Preceptors: A Critical Link to Improved HCAHPS Scores

By Traci Hanlon MN, RN, Consultant at Creative Health Care Management

Health care organizations are now focused on achieving great clinical and financial outcomes in a value-based culture where service excellence and the patient experience play a significant role in how organizations are being reimbursed. Gone are the days of a fee-for-service culture.

This shift is transforming how health care organizations deliver care, prioritize organizational initiatives, and how we think about the patient experience. Savvy organizations understand there is a positive correlation between financial, clinical, and patient experience outcomes. Leveraging opportunities to become better in all areas using resources already available just makes good sense.

Preceptor Programs are Growing in Importance

It is well documented that preceptor programs have a positive financial return on investment for organizations. A study done by Beecroft et al (2001) estimates that the cost to orient a new graduate nurse is between $39,000 and $65,000 and that 30 percent of them will leave their place of employment within the first year. Fifty seven percent of new graduate nurses will leave within two years. 

It is significant to note that poor training and lack of support systems are the main reasons nurses leave within that timeframe. (Patrick, 2000). Preceptor programs bridge the gap from transition to practice and have a positive financial impact on the retention rate of new graduate nurses.

Preceptor Programs and HCAHPS

What is not well studied or documented is the impact preceptors have on improving an organization’s HCAHPS scores.

Did you know that a significant number of preceptors who have been formally educated in precepting, and practice in organizations that have a formal precepting program, reported feeling more prepared to teach, and mentor nurses on practices that have been shown to improve the patient experience?

This qualitative information comes from focus groups I did with nurse educators and preceptors when exploring the influence preceptors have on transition to practice outcomes of new graduate nurses. It makes sense if you think about it. Formal preceptor programs demand the best of the best. Those selected to be preceptors are the individuals who are already engaged and active in culture changing initiatives and have had formal training in adult learning, communication, and the practice of creating healthy work environments.  

Improve Care and Improve HCAHPS Scores

Let’s face it; none of us went into health care to improve scores. We wanted to make a difference in the lives of others. It just so happens that when you build healthy environments that nurture self, each other and the patient, scores across the board improve.

Preceptors are the point-of-care staff who role model therapeutic relationships and then as part of their formal teaching role, teach the specifics of how to build and sustain trust with their patients. This is the heart of the patient experience, and if done well, will not only improve an organization’s clinical outcomes, but will also improve HCAHPS scores. 

Investing in preceptors and a formal preceptor program is a critical link to improving financial, clinical, and patient experience outcomes. More importantly, it’s the right thing to do for patients.  

Traci Hanlon MN, RN is a consultant with Creative Healthcare Management and specializes in preceptor, nursing orientation, and transition to practice program development.

SOURCES

Altier ME, Krsek CA.  Effects of a 1-year residency program on job satisfaction and retention of new graduate nurses.  J Nurses Staff Dev.  2006; 22(2): 70-77.

Beecroft P, Kunzman L, Krozed c.  RN internship:  outcomes of a one-year pilot program.  J Nurs Adm. 2001; 31 (12): 575-582.

Lindy CN, Reiter P.  The financial impact of staff development.  J Contin Educ Nurs.  2006; 37 (3): 121-127.

Myrick F, Luhanga F, Billay, D, Foley V, Yonge O. (2012). Putting the Evidence into Preceptor Preparation.  Nursing Research and Practice. 

Patrick, S. (2000).  Managers shoulder burden of retaining staff.  Retrieved April 20, 2013, from http://www.bizjournals.com/dallas/stories/2000/08/14/story7.html?page=all

Wolf, J., Palmer, S. (2012). Voices of Practice:  Exploring the patient experience in action. Highlights from on the road with the Beryl Institute.

Changing the Patient Experience Through Improved Hiring

By Steve Sasser, Chief Executive Officer, Assess Systems

At a time when hospitals are required to do more with less, the importance of having the right individuals in the right job becomes both a quality of care and bottom-line financial concern. The daily interactions between caregivers, patients, and their families create impressions that last long after the patient is discharged. Top performing employees demonstrate higher levels of patient care/service, increased satisfaction, and better engagement, all of which can ultimately impact your patient loyalty metrics.

