The Patient Experience

Improving the patient’s perception of care isn’t just the work of doctors and nurses, but all support personnel too. Including supply chain.The hospital room as sacred space? That’s how Grace Ibe, RN, perceives it.

“We treat our patients with respect and dignity,” says Ibe, senior director, service excellence and culture development, St. John’s Regional Medical Center, Oxnard, Calif. “When a nurse or physician goes into the patient’s room, it’s not the caregiver’s room, but a separate space for the patient, and we as caregivers are visiting the patient in their sacred space. If you look at the traditional hospital, you see people walking in and out, interrupting, with a lot of technology and different things. But what do our patients want? They want to heal quietly.” St. John’s – like hospitals across the country – is working hard to improve its patients’ experience of care. Most important, it’s the right thing to do. But there’s another factor at work – the Affordable Care Act’s Value-Based Purchasing program. The program financially rewards – or penalizes – hospitals based on how they perform on various clinical processof-care measures, as well as several patient experience measures, as recorded through the Hospital Consumer Assessment of Healthcare Providers and Systems survey, better known as HCAHPS.

For Ibe and others with whom the Journal of Healthcare Contracting spoke, improving patient experience isn’t just a matter of sending patients home happy. And it’s more than patient satisfaction surveys, though that is part of it. Rather, it is the belief that the hospital should be a healing environment, not just a curing one. The responsibility to create that environment extends beyond the nurses, doctors, and other clinicians, to include all who support them, including supply chain professionals.

Points measured
The Hospital Value-Based Purchasing Program applies to payments beginning in Fiscal Year (FY) 2013, that is, on or after Oct. 1, 2012, and affects payment for inpatient stays. The Centers for Medicare & Medicaid Services bases hospital performance on an approved set of measures and dimensions, grouped into specifi quality domains. Currently, the program focuses on two domains: clinical process-of-care, and patient experience. The clinical measures include actions taken for acute myocardial infarction, heart failure, pneumonia and surgical care. The dimensions of the patient experience of care domain for
FY 2013-2015 are:
• Nurse communication
• Doctor communication
• Hospital staff responsiveness
• Pain management
• Medicine communication
• Hospital cleanliness and quietness
• Discharge information
• Overall hospital rating
Each hospital’s performance in terms of patient experience is based on responses to the 32-question/item HCAHPS
survey. For years, hospitals have collected information on patient satisfaction. But prior to value-based purchasing and HCAHPS, there was no national standard for collecting or publicly reporting information about patients’ perspectives of care – information that could enable valid comparisons to be made across all hospitals, according to CMS. The survey contains 21 items that ask how often or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfid” with their care. It is administered to a random sample of adult inpatients between 48 hours and six weeks after discharge.

Determined to improve
The staff at St. Luke’s Hospital, Miners Campus, Coaldale, Pa., has worked to improve its patients’ experience of care, and the effort is paying off. Kimberly Sargent, BSN, RN, vice president, patient care services, recounted some of the hospital’s efforts at the Premier Breakthroughs Conference in June in San Antonio, Texas, and later, spoke with the Journal of Healthcare Contracting.

In FY 2013, the facility received a 0.15 percent payment from CMS as part of the Hospital Value-Based Purchasing program. Not satisfid, hospital leadership resolved to improve its performance in FY 2014 for clinical and outcomes measures, as well as patient experience. To address the latter, St. Luke’s:
• Developed a Patient Satisfaction Committee to discuss opportunities and actions to improve and sustain HCAHPS domains and scores. From this committee, sub-committees were formed to focus on each domain.
• Worked with the emergency department to focus on patient experience engagement, as most admissions begin in the Emergency Department.
• Instituted thorough, ongoing education on patient experience for all employees. Topics included positive patient communication and fist impressions.
• Instituted patient rounding, not only by staff, but leadership as well
• Shared HCAHPS data with administration, management and staff, in an effort to increase awareness and accountability at all levels.
The work paid off. St. Luke’s overall performance score went up, resulting in a 0.76 percent positive payment impact from CMS beginning FY 2014. This score and associated fiancial impact gained recognition as the eighth highest in the United States and the highest in Pennsylvania.

Patients’ expectations
Hospitals’ understanding of patient experience has changed in recent years, says Sargent, who has been in her current position since December 2010. As recently as seven or eight years ago, hospitals emphasized patient satisfaction, as measured through patient surveys, she says. Today, “it’s not just about executing patient satisfaction; it’s a matter of, ‘What is it we can do to make the hospital experience the best one the patient can have while he or she is ill?’”

