The head wound patient in the emergency department's bay three just threw up and a patient discharged over the weekend needs a follow up call regarding how he is recovering from his complicated procedure. Which patient is the priority? This dilemma is all too common for nurses and healthcare organizations that are striving to manage quality and patient satisfaction.
Study after study has shown that patients who have more interaction with nurses express higher satisfaction rates and increasing nursing time at the bedside has been shown to improve overall quality scores. The challenge, of course, is to reduce the administrative burden nurses carry so they can spend more time at the bedside. Studies conducted several years ago at Cedars-Sinai Medical Center in Los Angles indicated that, on average, nurses spend as little as 25% to 30% of their time at the bedside, though many hospitals are successfully working to increase that percentage.
Given the positive effect nurses have on patient satisfaction and quality, reducing the administrative burdens of frontline nurses should be one of the top priorities for nursing managers.
Nurses' responsibilities
In the wake of the country's nurse shortage, many nurses are wearing more than one hat during the workday, often taking their attention away from caring for patients at the bedside. One activity stealing this time is the responsibility to place calls to patients who have been discharged and need follow-up clarification on discharge instructions and prescribed medication. Nurses struggle to find time for this task while attending to their current patients.
These calls clearly have their place. The U.S. Agency for Healthcare Research and Quality recently cited that 20% of patients have a "complication or adverse event" after leaving a hospital. Many avoidable errors are due to patients misunderstanding post-discharge instructions such as cleaning a surgical site or taking prescriptions in correct doses. Follow-up phone calls educate patients and can help prevent further complications. However, these calls can be time consuming for busy nurses.
Considering there is an average of 120 million ED discharges annually in the United States, let's assume healthcare organizations conduct follow-up calls with 40% of that population with an average call taking five minutes. This translates into at least 150 million minutes, or 104,166 days, on the phone reviewing post-discharge instructions—and that's for ED patients alone.
Additional resources
One solution for some facilities has been to assign post discharge calls from nurses to centralized call centers staffed by trained call advisors or experienced nurses. Some facilities choose to create their own in-house call centers, while others rely on outsourced healthcare call centers. In either case, well executed programs can have a significant effect on nurses' job satisfaction—as nurses benefit from a reduced workload—and patients' satisfaction scores, as patients who receive post-discharge calls have been shown to have a more favorable impression of their care overall.
"We wanted to reduce or eliminate the need for our nursing staff team to engage in post-discharge calls if it meant they would be distracted from their current patient care duties," says Britt Berrett, president and chief executive officer. "Using an outsourced call center staffed with personnel who are trained to answer clinical questions was the best choice for us."
Results
The imperative to follow-up with patients after discharge is high because we know discharged patients can become readmissions if they fail to recognize the early onset of complications or if they fail to follow discharge instructions. However, there are two new factors spurring urgency in this arena. Medicare is positioning to eliminate payments for avoidable readmissions within 30 days of discharge, and it is tying reimbursement to HCAHPS patient satisfaction scores, making this an administrative priority for hospitals.
Many organizations are finding the right post-discharge program can help meet these challenges. A 200-plus bed Midwest hospital implemented a proactive call program for discharged ED patients and found a significant relationship between post-discharge calls and satisfaction scores. The chart below depicts the feedback generated based on a survey of 125 ED patients discharged between April 1 and June 30, 2009.
The scores represented here for overall rating shows the percent of patients who reported good, very good, or excellent care overall. The 'would recommend' data shows the percent of patients who said they would "yes, definitely" recommend the hospital to friends and family. Patients who received post-discharge calls were more likely to report good or better ratings of their overall care than their counterparts, and were more than 25% more likely to recommend the hospital.
One Florida hospital that aggressively used an outsourced call center strategy to manage inquiries from discharged patients uncovered an additional financial incentive. It estimated that it saved more than $11 million in one year by providing appropriate telephone triage that prevented readmissions.
From both the financial perspective and the quest to drive clinical quality, providing proper patient follow-up demands special focus and a selective strategy in order to reduce this common burden on nursing staff. If handled well, nurses and patients both benefit.
Mark Williard is senior vice president of Beryl, a healthcare-exclusive call center, where he oversees product management to support more than 450 hospitals, health systems, and private practices' call center programs. For more information, visitwww.beryl.net/.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
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A few weeks ago, in a non-descript ballroom at a nice Boston hotel, I experienced what I can honestly say was one of the highlights of my career. I stood teary-eyed with a roomful of applauding, cheering nurses—many of whom may admit to being teary-eyed themselves—as we recognized some pretty amazing nurses.
It was the end of a beautiful, New England fall day and the sun lit up the view across the harbor of the city's skyline, but the pride and joy radiating inside that room eclipsed any expensive vista the city had to offer.
We were there for the presentation of the 2009 Nursing Image Awards, and the pride I saw on people's faces was mirrored by my own pride at having the opportunity to help judge the awards, which were presented on September 21.
