City Patient Family Engagement Applied Research Project ... fileexpressed a need to develop a...

–

CITY HOSPITAL Patient/Family Engagement Applied Research Project

Jon Rottenberg

May 2016

2

TABLE OF CONTENTS

EXECUTIVE SUMMARY ....................................................................................................................... 3

BACKGROUND .................................................................................................................................... 5

DATA COLLECTION METHODOLOGY .................................................................................................. 5

Interview: ....................................................................................................................................... 5

Focus Group: .................................................................................................................................. 5

Survey: ............................................................................................................................................ 5

Extant Data: .................................................................................................................................... 5

INTERVIEW RESPONSES ..................................................................................................................... 6

FOCUS GROUP RESPONSES ................................................................................................................ 9

SURVEY REPONSES ........................................................................................................................... 11

EXTANT DATA COLLECTED ............................................................................................................... 29

CURRENT INITIAVES ......................................................................................................................... 31

FINDINGS AND RECOMMENDATIONS ............................................................................................. 32

APPENDICES ..................................................................................................................................... 37

APPENDIX A: CITY HOSPITAL ALIGNMENT MEETING REPORT ......................................................... 38

APPENDIX B: CITY HOSPITAL NEEDS ANALYSIS PLAN ....................................................................... 39

APPENDIX C: INTERVIEW INSTRUMENT ........................................................................................... 40

APPENDIX D: FOCUS GROUP INSTRUMENT ..................................................................................... 42

APPENDIX E: SURVEY INSTRUMENT ................................................................................................. 44

3

EXECUTIVE SUMMARY City Hospital serves the surrounding community that encompasses 6 zip codes. The hospital expressed a need to develop a patient and family strategy to improve the patient experience by delivering the highest quality and service. Community engagement would help promote City Hospital's successes and abilities, as well as improve the perception of the hospital and the HCAHPS hospital survey scores which affect the hospital’s funding. The goal of this project was to provide recommendations to positively impact City Hospital’s patient and family engagement and ultimately increase their patient experience scores. Though this analysis, several barriers affecting the hospital’s relationship with the patients and families were identified and recommendations were provided to in order improve the patient experience. The analysis was conducted using several methods of data collection, including two interviews with hospital leadership, a focus group with staff experienced with patient/family engagement, an online survey for clinical staff, and the review of extant data. The data collection instruments were developed to observe the issue from multiple angles in order to identify the factors affecting the hospital’s relationship with patients and their families. Staffing and communication stood out as the most commonly identified issues that are impeding progress. The data also concluded that delays, noise, cleanliness, and the need to improve the hospital’s reputation are areas requiring focus. Recommendations include increasing staffing and incorporate patient advocate positions, educating staff regarding communication, developing a cultural change with how staff communicates, educating the patient/family, having quiet zones by patients’ rooms, and the development of a patient/family advisory council. Interview Summary The hospital has been steadily competing with other hospitals instead of being focused on their own identity. In order to improve the patient experience, City Hospital implemented the Studer technique in 2013 to improve staff behaviors in order to help achieve positive outcomes based on the HCHAPS questions. Although this technique has been beneficial in improving HCHAPS scores, the hospital would like to accelerate progress even further. Several factors have been identified as potential areas for improvement. Clear communication is needed from physicians, nurses and support team employees who work directly with patients so that they understand their treatment plans. The culture of the hospital needs to shift to incorporate the “managing up” strategy and providers should focus on well-being in addition to healing. Staff turnover/retention has been an ongoing problem at City Hospital resulting in staff being reassigned to other areas of the hospital. Inadequate staffing can also negatively impact the patient experience and increase wait times for care.

4

The Vice President of Operations rounds with staff, but not all senior leaders do this. The hospital is involved with a number of community outreach initiatives. Patients currently have various means to provide feedback to the hospital. The patient experience entails many facets, and almost everything in the hospital can be linked to an individual’s experience. It is also a challenge to overturn the negative perception of the hospital from ten years ago. The Marketing Department has stated that the hospital is "just not known for having a good reputation.” Although City Hospital has made gains in HCHAPS scores in recent years and implemented strategies that are working, the process can be enhanced and accelerated. Focus Group Summary An informational welcome packet is provided to all new patients, but the staff-to-patient communication that explains the packet is lacking. The communication for this packet is an educational component that should not be overlooked. Employees need to communicate consistently and be well-informed on treatment plans before speaking to the families. Communication is a concern and sometimes inconsistent information is given to patients and their families. Sometimes visitors are given incorrect room numbers because there are 2 different systems that are not always in sync; Medipac for volunteers and Cerner for staff. Patients may be moved late at night and are upset as a result. Additionally, directional signage is lacking for elevators particularly by the front desk directing visitors to the south elevator. Patients and their families want to be engaged with the provider and be available but do know when the doctor will round. Family members want to be present when the doctor rounds so that they do not have to rely on the patient for information, because the patient could be disoriented. In terms of marketing the hospital brand and public relations, the annual fair is helpful as is the television commercial. A suggestion was made to send an oversized postcard with a family image as a regional direct mail piece to help promote the hospital. Online reviews via social media need to improve. Parking is also an impediment to the patient experience, particularly in the ED. Survey Summary The quantitative responses suggest that staff need to training to; communicate clearly to upset patients and family members, identify and communicate with key family members and to utilize data from discharge phone calls to improve patient satisfaction. The qualitative responses indicate that staffing, communication (staff-to-staff, staff-to-patient and patient-to-staff) and hospital cleanliness are areas that need improvement. Extant Data Summary

The majority of feedback collected from the Patient Comments Report was positive (52%). Negative feedback was 27%, and mixed and neutral feedback comprised of the balance. The hospital has shown an increase of HCHAPS scores over the past 4 years. All of the scores except

5

one, communication about medicines (63.4 in 2015 - 61.5 in 2016), have increased over the past year. The Employee Engagement Survey results were high, but showed that 2 particular areas need attention: staffing (3.73 out of 6 points) and communication (4.48 out of 6 points). Both positive and negative feedback were provided via Yelp and Google+. Common trends in the negative reviews were wait time, inconsistent staffing, cleanliness and poor customer service. The Urgent Care Center that recently opened around the corner should offset emergency department wait times. Additional and detailed information is provided in the Findings and Recommendations section of this report. The appendices include the data collection instruments.

