Hospitals across the country are searching for ways to create the "always positive" patient experience. For example, we want our patients to tell us that their pain was always addressed, that clinicians were always responsive to their needs and that our communications at discharge time always helped prepare them to take care of themselves once they left.
But what many may not have fully grasped is the commitment and work required to be a top performer in this realm. Are your hospital or departmental leaders willing to block off time every week to methodically conduct rounds with patients and ask if they have any concerns about their care? Do your nurses and nursing assistants conduct proactive, purposeful rounds every one to two hours to carefully check on patients and help meet their needs in a timely manner? Is staff time dedicated to calling patients within 48 hours of discharge to clarify any questions about how to care for themselves?
These are the kinds of steps taken by U.S. hospitals that were either top performers or that had made remarkable improvements in the national inpatient experience survey, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). As part of a national project funded by the Agency for Healthcare Research and Quality, a team from the Armstrong Institute for Patient Safety and Quality sought to understand how these high-performing hospitals reached their achievements. In a survey, 138 informants from 52 of these hospitals told us what they believed were the keys to their success. The findings were recently published online ahead of print in Medical Care.
Several distinct patterns emerged from the responses. As we expected, they told us about the importance of setting goals, communicating them across the organization, providing measurement and data feedback, and holding people responsible for results.
We also heard that these hospitals did not treat a positive patient experience as the "icing on the cake," secondary to the technical aspects of care. Rather, the patient experience was viewed as part of that cake, strongly linked to the mission of the organization, and what it stands for in regards to delivering safe and high-quality medical care. (Indeed, higher HCAHPS performance has been associated with positive patient outcomes, such as reductions in pressure ulcers and rehospitalizations.) Because of that perspective, they reorganized their work around the patient experience, took proactive approaches to surface patient needs and concerns, and made changes from boardroom to bedside.
The approach of many of these hospitals to leadership and executive rounds exemplifies how they truly embraced the importance of the patient experience at all levels of the organization. It’s not a new concept for hospital executives to periodically walk around a clinical unit in an effort to get "ground truth" from patients and staff members. Yet these rounds are usually infrequent, and they may focus on just one or two patients who have been selected beforehand.
What surprised our research team is the extent to which high-performing hospitals embraced regular and frequent leadership and executive rounds. At one hospital, nursing leaders blocked their meeting schedules between 9 and 11 a.m., to protect time to round on patients. At others hospitals, executive leaders rounded weekly and sometimes daily on patients.
These leaders made very conscious decisions to put themselves "out there" on a regular basis, to be open to the experiences of patients who are happy and those who have complaints. Rather than have information about patient care filtered up through several layers of the organizational hierarchy or tallied in survey results, they heard those voices directly, providing a new perspective that could inform the decisions they make on how to run their organizations.
Leadership rounds can certainly advance accountability. If you're a nurse and you expect the nursing director to visit your patients, you want to make sure that your patients provide positive feedback about your care. However, these rounds are also empowering to frontline clinicians. In fact, at many of the high-performing hospitals, as part of their rounding routines, leaders "round" on staff members, asking what they need to do their job well. Such an approach offers an opportunity for staff members to share their thoughts about any system issues affecting their patients' experience. Are inefficiencies in patient transport leading them to be off the unit for too long? Are staffing shortages making it hard to respond to patients' requests? Executives can often help find the solutions to these larger problems and direct resources to them.
Among the hospitals participating in the survey, 62 percent said that they were performing executive and leader rounds.
As we reported in Medical Care, other patient-level interventions employed at a majority of these high-performing hospitals included:
- Proactive nurse rounds (reported at 83 percent of the hospitals): Having a nurse or nurse assistant check in on a patient on a regular basis to ensure that needs are identified and addressed in a timely way. Typically, these rounds focused on basic needs, such as toileting, pain management and positioning in bed, but some hospitals also used the rounds to address safety measures, including fall prevention. One played "music on the hour" to remind staff members it was time to round.
- Setting behavioral standards (60 percent): Identifying specific behaviors, such as introducing oneself to the patient and offering "blameless apologies," that are expected of every employee, and clearly communicating these standards to staff. Highlighted at orientation, annual evaluations and other human resources processes, the standards are then constantly reinforced. At one top-performing hospital, 35 percent of employees' annual merit increase was tied to their performance on 10 service behaviors.
- Multidisciplinary rounds (56 percent): Conducting daily rounds by a team that includes the physician, primary nurse, pharmacist, respiratory therapist, charge nurse and other experts to improve communication and collaboration. The meetings sometimes also engaged patients and family members at the bedside. Such rounds help to foster greater agreement and more consistent communication to patients and families about the discharge plan.
- Postdischarge phone calls (54 percent): Proactively calling patients after discharge, with the goal of identifying and resolving questions and issues, making sure that prescriptions have been filled and helping with the transition to home. At one top-performing hospital, about 25 percent of all calls from nurses resulted in the need to clarify discharge instructions. Some targeted more vulnerable patients: At a "most-improved" hospital, a pharmacist called high-risk patients with multiple medications.
- Discharge folder (52 percent): Collecting a package of discharge information over the course of a hospital stay for the patient to take home. The folder keeps the focus on continuing patient education and preparing for a safe transition from the hospital.
Most of the study hospitals used a combination of these strategies.
Here’s what didn't get credit for strong HCAHPS scores: free parking, great food or hotel-like amenities. This is not say that patients do not appreciate those, but rather that those are the "icing on the cake" and by no means replace the need for close attention to meeting essential patient needs in a timely manner.
The good news is that any hospital can use the low-tech strategies employed by these high-performing hospitals. It didn't matter if they were big, gleaming, new academic medical centers or rural community hospitals. Of course, that doesn't mean it's easy. Their success depended on strong commitment and relentless focus across the organization, engagement of all people from executives to frontline staff members, consistent efforts to surface and meet patient needs, and a willingness to change long-standing habits and practices.
- Read the proceedings from the Best Practices in Patient-Centered Care Conference, in which HCAHPS high performers shared their strategies for improving the patient experience. Abstracts and slides are also available.
Learning from the Leaders in Patient Experience,