I thought these awards were an interesting topic for the first issue of NursingLeaders, our new weekly e-newsletter. I've been covering nursing for more than four years for HCPro, Inc., HealthLeaders Media's parent company, and now I'll be offering my perspective on nursing issues and news in this weekly column. The e-newsletter will include original reporting and analysis, guest features, audio interviews, and links to interesting articles from HealthLeaders magazine and other news sources, all focused on issues that matter to nursing leaders.
The awards were conceived last year as a way to recognize nurses who embody a professional image of nursing. We sought nominations in two categories, leadership and clinical excellence, and healthcare professionals were invited to nominate nurse individuals or teams who personify a positive image of nursing in those categories.
We received around 200 nominations, awe-inspiring considering we required a 500-word essay, and I read every single one of them. Sitting at my desk, pouring over the 199th essay, something jumped out at me.
Along with hard data about the measurable outcomes nominees achieved—staff satisfaction levels up, turnover reduced, quality improvement initiatives succeeding—the essays contained themes about mentoring, learning, educating, and inspiring, which were repeated over and over again. And it made me think about how the presence of excellence can have a positive effect in any workplace. Think about when you first started out as a new nurse and watched the experienced nurse on your unit in awe, determined to one day be a skilled, competent nurse just like him or her. Or consider the inspirational leaders who you have sought to emulate and who have mentored you—whether they knew it or not—as you moved up the career ladder.
Dianne Aroh, RN, MS, NEA-BC, is one of those leaders. Aroh was the winner of the Image of Nursing in Leadership award and the nomination essay noted Aroh's abilities as a transformational leader, who increased staff nurse involvement in shared governance and fostered a transparent, dynamic culture of excellence, collaboration, harmony, and synergy across the entire organization.
Aroh is chief nursing officer at Hackensack (NJ) University Medical Center and the judges picked her for all the positive, measurable outcomes she had achieved, but also because she serves as a role model for promoting a collaborative, professional nursing environment.
"What an inspiration this leader is!' says judge Shelley Cohen, RN, BSN, CEN, president of Health Resources Unlimited, and co-author of the book The Image of Nursing: Perspectives on Shaping, Empowering, and Elevating the Nursing Profession, "Empowering nurses at the staff level not only promotes excellence in patient care, but role models excellence in leadership."
I was delighted to note that Aroh was accompanied to the award presentation by a large contingent of senior leadership from her hospital, including the president and CEO, which says a lot about how nursing leaders can succeed when working in a supportive, collaborative environment.
Equally impressive were the winners of the clinical practice category. The judges chose the neonatal ICU team at University Hospital of Brooklyn SUNY Downstate Medical Center for their focus on quality improvement issues and dedication to providing compassionate, competent care to patients and their families. The team focuses on continuing education and works to present a positive image of nursing.
The two nurse managers of the unit were there to receive the award, along with several members of their staff, and it was heartening to see their reaction as the entire audience gave these top performers a rousing round of applause.
It's an oft cited notion that managers spend too much time coaching the bottom performing 20% of staff and trying to help them improve, rather than spending time with the top performing 20% of staff and helping them excel even higher. These are the employees who are so competent and good at their jobs that we largely leave them to it, knowing they will be just fine, rather than helping them excel even further.
So it's worth turning our full attention to our exceptional employees—the Dianne Aroh's and NICU teams of the world—both because we should be recognizing and rewarding them for all they do, but also because given the right environment and encouragement, exceptional employees can be role models, mentors, and teachers. They lift up the spirit and performance of all of us around them—as they did in the hotel ballroom in Boston, where we all felt a little more inspired for having met them.
Editor's note: I'd be interested in hearing about ways readers promote a positive image of nursing at your facilities and ways you recognize and reward the shining stars at your organization. You can contribute your thoughts on this topic, nursing leadership, or the business of healthcare by e-mailing me directly at rhendren@hcpro.com.
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Social networking Web sites and modern communication media, such as text messaging, e-mail, and smartphones, are a part of our daily lives. Although such technologies have a place in society, they are taking a toll on the professional image of tomorrow's physicians.
In fact, 60% of medical schools that responded to a recent survey reported incidents of students posting unprofessional content online, according to a study published this month in the Journal of the American Medical Association. Medical schools also reported finding frequent references to intoxication (39%) and sexually suggestive material (38%).
Medical students are not the only Gen Xers or Yers divulging too much information online. A 2008 study in the Journal of General Internal Medicine found that residents are also posting information that they may not have otherwise shared with patients.
Medical educators can address these issues with students and residents using institutional policies or codes of conduct to help guide the discussion. However, these discussions often aren't as strong as they could be because many institutional policies regarding appropriate online behavior are outdated or inadequate, says Nancy Spector, MD, associate pediatric residency program director at St. Christopher's Hospital for Children in Philadelphia.
Most policies are stuck in the early 2000s and only cover e-mail and Internet usage. They neglect to address smartphones or text messaging, which leaves many gray areas.
For example, is it appropriate for residents to use their smartphones to find an answer to patients' questions in front of the patient? Or is it OK for them to look up an answer to a question during an educational session? Appropriate etiquette for such situations is largely undefined.