BACKGROUND There has been a lack of community engagement between the hospital and their patients and families resulting in lower than desired HCAHPS hospital survey scores. Approximately 92% of patients are admitted to the hospital via the Emergency Department, which is the largest in the State. Improvements have been made and the hospital is seeking additional recommendations. The focus is challenging since almost everything in the hospital can be linked to the patient experience.

DATA COLLECTION METHODOLOGY Interview: An interview instrument was developed to obtain the high level perspective of the issue from the leadership team. Two interviews were conducted. The first interview was with the Vice President of Operations, and the second interview was with the Director of Patient Experience. Questions were asked to review current strategies, barriers, how feedback is obtained and processed, and community outreach initiatives.

Focus Group: A focus group was held with six members of the Guest Relations team to discuss their direct experiences with patients and their families, and to identify barriers and possible solutions based on their observations.

Survey: A 16 question online survey was implemented for hospital staff who work directly with patients and their families to identify areas that may need training or improvement. This survey was targeted to clinical and support staff to measure their levels of engagement with patients and families, and to analyze their perspective of the issue.

Extant Data:

Patient Comments Report – January 2014 – December 2015 HCHAPS survey results for the past 4 years Employee Engagement Survey Online reviews: Yelp and Google+

6

INTERVIEW RESPONSES

Vice President, Operations

1) What is your perspective and perception of the problem? We have received outstanding scores in quality but the patient perception doesn’t

match that Desire to be the best in service and quality Competing with everyone else instead of being “who we are” (resulted in a lost

opportunity to engage and meet the needs of the community) Want to improve how we promote the hospital Need to instill confidence in patients and families

2) What would you like to see as a result of this applied research project?

Directional advice Strategies for top 3 projects “Stop being the best kept secret”

3) What strategies is the hospital employing to improve the patient experience?

Studer technique – hard wire tactics Improving behaviors by “teaching to the test” Using a more scripted approach to communicate

4) What levels of success have you had with those?

Implemented in 2013 and typically takes approx. 2 years to see progress The following improvement were made…

o bedside shift reports o hourly rounding o nurse leader rounding o physician communication o test scores increased over 10 points

ED is still a struggle Largest and highest admitting (92%) ED in the state

5) What are the challenges facing clinical staff, patients and families?

Not identifying the patient’s key family member Shift workers rotate and very strong handoff communications are necessary We have been challenging clinical staff to be service focused Putting tactics in place so patient engagement doesn’t feel like extra work for staff

6) What would you like to see performed differently that is not being done presently?

Managing up – cultural transition Pride in team and workplace Talk positively about everyone supporting the patient

7) What areas in the hospital require the most focus in order to improve the patient

experience? (This could range from communication to cleanliness, quality of food, timeliness of receiving medications, staffing issues, etc.)

7

Turnover and retention Having the resources to stay geographically assigned Environmental Services has been a strength and also a weakness Noise – cultural challenge

o Ask patients if door should be closed o Stop overhead paging

8) What type of training is provided to hospital staff that would help provide effective

communication to the patients and families, making them feel more engaged with the hospital? How effective is it? What could be improved?

Welcome packet o Inconsistency in reviewing with patient/family o Need to do a better job and make the communication a priority o Once it is a priority with nursing leadership, they will hold others

accountable

9) How do patients and families currently provide feedback while they are in the hospital? Notes in room HCHAPS survey Discharge phone call During nurse leader rounding Freedom to Recognize cards

10) What feedback have you received from hospital staff regarding their interactions with patients?

Large sessions held with staff asking “what can we do better?” o Interdisciplinary communication o Suggestion to implement cues as a means to communicate o Employees provide great feedback (i.e. how to utilize interpreter services) o Imaging has provided helpful ideas based on their experiences

11) Does senior management ever make rounds to visit patients to see how they are doing? If

yes, describe what the experience is like. If no, would that be considered? Leadership rounding is performed (by VP Operations) to obtain feedback Not every senior leader rounds There is a daily VIP list (3 or 4 people) for leadership to round

12) What strategies have been made to positively engage hospital employees so that their efforts as high performers could help improve patient satisfaction?

High performer incentives based on evaluations High performers invited for a meal with HR and leadership

o Obtain their feedback on how to improve o Focus has been on service

Quarterly lottery drawing based on positive peer, supervisor, patient and Press Ganey feedback

8

Closing points…

Trying to overturn negative perception of the hospital Marketing has told us “you’re just not known for having a good reputation”

INTERVIEW RESPONSES

Director of Patient Experience

1) What is your perspective and perception of the problem? We are a good hospital but need to focus on ourselves (instead of competing with

others) Patient perception needs improvement Incorporate a patient/family advisory council to meet the needs of the community Doing a lot with branding but need to improve the service Getting better but have a long way to go

2) Can you describe the term patient experience?

It can entail signage, patient guides and brochures, paint, trash, etc. Volunteer services and guest relations Guest services rounds daily and fields incoming calls Chair for patient rights chapter of Joint Commission Facilitated the welcome video

3) How does the hospital keep in contact with patients after they have been discharged?

Discharge phone calls No other contact unless they have a follow-up appointment or return to the ED

4) What community outreach initiatives have you conducted/implemented?

