Nurse leader rounding software on iPad Minis raises HCAHPS scores, but will need to be carefully integrated with the EHR.
Realizing that the typical electronic health record, despite vendor slogans to the contrary, is far from patient-centered, Northwell Health's Lenox Hill Hospital found breakthrough HCAHPS scores by adding a second piece of technology to tell the story of inpatients' point of view.
Utilizing software from CipherHealth, Lenox Hill nurse leaders improved patient care handoffs between shifts, ultimately improving patient experience scores as reflected by HCAHPS.
"We redesigned and reimagined the role of our unit ward clerks, transitioning them to patient service facilitators, and giving them Cipher," says Joe Leggio, associate executive director and vice president of experience at the hospital, which employs 4,200, including up to 1,900 nurses.
The transition began two to three years ago, when leadership was trying to find ways to improve the way nurses rounded among inpatients.
"We all have HCAHPS data, which is great, but it's not helpful to know that someone eight weeks ago was upset," Leggio says. "It's very hard to fix that experience."
Instead, leaders wanted real-time information on patient experience that they could aggregate, and then apply process improvement measures quickly.
"We made the round be at the center of what we do, so that we were patient-focused," Leggio says.
Joe Leggio is the associate executive director and vice president of experience at Northwell Health’s Lenox Hill Hospital. Photo courtesy of Lenox Hill Hospital.
Patient engagement software is linked to ADT data
The CipherHealth technology is linked to admission, discharge and transfer (ADT) feeds generated at the hospital. "It knows where patients are, when they're there," Leggio says. The technology lets clinicians build scripts tailored to each patient, include checking on nursing's "5 Ps"—potty, pain, position, possessions, and peaceful environment.
The technology also allows nurses to capture notes in free text "to have an organic conversation with the patient as to what matters to them," according to Leggio.
Also present in the technology is what Leggio calls a communication and escalation algorithm. For example, a nurse making rounds may see that garbage needs to be taken out. Nurse leaders can take a photo with the CipherHealth mobile app, which they carry on iPad Minis, and send the photo to the hospital's environmental services according to their preference (via text message or email).
"It's all timestamped, so it gives us a sense of what our response times are, and it allows the person who's trying to solve that problem know what they're looking for when they get into that room."
Patient satisfaction isn't the only beneficiary of this round-centered tech. Pain management is a big area of focus, Leggio says.
Patients have been able to get an increased frequency of pain consults with clinicians, plus different therapies such as music therapy, art therapy, and pet therapy, all preferred alternatives to reduce reliance on opioids, he adds.
"So much of what happens is sometimes patients' expectation of zero pain, and sometimes we can't get to zero," Leggio says. With that in mind, clear communication between providers is crucial, he adds.
"There's so many people walking in and out of that [patient] room, between physicians, pain management, [and] nursing," he says. "This tool has given us insight into that communication clarity."
Another piece of insight comes from understanding what is happening at the other end of the patient's call button.
"Right now, most hospitals don't have a piece of technology built into a call bell system that says, 'I'm calling for pain' or 'I'm calling for ice.' We've been able to improve workflow efficiencies because we were able to see what patients are asking, by unit and by service."
Tasks like these often resulted in nurses jotting and pocketing handwritten notes, records of which aren't retained after the shift is done.
"It's nothing against our nurse leaders," Leggio says. "They were working with the technology they had. But now I've got a tool that aggregates this data, and proactively sends it to me on a weekly, monthly, and quarterly basis with the trends built into it."
Currently, only Lenox Hill nurse leaders (as opposed to all nurses) use the CipherHealth technology, and it is in use at nine other Northwell hospitals.
But the narrative that emerges is something previously unavailable to nurse leaders.
"In a 48-hour stay, the patient will come in contact with over 65 of our employees," Leggio says. "It just starts adding up. The key is that communication."
Lenox Hill's HCAHPS scores for responsiveness have improved dramatically, rising from the 19th percentile in 2018 to the 32nd in 2019, 44th in 2020, and 93rd so far in 2021. Patients' likelihood to recommend the hospital rose from the 49th percentile in 2018 to 95th so far in 2021.
EHR integration challenge remains
All this improvement has, however, left a formidable task for Lenox Hill and other users of this technology. For decades, EHRs have been sold to them as the "single source of truth," but now, technology such as CipherHealth's represents a second "unofficial medical record," as Leggio puts it.
"We're not there yet, fully integrated where we want to be," he says. "But we are working on it. Making a change like this was a very large shift. What we don't want to do is just throw another piece of technology in front of us, thinking it's going to solve all the problems.
"We are now on the journey to figuring out, how do we link this to the medical record? We're figuring out those steps right now."
The COVID-19 pandemic also played a role in the timing of the rollout of the CipherHealth technology. "March, April, and May  were our three biggest months for the pandemic," Leggio says. "We put the tablets down and reprogrammed them to help with patient and family communication. I knew our nurse leaders were rounding on every patient."
After the first pandemic wave, "we felt it was important to go back to the [CipherHealth] technology again, because it's about structuring our process with the round, and using information in real time."
And as long as the feedback remains positive, Lenox Hill will keep the initiative going. "Our latest CMS Star rating came out in early May, and we went from a three-star to a four-star hospital," Leggio says.
One lesson learned: build more custom scripts for each specialty from the outset, Leggio says.
"We're doing this now, by service line, a bit [more] of a crafted, individualized script," he says.
Editor's note: This story has been updated 6/9/21 at 1:39pm.
“We all have HCAHPS data, which is great, but it's not helpful to know that someone eight weeks ago was upset. It's very hard to fix that experience.”
— Joe Leggio, associate executive director and vice president of experience, Lenox Hill Hospital
Scott Mace is a contributing writer for HealthLeaders.
New approach supplements HCAHPS data with real-time patient experience data that can be sent to leadership promptly.
HCAHPS responsiveness score rose from 19th percentile in 2018 to 93rd percentile in 2021.
Hospital is "on the journey" to figuring out how this data flow gets linked to the EHR.