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October 10, 2017

When not to say 'thanks for coming to our hospital' and other patient experience tips from 7 leaders

Daily Briefing

Editor's note: This story was updated on February 22, 2018.

iRound for Patient Experience members recently reached a milestone: completing 10 million rounds. After so many one-on-one encounters between leaders, patients, and staff, what have providers learned about how to improve the patient experience and build patient loyalty?

A few months ago, the Daily Briefing posed that question to iRound members. Here's what they told us:

March 13 webcon: How 2 member organizations improved patient safety with iRound

Laurie Michael
Director, Service Excellence, Saint Agnes Medical Center (Fresno, Calif.)

One of our best practices is involving patients more in decision-making. We just started a patient and family advisory council, and I shared some scripting that we were going to roll out in the ED, part of which was, "Thank you for coming to Saint Agnes." And they were appalled. They said, "Thank you for coming here is an awful thing to say to somebody who is in the emergency department, because they don't want to be here." That was a stark example of how we need to engage our patients more in these discussions.

Another best practice has been increasing nurse leader rounding on patients. The data showing significantly higher HCHAPS scores for patients who said they were rounded on by a nurse leader during their stay was truly shocking. This had a big impact on our leaders.

One of our biggest challenges has been getting nurse leaders to fit rounding into their days amid many competing priorities. Rounding can actually free up time in a nurse's day by surfacing smaller problems before they become bigger service recovery issues. But getting over that initial hump so rounding becomes routine is incredibly difficult. It requires hospital leadership to really support nurse leaders and make clear that rounding is a major priority.

Another thing we're focused on is recognizing the things our staff are doing well. I would love to have the notes on every single round include a comment on what a nurse is doing well because that's just so encouraging, especially for those who struggle a bit. Those small wins can be huge.

Bryce Rosche and Tonia Campbell
Service Excellence Consultant/Service Excellence Manager, ProMedica Monroe Regional Hospital (Monroe, Mich.)

We've put a lot of focus on transparency and creating systems of accountability. We started by posting blinded HCAHPS scores for individual physicians. Then, after a couple months, we started to post them unblinded.

There was huge initial pushback for unblinding scores, but we were ready for it: Our CMO had worked with our chief of staff and our top admitters to get them on board. Having the chief of staff bought in was key. He happened to be a top performer, and he made patient experience scores a regular agenda item in medical staff and department meetings. At monthly general medical staff meetings he recognized departments for their patient satisfaction scores. We also reviewed aggregate medical staff and/or medical department iRound performance on the evidence-based behavioral drivers that impact the HCAHPS questions and sent each physician weekly iRound patient feedback in aggregate and by units where their patients were rounded on.

Bryce Rosche (center) speaks with attendees of the iRound for Patient Experience Summit

Today, not everyone is on board—you still have performance denial and finger-pointing. However, we've come a long way; there is a realization that unblinding scores isn't about shaming low-performers, it's more about identifying the high-performers and spurring peer-to-peer discussions. We've had some people see their scores across different groups of patients and say, "I use the same style with everyone, I don't get it," which leads to a conversation about how the same style may not work as well across genders and generations. And that clicks a lightbulb on.

Our organization has also focused on how process changes can improve our HCAHPS scores. For instance, we had low scores in the ED from young women with vague abdominal pain, so we now have staff interface more frequently with those patients and ensure that clinicians get results back sooner from the radiology department.

For promoting leader rounding, it may sound simple, but we've really learned that you have to set a goal and hold people to it. In the beginning, we gave nurses a lot of leeway—we thought, well, they're not used to this type of rounding and they're busy. But as we got into the second year, the compliance rate wasn't really moving, it was hovering around 30 percent. So we set a target of 75 percent compliance, and that's when we really started to see movement.

Shawn R. Smith, MBA, CPXP
Vice President Patient Experience, Christiana Care Health System (Wilmington, Del.)

If you treat patient experience as a series of boxes you need to check, you get a factory experience; you don't get an exceptional, five-star experience. Our experience work has to be part of the bigger picture of doing the right thing for the patient and family.

One way we go about that is by having patient and family advisers built into just about everything that we do. Whether we're talking about décor of a waiting room, our visitation policy or a clinical pathway for COPD —they're involved. Some organizations take a baked-bread approach and say, "How's this bread?" We're saying, "Come to the kitchen and help us develop the recipe."