Host local business association meetings Board member for the regional Chamber of Commerce We provide a lot of financial support to the community groups Have been engaging faith based organizations Elementary school asked for community partners to help so the hospital assisted Host an annual event promoting healthy living to the community Center Trying to educate the community making them aware of our services Some patient and families see us as a friendly hospital but others do not Trying to improve our reputation

5) How successful have these community outreach initiatives been?

Local business association has been successful Meetings are held at the hospital to keep business coming back to the campus

9

6) What feedback have you received from patients about their experiences at the hospital? Press Ganey – inpatient surveys ED - complaints and grievances (negative feedback is regulated) Letters to the president

7) What feedback have you received from hospital staff regarding their interactions with

patients? Nurse leaders round daily and collect data for a trend report The trend report is sent out to nurse managers weekly

8) How are you currently implementing patient and staff feedback into your customer

service strategies/initiatives? Review HCAHPS score, discharge phone calls, feedback from nurse leader

rounding and discuss with leadership team Tactics are in place – more work is needed to emphasize them Lean Development

- Nurse leader huddle once a week - Patient experience oversight - Grievance committee

Make changes based on feedback Nurse managers develop skills lab (one-on-one training) Studer tactic – managing up

FOCUS GROUP RESPONSES 1) What are your experiences like when interacting with patients and their families?

Depends on the patient and situation – they can be pushy sometimes Team approach to ensure “employees don’t play against each other” Patients take frustrations out on us We are good listeners and let them vent Try to calm them down

2) What occurs during the admission process that engages patients and families with City

Hospital? 90% admitted through ED Try to get off on a “good foot” through ED GR employee in ED helps guide them through the process Welcome script read most but not all of the time Patient guide book provided They receive papers, but communication is lacking Another committee is reviewing the welcome process

3) What are the most common reasons why patients and families may be dissatisfied with their level of service?

Wait times in the ED

10

Physicians visit within 24 hours but it is not known when patients will be seen Communication Inconsistent information is given “Everyone needs to be on the same page before speaking to the family” Confusion with scheduling consults – attending physician or nurse should

communicate better to patients/families Front desk does not always provide the correct room numbers (Cerner and

Medipac are not in sync.) Signage directing visitors to the south elevator is unclear Moving patients late at night

4) What barriers do you see that may affect City Hospital’s relationship with patients and

families? Providers see patients every 24 hours including ED (not understood by patients) GR position helping patients in ED works one shift (11am – 7pm) There is a gap in the ED at night as a result

5) What would it take for City Hospital to provide better engagement with patients and

families? Families want to hear from doctor but may not be present when he/she visits

patient (patient may or may not be alert and families do not receive information) Families want to be more engaged and know the plan of care Multidisciplinary rounding

6) What could be done to improve City Hospital’s reputation and brand in the community?

Direct mail postcard with a family image promoting the hospital in the community

“Engaging is everything” Improve reviews on social media

7) Is there anything that wasn’t mentioned, but should be addressed? Parking – particularly for the ED Signage in front of hospital would prevent families from parking in the fire lane

11

SURVEY REPONSES 1) Select the role that is most closely associated with your position:

Answered: 32 Skipped: 0 Nurse

Physician

Tech

Support Team

0% 10 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices Responses Nurse 53.13% 17

Physician 15.63% 5

Tech 6.25% 2

Support Team 25.00% 8

Total 32

Reason question was asked To identify the position of the employees who are participating in this survey. It was targeted to clinical staff, but anyone who interacts with patients and families could complete this.

12

2) How important is patient satisfaction?

Answered: 32 Skipped: 0

Very Important

Important

Somewhat Important

Not Important

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices Responses Very Important 78.13% 25

Important 18.75% 6

Somewhat Important 3.13% 1

Not Important 0.00% 0

Total 32

Reason question was asked To measure the importance of patient satisfaction in the everyday responsibilities of employees. Studies have indicated that it needs to be a priority.

13

3) I have a clear understanding of the term patient experience.


Strongly Agree

Agree

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices Responses Strongly Agree 84.38% 27

Agree 15.63% 5

Disagree 0.00% 0

Strongly Disagree 0.00% 0

Total 32

Reason question was asked To identify whether staff has a firm grasp on the multitude of items that define the patient experience.

14

4) When a patient is unhappy with the level of service, my team responds promptly to resolve the issue.


Strongly Agree

Agree

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Agree 12.50% 4

Disagree 3.13% 1


Total 32

Reason question was asked To determine if patients who are unhappy are attended to swiftly. If not, they would have a negative perception of the hospital.

15

5) When a patient's family member is unhappy with the level of service, my team responds promptly to resolve the issue.


Strongly Agree

Agree

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Agree 16.13% 5

Disagree 3.23% 1


Total 31

Reason question was asked To determine if family members who are unhappy are attended to swiftly. If not, they would have a negative perception of the hospital.

16

6) My department has taken action to improve based on previous patient satisfaction feedback collected from HCAHPS surveys.


Strongly Agree

Agree

Neither Agree nor…

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Agree 21.88% 7

Neither Agree nor Disagree 6.25% 2

Disagree 3.13% 1


Total 32

Reason question was asked To determine if the data collected from previous patient feedback (survey scores) is being utilized to improve the areas that received low scores.

17

7) My department has taken action to improve based on previous patient satisfaction feedback collected from discharge phone calls.


Strongly Agree

Agree

Neither Agree nor…

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Agree 21.88% 7

Neither Agree nor Disagree 25.00% 8

Disagree 0.00% 0


Total 32

Reason question was asked To determine if the data collected from discharge phone calls is being utilized to improve the factors causing poor patient satisfaction.

18

8) I feel adequately trained in order to effectively communicate to patients when they are upset.