In years past, the focus of patient surveys was usually, “How did we do?” she continues. “Now we want to address, ‘What are our patients’ expectations?’” It’s an important question, because patients’ attitudes have changed, fueled in part by social media, electronic networking and more, she says. “And we’ve gone from a society where, in the past, you went to the doctor and did what you were told to do, no questions asked.” Today, patients can compare one hospitals’ outcomes to others simply by going online, and patients have opinions – and expectations – about some of the amenities associated with a hospital stay, such as food, parking, and even what the lobby looks like. To meet these expectations, all staff must be involved, not just those responsible for patient services, says Sargent. “If your employees are happy and prideful in what they do, that will spill over into how they treat patients and the patients’ perceptions of employees.”

Materials management
Says Kevin Hines, associate vice president, network materials management, St. Luke’s University Health Network, “I think everybody in our organization has a heightened awareness of patient experience, and I’m seeing more and more discussions, committees and meetings that include the ancillary and support departments. “Materials managers should be concerned about patient experience and the role we play,” he continues. “If the clinician is unable to perform a procedure or test because of a missing piece of equipment or supply, that delays patient care, which can lead to frustration not only on the clinician’s part, but that of the patient as well.
“We talk to our staff and ask, ‘If your loved ones were receiving care, how would they feel about the way we deliver it?’ hesays. “Rolling a cart with a squeaky wheel down the hall can be a disruption. So we want our people to be aware of their presence on the flors and the impact they can have on the clinicians. “And a smile and a ‘Good morning’ from someone pushing a cart may not seem like a lot, but it goes far toward helping patients feel more comfortable.”

Transformative experience at 21
Grace Ibe has been a nurse for 35 years, but it was during his fist year – at age 21 – that she had an experience that would transform her approach to her profession.

“I had open heart surgery,” she says. “When I was in the midst of it, I promised myself that when I got better, I would work to take care of patients safely and compassionately.” The experience inspired her to look for innovative projects that could bring the entire hospital staff together to optimize the overall patient experience.

Years ago, open heart surgery meant an inpatient stay of weeks, she says. “Now, you’re up and feeling better and ready to go home in four days.” Given that, the need to create a healing environment is more urgent than ever, she says. Her vision – of the hospital as healing environment – was one she shared with Laurie Harting, who was the CEO of St. John’s prior to becoming senior vice president of operations for the Sacramento (Calif.) service area for Dignity Health, of which St.John’s is part. Work began in earnest in January 2011.

St. John’s created a Service Excellence Steering Committee, designed to increase employee engagement in improving the patient experience; as well as “Sacred Work Retreats” for all leadership and frontline staff, designed to teach the principles of building a healing hospital. St. John’s also established a formal HCAHPS team in 2012, which established seven action items involving the hospitals’ HCAHPS scores: communication with nurses, communication with physicians, communications about medications, pain management, responsiveness, cleanliness/quietness and discharge information. The team developed specifi opportunities and supporting tactics for each.

Uppermost in the hospital’s approach was the belief that improving patient experience is the responsibility of everyone, and that it includes taking care of the people who take care of patients. By necessity, then, hospital operational and clinical leadership must be involved, says Ibe, who, with several colleagues, wrote a paper on the topic, “Cultivating the Healing Environment: Changing the Cultural Perception of Quietness in the Hospital.” Accordingly, administrative leadership increased their involvement by participating in leadership development retreats, daily rounds, daily huddles and the creation of a new position, the “measureventionist,” whose responsibility it is to measure actions and interventions during medication passes.

It’s not easy to change a hospital’s culture, says Ibe. “It was a challenge, and an absolute learning curve for me.” But from the start, she has focused on three themes: education and training, leadership accountability, and employee accountability. “My mantra – how I educate our leadership, the front line staff, everyone – is, ‘How would you like your mother to be treated when she steps through the door in our hospital?’ We want to provide the best of care. Treat everyone like your mother.”
The physical environment
Improving the physical environment is an important part of creating a healing hospital, says Ibe. It begins with respecting the patient room as sacred space. But it comes down to some basics as well.

“When the patient is in the room, they have nothing to do; maybe they’re waiting for some tests or surgery; they look at the ceiling and they can see every little bit of dust,” she says. “They think the room is infectious and fithy,” when in fact, it isn’t. Still, perception is everything.

St. John’s staff takes pains to keep patient rooms clean. Garbage is discarded often, bathrooms are clean, utensils (bedpans, urinals, pitchers, etc.) are tidy, organized and easily accessible. “Without that, it looks like clutter to the patient,” says Ibe.

Another important component of the healing hospital is quietness. Hospitals can be noisy, says Ibe. Some of that noise is unavoidable, but some can be controlled. The hospital’s HCAHPS team evaluated quietness in the facilities, attempting to address as many aspects of distraction and noise that a patient might identify. Hospital leadership began rounding the flors, talking to patients about noise and how to address it.

Avoidable noises include over-paging in hallways, says Ibe. Communication in medicine is vital, and physicians need to be able to call and be in action immediately. But the noise of paging is generally unacceptable to patients. So is the noise of squeaky carts. In fact, the HCAHPS team identifid a specifi needle exchange cart as especially disruptive, and discussed with the vendor ways to redesign it.