While selecting for a specific skill set and experience (learned capabilities) is very important in the healthcare industry, identifying candidates who also have the natural tendencies (innate capabilities) to display the right behaviors and competencies to deliver a positive patient experience can contribute to higher HCAHPS scores. Our research with healthcare organizations has found that personality characteristics such as empathy, multi-tasking, frustration tolerance and collaboration, etc., while hard to see on a resume will become readily apparent on the job.

Yet, how do recruiters and hiring managers discern which applicants are the “right fit” from the applications they are inundated with on a daily basis?  On paper everyone can look good, but who will ultimately perform well?  Aberdeen’s Assessments 2013: Finding the Perfect Match report concludes that best-in-class companies incorporate the use of assessments as part of a well-defined section process to improve both the speed and quality of their hiring decisions. Additionally, these best-in-class companies utilize assessments throughout the talent lifecycle from recruitment through on-boarding, development, promotion, and succession planning.

Behavioral assessments, when properly chosen for the purpose intended and when implemented within a well-constructed selection process that include good training, offer many positive advantages:

• Improves and standardizes the decision making process by providing objective data for comparison  between candidates
• Measures things that are difficult to train and hard to see in the interview such as:
  • Positive service attitude
  • Work pace
  • Frustration tolerance; resilience
  • Empathy
• Screens out candidates who are a poor job fit and help to identify candidates with high probability of success
• Enhances interviews with probes/suggestions based on the candidate’s specific results
• Provides hiring managers with additional insight into candidates, thus enabling them to more successfully on-board new hires

In a research study of entry-level employees in high patient contact roles, we found a strong relationship between behavioral assessment results and supervisor ratings of performance (see graph).

We are excited about our partnership with HealthStream and the opportunity to help their customers make better hiring, placement, and promotion decisions for their workforce by using behavior-based, non-clinical assessments designed for the healthcare industry: Select for Healthcare™ and Assess for Healthcare™.

When coupled with Healthstream’s research, learning, and competency solutions, we have an important, unifying purpose – to help our customers improve healthcare.

Learn more about HealthStream's workforce solutions from Assess Systems.

The Impact of Emergency Department Experiences on HCAHPS Scores

By Todd Sorenson, Consultant (HCAHPS & Other Surveys), HealthStream

Statistics provided by the Centers for Disease Control reveal that there were 136.1 million emergency department visits in the U. S. in 2009, with over 17 million of these visits resulting in inpatient hospitalizations.  Nationally, roughly 50% of all inpatient admissions come through the ED.  

Research performed during the HCAHPS testing period several years ago found that patients admitted through the Emergency Department rated care across all dimensions of care more negatively than those patients admitted through other avenues.  HealthStream has documented this occurrence as well, summarized by the results of a study done in 2012.    

HCAHPS Dimensions of Care Mean Scores By Type of Admission
Measure	Admitted through ED	Not Admitted through ED	Difference
Communication with Nurses	3.68	3.73	-.05
Communication with Doctors	3.67	3.75	-.08
Responsiveness of Hospital Staff	3.43	3.54	-.11
Cleanliness of the Hospital Environment	3.56	3.62	-.06
Quietness of the Hospital Environment	3.40	3.52	-.12
Pain Management	3.57	3.65	-.08
Communication about Medicines	3.24	3.37	-.13
Discharge Instructions	1.83	1.86	-.03
Overall Rating of Hospital	8.68	8.86	-.18
Willingness to Recommend the Hospital	3.63	3.67	-.04

This analysis revealed that inpatients who were admitted through the ED rated all HCAHPS Dimensions of Care lower than those who were not, most decidedly so for the Overall Rating of the Hospital, Communication about Medicines, Quietness of the Hospital Environment and Responsiveness of Hospital Staff.  Previous research conducted by HealthStream has also shown that hospitals scoring high on ED overall patient satisfaction tend to have high HCAHPS scores, while those with low ED overall patient satisfaction tend to have low HCAHPS scores.  These data imply that experiences in the ED have an impact, either positively or negatively, on inpatient HCAHPS scores. 