Strongly Agree

Agree

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Agree 28.13% 9

Disagree 6.25% 2


Total 32

Reason question was asked To determine if employees are properly trained to communicate effectively to unsatisfied patients. Communication is a vital component of customer service.

19

9) I feel adequately trained in order to effectively communicate to the patients' families when they are upset.


Strongly Agree

Agree

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Agree 32.26% 10

Disagree 6.45% 2


Total 31

Reason question was asked To determine if employees are properly trained to communicate effectively to family members of patients who are upset. Communication is a vital component of customer service.

20

10) When multiple family members visit a patient, I identify the key family member with whom to communicate.


Strongly Agree

Agree

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Agree 32.26% 10

Disagree 3.23% 1


Total 31

Reason question was asked To find out if employees are using the approach to identify a key family member of patient instead of providing information to someone who may not speak with other family members. This was mentioned as an issue in the interview.

21

11) I always communicate in a clear manner making sure that patients understand what I am saying.


Strongly Agree

Agree

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Agree 21.88% 7

Disagree 3.13% 1


Total 32

Reason question was asked To determine if employees are taking the time to communicate in a clear manner in order to educate patients. Educated and informed patients will likely have a higher level of satisfaction than those who are not.

22

12) I always communicate in a clear manner making sure that the patients’ family members understand what I am saying.


Strongly Agree

Agree

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Agree 18.75% 6

Disagree 0.00% 0


Total 32

Reason question was asked To determine if employees are taking the time to communicate in a clear manner in order to educate family members. Educated and informed family members will likely have a higher level of satisfaction than those who are not.

23

13) What best describes how the patient experience relates to your job?


It is ingrained in...

It is a checklist of...

I focus on it sometimes

It is not something..,

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices Responses It is ingrained in my culture 84.38% 27

It is a checklist of things I do to help engage patients (on top of my everyday responsibilities) 15.63% 5

I focus on it sometimes 0.00% 0

It is not something I pay attention to 0.00% 0

Total 32

Reason question was asked To determine how large a role it plays for each employee. It was mentioned during the interview, and in external readings, that this needs to be a part of each person’s job and not viewed as an additional checklist or extra work.

24

14) (2nd & 3rd shift staff only) I make sure the area by patient rooms remains quiet at night.


Strongly Agree

Agree

Disagree

Strongly Disagree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Agree 37.50% 3

Disagree 0.00% 0


Total 8

Reason question was asked To measure how many employees are making sure that the areas by the patient rooms are quiet at night. This was mentioned during the interview as a concern, and noise can certainly affect patient satisfaction adversely.

25

15) Discuss any barriers that may currently interfere with a patient’s level of satisfaction in the hospital.


Key Responses: “I believe miscommunication could be a barrier. If there is no communication the patient may feel confused, anxious and irritable and it could interfere with the patient's well-being and level of satisfaction.” “There are hospital culture barriers that currently interfere with patient satisfaction. Please note this is a hospital wide issue and only partially related to this specific unit. The hospital as a whole has a barrier to change related to feelings voiced about the system not being broken and a comfort level of doing things the way they have always been done. The general patient satisfaction level is high here; however, it could be said that some patients are unaware of how excellent their experience could be. We need to work together to involve the patient and their family in their care decisions. This could be as simple as providing medications at the times the patient routinely takes them at home (unless this is detrimental to hospital therapies ordered to treat the acute conditions). One of the barriers, again related to culture, is we (nurses) must perform things as the provider has ordered. This is not always so, and there should be more education regarding advocacy. Nursing can inquire in order to understand the rationale for therapies without questioning the skill or knowledge of the physician.” “Having to perform every 2 hours activity when a patient is sleeping or wants to sleep. Overhead announcement at night that interferes with a patient sleep. Family visiting throughout the night that keeps the patient up.” “Delay in receiving medications from the pharmacy. For example, Phenergan is frequently ordered for vomiting patients and the patient continues to vomit until the Phenergan arrives from pharmacy. This is a common area of concern for the ED. Staffing has been an issue in the ED. With the initiation of new patient care areas in the ED, we have continued to have the same staffing guidelines as we previously did. There should be adequate technicians and nurses to accommodate for all patients. I personally feel as though my patients are much more satisfied when I have less patients and a technician to assist with their needs. I truly believe that our nursing leaders are trying to address this issue however while attempting to gain new team members, our current team and patients are suffering.” “Only focusing on patient satisfaction hinders patient safety when it comes to patient care. When taking care of a patient, patient safety should come first meaning proper staffing on the floor to care for the sick which will improve patient satisfaction.” “Waiting and breakdowns in communication.” “Patient-staff ratio, delayed response from Physician Assistants particularly at night.”

26

“Time and availability of staff.” “Radiology delays in reading films delays patient throughput and decreases the patient and family's level of satisfaction. Also the delay in seeing an Emergency Psychiatric Evaluator causes the patient and family's level of satisfaction to decrease.” “Time of discharge is sometimes too long a wait, or the patient is discharged later than they want to be.” Reason question was asked Hospital staff who work directly with patients may observe barriers that may not be known by others. Or, they may provide the same information collected via the other data instruments which would indicate that certain barriers are the primary ones affecting this issue. The survey was primarily based on quantitative data, and this question allowed employees to provide an open ended-response to capture qualitative data on this topic.

27

17) Based on your observations, what areas in the hospital require the most focus in order to improve the patient experience? (This could include communication, cleanliness, quality of food, timeliness of receiving medications, staffing issues, etc.)