Quiet kits
To help address the noise issue, St. John’s began working with Medline Industries – as well as consultant Trent Haywood, M.D. and designer Deborah Adler – to develop prototypes of so-called “quiet kits,” to be given to patients upon admission. Such kits could give patients control over their environment and potentially speed the healing process, they decided.

After examining the prototypes, the hospital agreed on a standard quiet kit for most patients as well as a second “premium” kit – later christened “Refresh & Relax” – for longer-term patients. The kit contains the following items in a pillow-shaped box, and is delivered to patients by Environmental Services:
• Ear plugs, to help patients “relax and reconnect with themselves,” and to soften the noise levels within the hospital.
• An eye mask, to encourage rest, to help patients calm themselves, and to block out their surroundings as they go into an MRI or CT scanner.
• A “Voices Down, Please” card for the patient’s door, which is a way to remind staff to be mindful of noise, or to silently ask them to come back later.
• Lip balm, to soothe dry lips, especially nice for patients on oxygen.
• A “Questions for My Care Team” notebook, prompting patients to record questions and jot down things to remember, such as doctors’ and nurses’ names. Also useful for families.
• Sudoku and crosswords, to help patients and families pass the time or simply ease the anxiety of being in the hospital.
Quiet-kit trials began on the ortho-oncology flor due to the variety of patients and the opportunity to teach the staff the value and importance of the kit for differing patient situations. As the kits rolled out across the hospital, the easiest implementation came in Labor & Delivery, where new mothers were used to receiving gifts.

The kits not only give the patient the opportunity for needed rest and quiet, but they also serve as a visual cue that the hospital staff respects that the patient has a need for rest and quiet, and that the kit gives patients the power to convey those needs. They afford clinicians one more opportunity to engage in dialogue with the patient, and they can even serve as a conversation-starter between patient, doctor and nurse, which changes the focus away from the patient’s injury or illness, to healing and human kindness.

The quiet kits serve patients and their families well, says Ibe, who recalls the gratitude one man felt for having Sudoku to occupy his mind while waiting for his wife to wake up from a C-section. And word about the kits has spread throughout the community.

“I call them patient ambassador tools,” says Ibe.” We distribute them to all our patients, and they are happy to have them.” The physicians have caught on too. It’s not uncommon to hear a physician tell the surgical tech, “Don’t forget the quiet kit; she’ll have dry mouth after this procedure.” “Involving physicians, nurses, materials managers – it seems like a little thing, but we knew it would be great,” says Ibe. JHC


The healing hospital
Editor’s Note: The following is an excerpt of “Cultivating the Healing Environment: Changing the Cultural Perception of Quietness in the Hospital,” a white paper by Laurie Harting, CEO; Cathy Frontczak, RN, BSN, MBA, HCM, CNO, vice president patient services; Grace Ibe, RN, MSN, senior director, service excellence and culture development; and Kriselle Lim Walton, MPH, CSSB, director, performance excellence, St. John’s Regional Medical Center, Oxnard, Calif.

Putting patients fist requires more than simply
providing top-quality health care. It is no longer enough to just treat a patient’s health issue: One must treat the patient’s perceptions of their hospital experience. These perceptions can be a challenge, as a patient does not require literacy in medicine to “know” whether they received good treatment or not. Patients need only the ability to know if the service provider “cared” and showed concern.

The seemingly elusive positive patient experience goal remains the proverbial pebble in the shoe for many hospitals. As one CNO states, “There is no neutrality in the patient experience: It is either positive or negative.” Multiple touch points throughout a patient’s hospital stay provide countless opportunities for both positive and negative experiences, and what may have been a positive experience to begin with can quickly change with a single negatively perceived incident. Inconsistency is the prime killer of patient experience, yet it takes years to hardwire practice consistency into very moment.

Dignity Health’s St. John’s Regional Medical Center (Oxnard, Calif.) recognized that delivering high quality care as effectively and effiiently as possible is required in order to achieve operational and fiancial success in the future. To realize this success, the hospital leaders knew they needed to transform their hospital culture. They chose the “Healing Hospital” concept as their platformfor organizational change, promoting caregivers as healers with a duty to provide thoughtful, compassionate care to patients and families during their vulnerability, treating patients’ needs holistically, which in turn would impact the overall patient care experience.

Far from simply sending patients home well or whole, what makes a “Healing Hospital” are building blocks such as human interactions, empowering patients through education and information, healing arts, human touch and complementary therapies. While curing focuses on the disease, illness, or injury, healing is multifaceted, involving the structural (physical environment), process (interactions with caregivers), and outcomes (interactions of process and interpersonal encounters).

A focus on healing can turn the caregiver’s attention from the clinical to the personal, inflencing how they perform treatments and interact with patients, providing high-quality care that is “patient centered” and responsive to patients’ preferences, needs, and values. In other words, a focus on patient experience. JHC