We also use iRound, which is a phenomenal tool that gives us real-time feedback. The challenge with the CAHPS program is that these are lagging indicators. You can't motivate people with old data. The iRound program gives us the ability to see leading indicators real-time, which is critical for success.

It's also crucial for us to have engaged employees who have a good work-life balance and are supported to find joy in their work. Engaged employees are able to deliver care that meets the patient's needs and makes them feel loved and cared for. Our organization does a lot of staff education. We had the first accredited patient experience academy in the country, where we trained staff on meeting new patient expectations, dealing with work-life balance and stress, working well in groups, and how to develop a culture of psychological safety so staff can be at their best.

Shelly Kretzler-Hoff
Manager of Nursing Operations, Christian Hospital Northeast-Northwest (St. Louis, Mo.)

The biggest rounding best practice we're focusing on right now is accountability from the top down. We have been doing rounding for a number of years now. However, going live with iRound and transitioning from logging rounds on paper—where the results would just sit in a drawer—to logging them electronically has made a huge difference.

Previously, our nurse leaders had rounded on their staff and patients but didn’t really have a mechanism to track who had been rounded on. Now, with the electronic system, they can track who has been rounded on and know they are going to be held accountable to their rounding practices. iRound has also allowed us to pull data and feedback from our rounds so that staff and patients know they are being listened to. When nurse leaders round on their staff, they are bringing up what they've previously discussed and asking, "How is this going for you? Did you get the education you needed? Were the resources helpful?"

That's a big shift, and employees really appreciate that nurse leaders are following up on what they discussed the previous month. It helps show they care, and that's led to staff being more engaged and communicating better with one another.

Another best practice we're working on now is promoting quality rounds. We spent the first year and a half or so hardwiring the electronic rounding tool, making it a part of our daily work — like taking vitals. Now we're focusing more on training staff to solicit honest feedback. They need to know that it's OK if a patient doesn't like the care they're getting, because we can log that and learn from it.

Lara Mead
Senior Consultant, Patient Experience, Vanderbilt University Medical Center (Nashville, Tenn.)

When it comes to promoting patient loyalty, a best practice for us has been to be more transparent. About a year ago, we started posting patient comments and ratings online. That sends a signal to patients that we are proud of our providers and we want to show what people are saying about them. There are some negative comments on there, which we can learn from, but the vast majority are really great and positive.

We've also been doing a lot of training around empathy and compassionate care, to make sure we're treating patients like people and not like a diagnosis.

For instance, we created what we call a PEP (Patient Experience and Perspective) Talk. It's a training package that includes a video clip on compassionate care that resonated with our nurse leaders and a self-assessment of behaviors—such as how often staff sit down when they talk to patients—that nursing staff fill out before having a group discussion on ways to be more empathetic with patients.

We're also doing what we call "52 weeks of empathy." Each week, the patient experience team sends out a tip like 'ask the patient what they want to be called and call them that' and 'hold the elevator for the patient'—just little reminders that are super-easy ways to make just a little difference in the patient experience.

When it comes to promoting leader rounding, a best practice for us has been to show the data on how much of a difference it makes. And we've found that when nurse leaders made the time to round, they started to say, "This is one of my favorite things—it's allowed me to go back to the bedside, to be an advocate for patients and make personal connections." So they might have been resistant to what they saw as another time commitment at first, but once they got in the room they remembered why they were there and what they enjoyed most about nursing.

CJ Merrill
Chief Patient Experience Officer, Mission Health System (Asheville, N.C.)

I would say the most important thing for the patient experience is training staff to connect the "why behind the what" for patients and families.

CJ Merrill (center) speaks with attendees of the iRound for Patient Experience Summit

We hone that skill in behavioral-based skills labs for rounding and bedside shift reports. That leads to teachable moments like, "I saw you pulled up the side rail. Why not tell the patient why you did that?" And during leader rounds, we train nurses to explain why they are there—to say, "As a nurse leader I love to talk to my patients, and I want to ensure they have an exceptional experience. Do you have a few minutes to have a conversation?"—rather than just going in and shotgunning the questions.

We also have worked feedback from our patient and family advisory council into many aspects of our care, including our whiteboards in patient rooms. At the very top is "excellent care means" and a blank, and we ask patients to tell us what excellent care means to them—to say, "I'm going to be your nurse for the next 12 hours. What's the one thing that I can do for you to make your day better?"

Patient experience can't be what you do. It has to be who you are. Culture has to be woven into the fabric of your organization. And if it's not, then it's not going to be sustainable.

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