Key Responses: “Communication remains an issue. This includes charges on the floor communicating with the ED charge nurse about delays in bed assignments, communication within the department, and communication with radiology when issues arise.” “Cleanliness is a big opportunity for some of the units because dust builds up around the rooms (especially if vacant). Staffing is always a concern for most employees and this can be corrected if more work was out into fixing some of the processes impacting the bedside nurse and techs. This includes pharmacy issues, team members not communicating (physician and nursing), and extra documentation. I witness bedside staff following up on missing items and coordinating tests for patients that take them away from the bedside. The pt experience should be centered around providing an environment that promotes the highest quality of care through efficient processes and caregivers.” “Staffing issues both on the part of the ancillary staff and nurses.” “Communication in healthcare will be an issue until we break down the barriers that continue to exist between the care providers. We are all here for the same purpose. Nursing should not be afraid to ask questions of ordering providers. On the same hand they should not be afraid to make recommendations based on years of experience and knowledge of current practices. Healthcare cannot exist in a vacuum. We must all adjust our way of thinking and incorporate the best practices into the care of each patient and family as individuals. Although, this has come a long way, this hospital can still make strides to perfect communication amongst the team. We should be informed prior to walking into a room, and dread the encounters when we are asked by patients/families if we talk to one another. Without team communication we cannot provide the continual care necessary to bring people to wellness and keep them there.” “In order to provide proper safe care staffing needs to be improved (nursing and tech.) In addition, no nurse should have to work a full 12 hr shift without a break whether it be mental or a breather this happens much too often.” “The waiting rooms for the ED and the main OR are not patient friendly and private.” “Cleanliness is very important as this is what patient and family members see, especially when waiting for treatment or a bed they want to be in a clean, orderly area communication is very important as patient and families need to be informed..they need to know who or why they are waiting and what is planned and when.” “Communication, staffing issues.”

28

"Nurse staffing levels have an effect on a variety of areas within nursing. One of the most profound is the effect on patient quality of care, which refers to the values and expectations of the consumer, i.e. the patient. Hospitals with low staffing tend to have higher incidence of poor patient outcomes. Poor nurse staffing affects not only the patient, but the employee as well. Insufficient staffing increases nurse workload and job dissatisfaction, and it decreases total patient care overall. Job dissatisfaction is four times higher for nurses than the average rate for all U.S. workers, and one in five nurses report they intend to quit their job within a year. Inadequate nurse staffing leads not only to adverse patient outcomes, but increased nurse burnout" (Martin, 2015). Martin, C. J. (2015). The effects of nurse staffing on quality of care. Academy of Medical-Surgical Nurses, 24(2), 4-6. “Staffing issues. There is a shortage of staff across the hospital and nursing staff is run dry.” “Cleaning rooms upstairs in a timely manner. Expediting reading of radiology and lab testing so patients aren't left waiting for an unnecessary amount of time. More qualified staff (making sure techs have all necessary training needed to complete their jobs like splinting and monitor certifications).” “Communication between staff and most importantly communication between staff and the patient.”

Reason question was asked Hospital staff who work directly with patients may see areas that require focus that may not be known by others. Or, they may provide the same information collected via the other data instruments which would indicate that areas requiring focus are the primary ones affecting this issue. The survey was primarily based on quantitative data, and this question allowed employees to provide an open-ended response to capture qualitative data on this topic.

29

EXTANT DATA COLLECTED Patient Comments Report: January 2014 – December 2015 There were 3,265 listing in this report. It contained documentation of comments provided by patients and how they rated their experience at City Hospital. The breakdowns are identified below.

HCHAPS Survey Results: 2013 – 2016

The hospital has demonstrated an increase over the past four years. The tactics that were implemented have delivered positive results. Communication about medicines is currently an area of concern.

52%

27%

9%

12%

Positive

Negative

Mixed

Neutral

30

Employee Engagement Survey There were many high scores in the results of the employee engagement survey that the hospital conducted in late 2015. Two areas that received low scores were staffing and communication.

Online Reviews

Positive and negative feedback was provided via Yelp and Google+. A common trend in the negative reviews was wait time. Other trends included inconsistent staffing, cleanliness and poor customer service. The Urgent Care Center that recently opened around the corner should offset the emergency department wait times.

31

Yelp: Results through May 2016

Google+: Results through May 2016

CURRENT INITIAVES The intention of the analysis in this report is to provide findings and recommendations to help remedy the issue of patient/family engagement. However, the data also reflected that the hospital is currently providing a number of initiatives to positively impact the hospital’s engagement with patients and their families. These efforts have improved HCAHPS survey results in recent years.

They include:

Providing a welcome packet and video to patients Offering multiple methods for patients/families to provide feedback Collecting feedback from hospital staff Implementing techniques from the Studer Group (beginning in 2013) Providing community outreach (including hosting a local business association and

reaching out to faith based organizations) Conducting multidisciplinary rounding Developing an annual health fair for the community Offering high performer incentives for staff Television commercial promoting the hospital Development of group homes in the community Giving cards to patients encouraging them to provide feedback on social media sites

32

FINDINGS AND RECOMMENDATIONS

FINDINGS RECOMMENDATIONS

Staffing and turnover/retention is a major challenge. The lack of adequate staff is perceived as the primary barrier interfering with patient satisfaction in the hospital. (obtained via interview, survey, focus group, extant data)

Increase staffing to improve employee engagement which will positively affect patient/family engagement. This will improve nurse retention so that the nursing staff can remain assigned in their area and feel supported. There should be enough staff to meet the needs of patients. Consider creating new Patient Service Navigator positions to serve as patient advocates addressing the needs of patients and their families and working between the patients and clinical staff. The Cleveland Clinic (www.clevelandclinic.org) includes these members on their nursing teams and nurses have reported an improvement in their job satisfaction as a result. City Hospital has a Guest Relations Representative in the ED, but additional positions could be created in the main hospital. Johns Hopkins Hospital (www.hopkinsmedicine.org) has several Clinical Customer Service Coordinator positions who communicate between patients/families and the physicians and nurses.