While hourly rounding on patients, post-discharge phone calls and numerous other strategies have been shown to improve HCAHPS scores, many hospitals can also benefit from improving patient satisfaction in the ED to drive improvement on HCAHPS as well.  Many of the same types of factors that drive the HCAHPS Overall Hospital Rating are also among the top drivers of the Overall Rating in the ED.  Querying the HealthStream Emergency Department Database reveals the following items are the most highly correlated to the Overall ED Rating: 

• How often did you feel that the care and services received during the visit were well coordinated?
• How often did the patient care staff do a good job of keeping you informed of delays in care or treatment?
• How often did you feel the doctor really cared about you as a person?
• How often did the nurses, doctors and other staff do a good job of working as a team?
• How often did the patient care staff do a good job of responding quickly to requests?
• During this hospital visit, how often did the hospital staff do everything they could with your pain?
• How satisfied were you with the amount of time the doctors spent with you?
• How satisfied were you with the total amount of time spent in the emergency department from arrival to discharge?
• How often did the patient care staff show the proper sense of urgency in treating your medical problem?
• How satisfied were you with how clearly and completely you were told what to do and what to expect after returning home?

From this list, the key drivers of the Overall ED rating include perceptions about the coordination of care, including teamwork and responsiveness of staff, the amount time spent waiting and keeping patients informed of delays, and the care provided by the ED doctors, in terms of time spent with patients and caring about patients as persons.  How is your emergency department performing on these important factors? 

With reimbursement dollars on the line, those involved in hospital quality and improving HCAHPS scores should not overlook the importance of the patient’s ED experience on  how they respond to the HCAHPS survey.

Learn About HealthStream Patient Insights/HCAHPS Surveys.

Read Consultant Bo Hansen's blog about HCAHPS and the Emergency Department, with prescriptive advice for hospitals.

New OSHA Compliance: Training Healthcare Staff on Hazardous Chemicals

To better protect workers from hazardous chemicals, the U.S. Department of Labor’s OSHA has revised its Hazard Communication Standard to align with the United Nations’ Globally Harmonized System of Classification and Labeling of Chemicals (GHS). While the original Hazard Communication Standard, HCS 1983, was commonly referred to as the “Employee Right to Know,” the revised standard now provides for the “Employee Right to Understand.” With the goal of increasing worker comprehension about the hazards in their work environment, the revised standard requires companies to employ the use of a standardized format for Safety Data Sheets (SDSs), as well as new labeling elements for chemicals. OSHA is rolling out this change in phases over the next several years, culminating in a final deadline of June 1, 2016.

New Requirements Aimed at Healthcare Worker Safety

The first compliance deadline is December 1, 2013. By this time, all facilities must provide training on new chemical label elements and safety data sheets.  In response to this rule, HealthStream has teamed up with MAXCOM to offer 19 GHS specific training modules that focus on every class of chemical an employee might come across in their working environment.

To address the enormous amount of chemicals used in hospitals, OSHA amended the rule to allow chemical training to be provided by groups of chemicals. They write, “where there are large numbers of chemicals, or the chemicals change frequently, you will probably want to train generally based on the hazard categories.”

Hazardous Chemicals Are Common in Health Care Facilities

Chemicals in use in the healthcare environment may be hazardous due to potential for toxicity, corrosiveness, and reactivity.  In addition to the usual routes of exposure by inhalation, ingestion, skin and eye contacts, a health care provider can also inadvertently self-inject a toxic drug intended for a patient.

These groups of chemicals include:

• Chemical disinfectants commonly used in health care facilities are often corrosive and/or toxic.  Glutaraldehyde, sodium hypochlorite, iodine, phenols, formaldehyde, and quaternary ammonium compounds are all corrosive.  In addition to being corrosive and toxic, some disinfectants such as quaternary ammonium compounds (benzalkonium chloride, Zephiran chloride, Rodalon)  also cause contact dermatitis.  Glutaraldehyde solution has to be freshly prepared every 2 weeks, and due to its volatile characteristic employees often inhale its vapors.  Formaldehyde used for cold sterilization of instruments and as a disinfectant not only has noxious odor but also causes dermatitis and has been shown to cause nasal and other cancers in experimental animals.
• Freons such as Freon 12 (dichlorodifluoromethane), Freon 11 (fluorotrichloromethane), and Freon 22 (chlorodifluoromethane) are routinely used in pathology laboratories (to prepare frozen tissue sections), in aerosol cans as a propellant, as a refrigerant gas, and mixed with ethylene oxide (a sterilant).  Freons can freeze the skin and eyes and cause depression of the central nervous system resulting in dizziness, convulsions, and irregular heartbeat. 
• Methyl Methacrylate, commonly used in operating rooms for securing surgical prostheses to bone, has to be mixed just before a procedure often resulting in inhalation of the product.  Methyl methacrylate affects the central nervous system, is an irritant and may cause low blood pressure and cardiac arrest.  The product also has been linked to birth defects, though not cancer.
• Peracetic Acid (PAA) or Peroxyacetic Acid is used to sterilize medical instruments, and also present in laboratories, and patient care units.  PAA is a severe irritant, and have been linked to skin papillomas (wart-like tumors), and liver, kidney, and heart problems.
• Solvents (such as Dioxane, Xylene, and Benzene) used mostly as cleaning agents in housekeeping are central nervous system depressants and irritants.  Chronic exposure to solvents have been linked to effects on blood formation, kidneys, liver, birth defects, and cancer.
• Anesthetic Gases exposure usually occurs in operating rooms, labor, delivery and recovery rooms; and ER.  Gases often leak from the instruments, and in the recovery room are present due to the exhaled breath of post-operative patients.  Effects of anesthetic gases on health care employees are similar to the one experienced by patients.  Although short-term exposure only causes dizziness and disorientation, long term exposure may cause cancer, birth defects, and liver and kidney damage.
• Ethylene Oxide used to sterilize equipment also exposes employees in surgery units and central supply.  Ethylene oxide is a corrosive, causes destruction of red blood cells, and inflammation of lungs.  It is also a carcinogen and a fire hazard.
• Cytotoxic Drugs (such as cyclophosphamide, chlorambucil, and melphan) used for treatment of cancer, also cause cancer and damage to the reproductive system of health care employees.  Accidental injection of a drug such as mitomycin-C can cause loss of function of a hand; and drugs such as mustine hydrochloride and doxorubicin  are powerful vesicants (corrosives).  Exposure to the smallest amount of bleomycin can cause severe allergic reaction.
• Pesticides ( Mecoprop, Metolochlor), Rodenticide ( Bromaldiolane and Diphacinone) and Fungicide such as Mancozeb are routinely used by hospitals as a biocide.  Most are toxic to the nervous system, damage kidneys and liver, and cause allergic reactions.

Safer Substitutes

Less hazardous products can be substituted for many though not all hazardous chemical products in health care facilities. For example:

• For Ethylene oxide in most instances: safer hydrogen peroxide 7.5% solution, peracetic acid or a mixture of hydrogen peroxide and peracetic acid.  Even hypochlorite (bleach)is effective in some disinfection systems.  Please note that the substitutes are not suitable for flexible GI endoscopes.
• For Glutaraldehyde: Ortho-phthalaldehyde (OPA) in Cidex (contains only 0.55% glutaraldehyde)
• For common toxic chemicals such as chloroform: dimethoxyethane (DME), Ethyl lactate, methyl tert-butyl ether or methylene chloride; benzene can be replaced by benzotrifluoride (BTF), dimethoxyethane (DME);  acetone can be substituted by ethyl lactate, or N-methyl pyrrolidone (NMP) etc.
• For toxic chemicals such as formaldehyde: dimethoxymethane (DEM); Phenol  by polyethylene glycol (PEG), and pyridine by isopropyl alcohol.
• For flammable chemicals such as ethyl ether: methyl tert-butyl ether (MTBE), n-octyl tetrahydrofurfuryl ether (n-OTE)
• Waste anesthetic gases can be controlled by a scavenging system.
• For powerful pesticides containing pyrethroids: UV light traps; pheromone traps can be substituted for Cockroach pesticides etc.

Although heath care facilities will never be free of hazardous chemicals, it is increasingly possible to use safer alternatives and better procedures to prevent exposure.

MAXCOM’s GHS Training Library provides a basic overview of the hazards associated with every class of chemical a healthcare employee could typically be exposed to and how an exposure to these chemicals could affect him/her in the course of performing their everyday workplace duties. Additionally, this training provides valuable information about the degree of risks or hazard levels associated with chemicals specific to a healthcare environment, and finally employees are provided details about the information contained within each section of the new Safety Data Sheet, GHS label elements and the pictograms recently adopted by OSHA.

Learn more about Maxcom training here.

Employee Engagement: Reconnect Staff to Caring's Meaning and Purpose

By Susan Edstrom, MS, BSN, RN, Consultant, Creative Health Care Management

I remember vividly my first experience as a patient at age 14, hospitalized for surgery to remove a lump in my breast—I was terrified! Years later, I still remember how I felt with one particular nurse. I don’t recall her name, but I remember her eyes. She saw my fear, and the way she looked at me let me know that everything would be OK. She always knew how to calm me; she allowed me to feel safe and cared for.