Consider updating your policies for all hospital employees. When creating guidelines for cell phones, professional e-mails, and smartphones, focus on basic etiquette. Consider specifically delineating when it is or is not appropriate to:
Answer a cell phone or check voice mails
Send or check text messages
Send or respond to e-mails on smartphones
Use the Web browser feature on smartphones
Outline the kinds of Web sites that are appropriate to access from work computers. This may be specified in an institutional policy, so check to make sure your guidelines align, Spector says.
Other than patient information protected under HIPAA, you can't dictate the content that residents post on their blogs or social networking profiles. You can only help them understand how personal postings can affect them professionally.
HIPAA is another concern hospitals should address in their online policies and in any e-professionalism training.
Residents, faculty, or program managers who blog need to be sure they do not engage in unauthorized disclosure of protected health information in their posts, says Reece Hirsch, Esq., of Sonnenschein Nath & Rosenthal, LLP, in San Francisco. Doing so is a HIPAA violation.
The danger for hospitals is when healthcare workers think they're doing enough to generalize the patient's information in their online post, but they're really not, Hirsch says. Patient data must be de-identified before it can be posted online. The JAMA study reports that 13% of medical schools found violations of patient information on medical students' online pages.
Reviewing HIPAA in the context of blogs, Twitter, Facebook, and MySpace is a must to protecting yourself from legal liabilities.
Also keep in mind that Web 2.0 fads will fade as soon as Web 3.0 is invented. Try to keep up with what's hot—you don't want your presentation to be dated. This is easier said than done, says Spector. "Technology moves so fast, and we've always been behind in knowing what's coming and the potential misuses residents and medical students may find," she says.
Julie McCoy is the editor for HCPro’s Residency department. Check out more residency-related content at www.residencymanager.com.
Advocate Christ Medical Center in Oak Lawn, IL, has become the first organization in the country to be certified according to the new Advanced Certification Program in Heart Failure, according to an official statement released on the Joint Commission's Web site.
Developed by The Joint Commission, in collaboration with the American Heart Association, the certificate will recognize those hospitals making efforts to foster better quality of care and outcomes for heart failure patients.
"The Joint Commission commends Advocate Christ Medical Center for demonstrating such a high level of patient care," said Jean Range, MS, RN, CPHQ, executive director of Disease-Specific Care Certification, The Joint Commission, in an official statement. "Achievement of certification signifies that the services at Advocate Christ Medical Center have met the critical elements to achieve long-term success in improving outcomes. It is the best signal to the community that the quality of care provided is effectively managed to meet the unique and specialized needs of heart failure patients."
In order to qualify for the certification program, organizations must:
Meet the standards and performance measurement requirements under the Joint Commission's Disease-Specific Care Certification program.
Achieve and sustain for 90 days or more at least 85% compliance with the five achievement measures of Get With The Guidelines—Heart Failure, the American Heart Association's hospital-based quality improvement program designed to close the treatment gap in cardiovascular disease.
Collect data on Joint Commission's core measures for heart failure and use this data in ongoing performance improvement activities.
Hospital for Special Surgery announced that Robert K. Steel, former president/CEO of Wachovia Corp., has been named a member of the hospital's Board of Trustees. Steel facilitated Wachovia's merger with Wells Fargo to create the second-largest retail brokerage in the country. Prior to running Wachovia, Steel served in the U.S. Treasury Department as Under Secretary for Domestic Finance, a Senate-confirmed position.
Nancy (Kremer) Barone has been named vice president/executive operations director at University Hospital, effective Nov 2. Barone will have executive oversight of University Hospital's operations, its Service Excellence and Patient Progression strategic projects, and key centers of excellence and service lines. Most recently, Barone was president/CEO of St. Luke Hospitals in Northern Kentucky.
Broadlane, a cost-management company for healthcare providers, has appointed Greg Ericson as CIO. Ericson most recently was vice president of global information services for Smith & Nephew, PLC, a medical device, biotechnology, and pharmaceutical multinational corporation.
HCA's Oak Hill Hospital has announced the appointment of Chance Phillips as CFO. Phillips has worked as an accountant for Outback Steakhouse International and an auditor for Pricewaterhouse Coopers. Phillips has also served as controller and co-ethics and compliance officer at Oak Hill Hospital from 2001 to 2005. Phillips most recently served as CFO of HCA Patient Account Services.
One week after the highly publicized escape of a potentially dangerous patient during a field trip to a county fair, longtime Eastern State Hospital CEO Harold "Hal" Wilson announced his retirement from the state-run mental health hospital, effective Oct. 1. The State of Washington is investigating the incident. Eastern State Hospital COO Connie Wilmot has agreed to become the acting CEO of Eastern State Hospital during the transition. The state will announce the steps in the recruitment of a permanent CEO in the near future. Wilson, who began his state service as an accountant at Eastern State Hospital, had been with the state for more than 28 years. He was named CEO of the hospital 10 years ago.