Communication is the second most commonly identified barrier, and the data also indicates that this area requires the most focus to improve. This includes:

staff-to-staff communication staff-to-patient communication patient-to-staff communication

Approximately 25% of staff does not strongly agree that they communicate clearly to patients. At least 33% of staff does not strongly agree that they are adequately trained to effectively communicate to patients and their families when they are upset. (obtained via interview, survey, focus

Develop a culture of open communication where staff can check with each other making sure what they are saying is clear. There should be a comfort level so that if anything is unclear, a team member can ask for confirmation to make sure they understand. Training should be provided to improve staff-to-patient communication that focuses on compassion and customer service. The training could be a combination of eLearning and role play. Incorporate a more scripted approach for physicians when speaking to the patient/family to ensure that the communication is clear. Educated patients will likely be more satisfied. Managing up is a solid fundamental approach that the hospital is implementing. Addressing this as a cultural professional practice will be beneficial.

33


group, extant data)

There is still a negative perception of the hospital in the community. (obtained via interview, focus group)

Develop a patient/family advisory council to look at ways of improving the relationship between the hospital and the community. A toolkit was developed by the Colorado Hospital Association. This is an excellent resource that provides step-by-step details on how to create one. https://www.cha.com/Documents/Focus-Areas/Patient-Safety/PFAC-Toolkit-_December-2014_Final.aspx

New patients receive the welcome packet, but the communication explaining this is not always provided and has not been a priority. (obtained via interview, focus group)

The charge nurse should verbally explain the contents of the packet with the patients or family members. Literacy may be a barrier for print communication. Accountability needs to be a priority for the nurse to explain the items in welcome packet. A script may be helpful, but a clear explanation is paramount even if a nurse does not want to recite a script. The 3-minute video should be also shown on the television at that time. Providing clear communication from the beginning is important because educating the patients and their families with this information will likely improve their level of satisfaction.

Noise is a factor during the night. This has a negative effect on the patient experience. Only 50% of staff strongly agree that their areas are kept quiet at night. Overhead paging creates additional noise. (obtained via interview, survey)

Eliminate overhead paging. Explore options such as secure messaging to replace it. There are reliable desktop and mobile communications platforms used in other healthcare facilities to improve the patient experience. Posters could be designed and displayed near patient areas with reading “Shhh!” to remind staff that this is a quiet zone, and employees need to ask patients if would like their doors closed at night. This could entail training or having other educational materials available for staff to remind them about this.

Senior leader rounding on staff is conducted by some members of senior management but not others.

If this could be done more often it would support the nurses and staff, and increase accountability which would ultimately impact patient/family engagement in a positive manner.

34


(obtained via interview) Quint Studer, CEO of the Studer Group® (www.studergroup.com) stated, “Senior leader rounding is one of the most powerful tactics we see in our work with organizations across the country. It re-engages and reassures staff members. It helps people ‘connect the dots’ on why we make the decisions we make. It lets us reward and recognize departments and individuals who are getting it right.”

Cleanliness is a common issue requiring focus to improve. (obtained via survey, extant data)

Address accountability and/or improve staffing in the Environmental Services department.

Approximately 15% of staff does not have a strong understanding of the term patient experience. (obtained via survey)

The Beryl Institute (www.theberylinstitute.org) recommends having a formal definition of patient experience for the hospital. They also suggest that the patient experience effort should include a formal mandate/mission.

Over 33% of staff do not strongly agree that they can identify a key family member. (obtained via survey)

A key family member could be formally identified as part of the admission process, or training on how to identify a key family member could be provided.

There is room to improve the action taken based on previous specific HCAHPS survey results. (obtained via survey)

Previous results from HCAHPS surveys should drive areas of focus to improve.

Approximately 15% of staff view the patient experience as an additional checklist of things to do on top of their everyday responsibilities. (obtained via survey)

Incorporate training and staff development so that the patient experience becomes ingrained in their culture instead of being perceived as extra work.

Delays from radiology, getting medication, and getting responses from staff in meeting the needs of patients is the another commonly cited issue as a barrier. (obtained via survey)

Improve staffing and communication. Direct communication should be provided to the patient so that the reasons for the delays are understood. If delays are a result of inadequate staffing, then additional clinical or support team members are needed.

35


Patients are moved to different rooms late at night because of staffing. (obtained via focus group)

Explore alternatives to stop this procedure as it results in patients and families being upset that they were moved at night which disturbed their sleep.

Physicians come in to see the patient at times when the family members are not present. (obtained via focus group)

Have a communication tool left for key family members who are not there when the doctor saw the patient.

The ED has a full time guest relations position which has been beneficial for patients. There is a gap in providing this service when this employee’s shift is over. (obtained via focus group)

Add an evening shift position beginning at 7:00 p.m. that has the same responsibilities working with patients.

More work could be done to help the branding of the hospital in the community. (obtained via focus group)

Develop an oversized postcard as a direct mail piece to promote the hospital to the community. It could include the image of a family to make the hospital look warm and inviting. Focus on social media as a tool for public relations.

Delays/wait time in ED (obtained via focus group, extant data)

If the proper communication is made and explained clearly, the patients would understand what they are waiting for and how long they are going to wait. The evening shift recommendation (above) could curtail frustration for ED patients at night.

If someone is not at the front desk, patients may not know how to get to the south elevators because the sign is far away. (obtained via focus group)

Display signage that is visible from the front desk that provides information for family members to get to the south elevators. This would reduce the amount of confusion.

When visitors are given a patient’s room number, it is not always correct, and they return to the front desk. There are two systems used for this information. Cerner is up-to-date but Medipac is not which can negatively affect the engagement between family members and the hospital.

Look into synchronizing the two systems, or provide read-only Cerner access to the volunteers who can only access the Medipac system.

36


(obtained via focus group)

Complains have been made that parking is inadequate in the ED and main hospital. (obtained via focus group)

Explore plans for additional parking options, particularly for the ED.

