% of their diagnosis-related group amounts, or about $850 million. They can earn that money back and more, however, if their scores exceed those of their competitors.

For Lehigh Valley’s 950-bed system, the amount of potential loss translates to about $2 million.  

Resolving the noise issue, however, isn’t the only thing Lehigh is doing to get its scores up. The system is conducting training sessions for every one of its 9,500 employees—from groundskeepers to physicians and even vendors—using the AIDET tool (Acknowledge, Introduce, Duration, Explanation, and Thank You) on patient interaction, developed by the Studer Group.

“This is a team thing; we’re all in this together,” Ardire says.

Seven hundred miles west in Grand Rapids, MI, Kris White is coping with challenges at Spectrum Health, where she is vice president for innovation and patient affairs for the nine-hospital, 1,370-bed system. But White insists that unlike many other hospitals trying to improve patient experience, Spectrum “is not designing a strategy for HCAHPS. We’re just not going to do that.

“Our intent as an organization, our strategic priority, is to create an experience for fully engaged, informed consumers who are our partners, and HCAHPS is only one indicator of that experience.”

Rather than “teaching to the specific question,” Spectrum is aiming for a change in its entire system’s culture. “If you’re hearing me say ‘Go out and try harder and smile more,’ that’s the opposite of what we’re actually doing. In fact, I say, ‘This is not about being nice.’”

What Spectrum is trying to create “is an environment in which patients feel they can speak up and share their fears and concerns and worries,” White says.

Every employee is expected to think of his or her job in terms of how it actually impacts each patient’s stay. One day, White invited 1,000 of the system’s workers to a leadership event to hear a trauma patient talk about the care he received when he was airlifted to the hospital. First, the patient acknowledged the doctors on the flight.

On a board behind the patient, White displayed a list of all the employees—the mechanics, the dispatchers, others—who made that airlift happen safely.

Each time the trauma patient described another aspect about his care, even how much he enjoyed a Popsicle, the backdrop displayed the names of all the people who made that part of his hospitalization possible.

In fact, being nice is part of the formula, but it’s a byproduct of culture change, not the focus of it, White says.

To illustrate this, she talks about an employee named Michael, an attendant in the hospital’s parking lot booth.

“We’d received five or six letters from people complaining how rude he was. So I went out there and asked if he was aware of this. He said, ‘Yeah, what do you want me to do about it? I spend 10 seconds with these people.’

“I said, ‘How about something other than making them angry?’ Then I got in the booth with him and realized he had the most miserable job ... as he said it, ‘keeping the kids out and getting the patients in as fast as I can.’”

White told him he had two choices. “Either you’re going to increase
anxiety or you’re going to put them at ease. Why don’t you start asking people if they have any questions?”
 she suggested.

“Just then, a car pulled up with a patient who’d driven several hours for a surgical appointment and was extremely late and stressed about it. I asked Michael to call the nurses to let them know the patient had arrived, but he said he wasn’t allowed to do that. So I climbed in the booth and said, ‘No worries. I’ll call.’” She reassured the patient, whose stress level was immediately reduced.

“They said, ‘Oh, thank you. We were worried; we couldn’t get ahold of him.’ And from that day forward Michael knew what his job was.” Since then, when cars stop at his booth, Michael makes sure they know where they need to be, even if they don’t ask, and he’s become a model employee.

But in more urban settings, healthcare leaders say good scores are a tougher challenge because their patients are more disgruntled—that is, culturally less likely to say they’re pleased. They say their hospitals are bigger and busier, and their patients are sicker, and that Medicare’s formula does not adequately adjust for that.

Lauren Johnston, RN, MPA, CNAA-BC, FACHE, senior assistant vice
president for patient-centered care for New York City Health and Hospitals Corporation’s 11 acute care facilities, agrees that her patients are tougher to please. For now, she says, the amount at stake will not be as large because the number of Medicaid patients her facilities serve is far greater than their Medicare population.

“Although CMS is starting with Medicare patients, when it adds Medicaid patients to the payments for patient experience scores, the impact is potentially devastating,” Johnston says. “So we’re going to fix this. And we’re
making progress.”

The scores for overall ratings of the system are better than most of the private hospitals in the city, she says.

NYCHHC has 250,000 discharges a year and 1 million ED visits. “We’re huge, in the most diverse city in the nation. When you walk into our hospitals, there are signs in 14–15 languages,” Johnston says. “Everybody has to deal with multiple cultures; they have to be specific in how they respond to each patient. And we’ve learned that what works in one place may not work in another.”

So NYCHHC is just working harder, trying lots of strategies. It has launched a charm school “for a few of its hospitals, a three-day course that teaches staff a cornerstone of behavior: respect. “You have to graduate from the school to work at those facilities,” she says.

Another NYCHHC strategy tries to improve staff accountability. “We have a board up on the nurse’s unit with every single staff member’s picture, name, and title right on the picture. So there’s no hiding who you are. You can’t be disrespectful and think no one will know you, because a patient can go up to that board and say, ‘It was that person right there,’” Johnston says.

The staff was uncomfortable with that initially, she acknowledges. “But now, it’s how they work, and they all take their behavior more seriously.”

An effort at Bellevue Hospital Center involves each nurse manager making rounds as if they were “concierges,” Johnston says. “They don’t just ask, ‘How’s your health?’ They ask, ‘How has your day gone so far, and is there something I can do to make your experience better?’”

Johnston says that NYCHHC as a system has seen overall scores rise, with varying rates of improvement at each facility. But Elmhurst Hospital Center, which Johnston says is one of the most culturally and ethnically diverse in the nation, saw a 13 percentage point increase over three years, from July 2007 to June 2010, followed by Coney Island Hospital, which rose 11 percentage points. She says the use of individuals as navigators or advocates who assist patients and families for whom English is not their primary language, is a likely reason for the improvement.

Nina Setia, administrative director of service excellence at Hackensack (NJ) University Medical Center, a 745-staffed-bed hospital, says her team saw from the last survey report “that responsiveness of staff, along with noise, are the two areas that are going to be hurting us the most in VBP.”
For noise, she says, cell phones and a liberal visitation policy that is patient-driven make these “two very tough areas to improve.”

So her team focuses on using skills lab settings to validate staff in their behaviors around the hourly rounding practice. In six months, more than 500 nurses have been validated.

Caregivers—usually nurses—focus on eight behaviors, such as making sure patients’ comfort needs and their pain are addressed and that they know when someone will return to the room. This has, so far, been effective.

They’ve boosted scores from 77% to 81% for “communication with nurses” between the first and second quarter of 2011, Setia says.

More improvement came in scores for “overall rating of hospital,” which went from 73% to 76% in one quarter, and in “willingness to recommend,” which increased from 79% to 83%.

Barbara Balik, a member of the senior faculty with the Institute for Healthcare Improvement and a former executive vice president for safety and quality with Allina Hospitals and Clinics in Minnesota, notes that “what we’ve seen nationally since HCAHPS has been in place is a general trend upward for everybody. And that does tell us we can move this when we put focus and attention on it.”

Aldire says the entire hospital staff has to understand that they all play a part in improving and sustaining HCAHPS, not just for financial reasons, but to improve patient care overall.

“For a hospital to be successful, they really have to hardwire, to make sure everyone who has contact with the patient is aligned. Because the patient can have a great, great
hospital experience, but boy, if going
out the door someone says something that’s wrong or rude, or doesn’t communicate well, it sticks in their mind, and then the response goes from ‘always’
to ‘sometimes.’”

 

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