Family members of patients park in the fire lane at the entrance of the hospital. (obtained via focus group)

Place a larger sign that clearly indicates that it is illegal to park at the front entrance as a deterrent.

37

APPENDICES

38

APPENDIX A: CITY HOSPITAL ALIGNMENT MEETING REPORT

Alignment Meeting Date February 29, 2016

Alignment Agenda Meeting purpose Verify project goal and data collection instruments Discuss target dates Confirm project roles Completion date Deliverables Summary

Request City Hospital is seeking the voices of the patients and families in their community to improve the patient experience by delivering the highest quality and service.

Scope of Analysis The goal of this analysis is to positively impact City Hospital’s patient and family engagement and ultimately increase their patient experience scores.

Analysis Type Jon Rottenberg will conduct a TNA for City Hospital

Project Roles Jon Rottenberg, Analyst Director of Patient Experience Vice President of Operations Quality Improvement Assistant

Subject Matter Experts Director of Patient Experience, Guest Relations Staff

Documentary Sources of Information

Past Hospital Survey Scores Feedback from Patients/Families Research Successful Hospitals Interviews: VP Operations and Director of Patient

Experience Online Survey with Hospital Staff Focus group with Hospital staff

Target Dates March 14 – Interviews (Director of PE & VP Operations) March 25 – Surveys (Hospital Staff) April 8 – Focus Group (Hospital Staff)

Project Completion Date The projected completion date of the analysis effort is May 16, 2016.

Follow‐up on Design and Development

Design and development of any recommended interventions are beyond the scope of this analysis project.

Final Delivery Report Jon Rottenberg will deliver the final written report to the client, Director of Patient Experience, on May 16, 2016. Ongoing discussions and a review of the final report will be conducted on or before the delivery date. The report will include the findings and recommendations of the analysis.

39

APPENDIX B: CITY HOSPITAL NEEDS ANALYSIS PLAN Background: City Hospital has expressed a need to develop a patient and family strategy within their community. City Hospital is seeking the voices of the patients and families in their community to improve the patient experience by delivering the highest quality and service.

Problem Statement: City Hospital is striving to improve their reputation and brand in the community, in order to be the hospital that the community looks to for their medical needs. There has been a lack of community engagement between the hospital and their patients and families resulting in lower than desired HCAHPS hospital survey scores which affects State funding.

Overall Project Goal: The overall goal of this project is to improve the relationship between the hospital and the patients/families within its community so that the HCAHPS survey scores improve.

Analysis Tasks and Objectives:

Identify what barriers are affecting the hospital’s relationship with the patients and families and how these factors are hurting the brand/reputation of the hospital

Obtain information and ideas from the hospital’s leadership based on their experience Review existing information including previous HCAHPS hospital survey scores,

complaints (and compliments) received that are available via Google+ and Yelp, and grievances filed by patients

Research what successful hospitals are doing regarding this issue Identify strategies for the hospital to engage with patients and families within their

community Recommend the best solutions that will improve the patient experience

Data Collection Scheme:

INPUTS PURPOSE METHOD

Documentation of Interview

To discover what barriers are occurring and to obtain detailed information from the hospital about their concerns and desired outcome.

Interview (VP Operations and Director

of Patient Experience)

Feedback received by the hospital

To identify key issues which have caused distress for patients/families.

Extant Data

Prior HCAHPS Hospital Surveys

To review the scores of the surveys over the past several years.

Extant Data

Research To discover what successful hospitals doing in regards to this issue.

Independent Research (Benchmarking)

Hospital Staff Survey To see what the views of the staff are to help determine what areas need improvement.

Online Survey (Hospital staff who have direct involvement with

patients/families)

Focus Group To obtain direct feedback from hospital staff. Focus Group

(Guest Relations staff who are subject matter experts)

40

APPENDIX C: INTERVIEW INSTRUMENT Interview Date March 14, 2016 Interview Agenda

Introductions Review Alignment Meeting Report Review Data Collection Plan

Review Business Goal

Interview Questions

Summary

Data Materials

Alignment Meeting Report

Data Collection Plan

Attendees

Jon Rottenberg, Analyst Vice President of Operations Director of Patient Experience Business Goal from Alignment Meeting Report The goal of this analysis is to positively impact City Hospital’s patient and family engagement and ultimately increase their patient experience scores Confidentiality

The data collected from these interviews will not include the hospital name or names of the interviewees. Interview Questions: VP Operations

1) What is your perspective and perception of the problem?

2) What would you like to see as a result of this applied research project?

3) What strategies is the hospital employing to improve the patient experience?

4) What levels of success have you had with those?

5) What are the challenges facing clinical staff, patients and families?

6) What would you like to see performed differently that is not being done presently?

7) What areas in the hospital require the most focus in order to improve the patient

experience? (This could range from communication to cleanliness, quality of food,

timeliness of receiving medications, staffing issues, etc.)

41

8) What type of training is provided to hospital staff that would help provide effective

communication to the patients and families, making them feel more engaged with the

hospital?

9) How effective is it?

10) What could be improved?

11) How do patients and families currently provide feedback while they are in the hospital?


patients?

13) Does senior management ever make rounds to visit patients to see how they are doing?

14) If yes, describe what the experience is like.

15) If no, would that be considered?

16) What strategies have been made to positively engage hospital employees so that their

efforts as high performers could help improve patient satisfaction?

Interview Questions: Director of Patient Experience

1) What is your perspective and perception of the problem?

2) Can you describe the term patient experience?

3) How does the hospital keep in contact with patients after they have been discharged?

4) What community outreach initiatives have you conducted/implemented?

5) How successful have these community outreach initiatives been?

6) What feedback have you received from patients about their experiences at the hospital?


patients?

8) How are you currently implementing patient and staff feedback into your customer

service strategies/initiatives?

42

APPENDIX D: FOCUS GROUP INSTRUMENT

Focus Group

Meeting April 25, 2016

Purpose

Focus Group: A small group of people who meet to discuss a particular issue. The participants in this group are considered subject matter experts on the issue. The meeting is facilitated by one or two moderators. Project: To gather information based on the reasons why patients and their families may not feel engaged to City Hospital.

Business Goal The goal of this analysis is to positively impact City Hospital’s patient and family engagement and ultimately increase their patient experience scores.

Audience Six hospital team members who perform various roles in the Guest Relations department. They are all experienced in dealing with patient/family engagement.

Agenda Facilitator Introduction Project Purpose & Goal Explanation Business Goal Confidentiality Ground Rules Participant Introductions Introductory Questions Key Questions Closing

Facilitator

Introduction Jon Rottenberg, Analyst

Project Goal

Explanation

To positively impact City Hospital’s patient and family engagement.

To identify what barriers are affecting the hospital’s relationship with patients and families.

To improve City Hospital’s reputation and brand in the community.

To increase the patient experience scores of the HCAHPS surveys.

To deliver a report based on the analysis and make recommendations based on the findings.

Confidentiality All of the information provided in this focus group will be kept strictly confidential. No names will be used in the report.

43

Ground Rules We have one hour and ask that we all try to keep focused on the question at hand.

We will begin with introductions.

When a question is asked, each person will answer the question before the group begins the discussion.

The facilitator will try to make sure everyone gets equal time.

No side conversations, cross talk, or interrupting.

Please be respectful of each person’s answer, there are no wrong answers. Say what is true for you.

Thank you for your time; it is greatly appreciated

Participant

Introductions and

Introductory

Question

Please provide your name and title.

What is your direct level of involvement with patient and family engagement?

Key Questions 1. What are your experiences like when interacting with patients and their families?

2. What occurs during the admission process that engages patients and families with City Hospital?

3. What are the most common reasons why patients and families may be dissatisfied with their level of service?

4. What barriers do you see that may affect City Hospital’s relationship with patients and families?

5. What would it take for City Hospital to provide better engagement with patients and families?

6. What could be done to improve City Hospital’s reputation and brand in the community?

7. Is there anything that wasn’t mentioned, but should be addressed?

Closing Thank you very much for your participation and valuable feedback!

I appreciate your time and willingness to discuss your opinions and provide your insight about this topic. Your input is important and will be used to ensure that City Hospital is providing the best possible service it can offer.

44

APPENDIX E: SURVEY INSTRUMENT Welcome!

City Hospital is currently conducting a survey in order to improve patient and family engagement, as we are on our Quest to be The Best. This survey is for staff who interact directly with patients, families and customers.

We appreciate your time and feedback in completing this survey as it will help inform us of what areas may need support and what strategies can help improve the patient and family engagement with the hospital.

The survey is completely anonymous, and the results will be used to ensure that City Hospital is providing the best possible service it can offer. The survey should take approximately 10 minutes to complete and it will be available until April 27, 2016.

Your feedback is valuable to us. Thank you!

______________________________________________________________________________

(Select 1 answer for each multiple choice question)

Select the role that is most closely associated with your position/department: Nurse Physician ED Other ______________________________________ How important is patient satisfaction? a) Very Important b) Important c) Somewhat Important d) Not Important I have a clear understanding of the term patient experience. a) Strongly Agree b) Agree c) Disagree d) Strongly Disagree When a patient is unhappy with the level of service, my team responds promptly to resolve the issue. a) Strongly Agree b) Agree c) Disagree d) Strongly Disagree When a patient’s family is unhappy with the level of service, my team responds promptly to resolve the issue. a) Strongly Agree b) Agree c) Disagree d) Strongly Disagree My department has taken action to improve based on previous patient satisfaction feedback collected from HCAHPS surveys.

45

a) Strongly Agree b) Agree c) Neutral d) Disagree e) Strongly Disagree My department has taken action to improve based on previous patient satisfaction feedback collected from discharge phone calls. a) Strongly Agree b) Agree c) Neutral d) Disagree e) Strongly Disagree I feel adequately trained in order to effectively communicate to patients when they are upset. a) Strongly Agree b) Agree c) Disagree d) Strongly Disagree I feel adequately trained in order to effectively communicate to the patients’ families when they are upset. a) Strongly Agree b) Agree c) Disagree d) Strongly Disagree When multiple family members visit a patient, I identify the key family member with whom to communicate. a) Strongly Agree b) Agree c) Disagree d) Strongly Disagree I always communicate in a clear manner making sure that patients understand what I am saying. a) Strongly Agree b) Agree c) Disagree d) Strongly Disagree I always communicate in a clear manner making sure that the patients’ family members understand what I am saying. a) Strongly Agree b) Agree c) Disagree d) Strongly Disagree What best describes how the patient experience relates to your job? a) It is ingrained in my culture b) It is a checklist of things I do to help engage patients (on top of my everyday responsibilities) c) I focus on it sometimes d) It is not something I pay attention to (2nd & 3rd shift staff only) I make sure the area by patient rooms remains quiet at night. a) Strongly Agree b) Agree c) Disagree d) Strongly Disagree Discuss any barriers that currently interfere with a patient’s level of satisfaction in the hospital. (Type your comments in the comment field) Based on your observations, what areas in the hospital require the most focus in order to improve the patient experience? (This could include communication, cleanliness, quality of food, timeliness of receiving medications, staffing issues, etc.) (Type your comments in the comment field)

City Patient Family Engagement Applied Research Project ... fileexpressed a need to develop a...

Documents

Transcript of City Patient Family Engagement Applied Research Project ... fileexpressed a need to develop a...