She is the reason I became a nurse.

I’ve heard similar stories over the years as I facilitate the three-day program Re-Igniting the Spirit of Caring (RSC). I believe most people working in healthcare are there because they want to help others. In today’s chaotic, task-driven healthcare environments, many staff members are disengaged and suffering from varying degrees of compassion fatigue. I believe this is because people have lost their connection to the core purpose of the work they do.  The science of caring is as important to patients as the technical and clinical knowledge and skills we bring. After listening to countless patients relate their personal hospital experiences during the RSC program, not one has reported that a caregiver’s clinical skills are what were most important. In their minds, those skills were a given, and it was the acts of caring that were most important in creating a positive experience for them. Compassionate care promotes healing and helps people feel safe and cope with their illness. Caring is not a “soft skill” and it’s far from optional; it’s what patients tell us they want most.

In my work as a facilitator of RSC, I’ve discovered several practical things that all caregivers can do to reconnect or connect more deeply with their purpose:

• Engage others in conversations about caring. Use appreciative questions at department/unit meetings, reports, and in conversations in the hall. What are the behaviors that demonstrate caring? What do we want care to look and feel like for patients on our unit? What would we want for ourselves or our loved ones? Talk about a time of which you are most proud, when you provided care that you know made a real difference to a patient and family. What were the circumstances? What did it take?
• Dispel the myth that there isn’t time to really care. Compassionate caring is not about time. It’s a mindset that allows us to be fully present to another. It isn’t something more to do; it’s a way of being and a way of doing. In order to cultivate a caring way of being, center yourself before entering a patient’s room while hand washing, by touching the door jam, or taking a deep, mindful breath and committing to really making a connection: “I will be fully present to this person.”
• Sit at the bedside for 5 minutes at the beginning of a shift and really connect. Introduce yourself and explain your role and what you will be doing. Ask the patient “What’s the most important thing I can do for you today?” Really listen and follow up. If you take the time to listen, you’ll save time in the end.
• Incorporate caring for colleagues into daily practices. Start each shift in a staff huddle, having everyone “check in” about how they are today, being aware of who may need help or support.  Find ways to affirm and appreciate others’ contributions and acts of caring for patients and colleagues.  When we acknowledge and care for one another, it helps us care for others.
• Be impeccable with your language.  We objectify people when we use labels, referring to them as “the knee in bed 2,” the “frequent flyer,” or the “demanding family member.”  The way we talk about patients affects whether we see them as people.

These are some simple practices that any caregiver can integrate into daily practice in order to help reconnect with the meaning and purpose of caring. The impact they have in helping to create a positive patient/family experience will help facilitate healing, positively influence the patient’s experience, and help keep caregivers focused on what matters most.

Learn more here about measuring and improving employee engagement with HealthStream Employee Insights.

Susan knows how important that commitment to caregiving is; she’s a nurse with more than 30 years of experience as a staff nurse, nurse practitioner, educator, and health care leader. She has a BSN and MS in public health from the University of Minnesota. While she’s no longer providing direct care to patients herself, her goal in her role as a consultant at Creative Health Care Management is to re-ignite a passion for caring in those who do.

Patient Navigation: Positively Impact Patient Experience and the Bottom Line

By Gwen Faust, Consultant, HealthStream; Sarah Kresnye, MBA, Director, Client Services, CHAMPS Patient Experience; and Carol Santalucia, MBA, Vice President, CHAMPS Patient Experience

 

 

 

 

 

 

 

 

 

A field that has been developing over the past 20+ years, patient navigation has recently gained national attention as the American College of Surgeons’ Commission on Cancer has mandated patient navigation services for accreditation beginning in 2015.

What is Patient Navigation?

Patient navigation is a process in which an individual guides a patient through and around barriers to care and virtually integrates a fragmented and complex healthcare system. The barriers address by a patient navigator may fall into a number of categories, including[i]:

• Financial
• Cultural
• Communication
• Transportation
• Bias based on culture/race/age
• Fear

By working to eliminate these barriers, patient navigators ensure that our patients receive access to timely care thereby increasing their length and quality of life. 

The History of Patient Navigation

Pioneered at Harlem Hospital Center in 1990 by Dr. Harold P. Freeman, patient navigation focused on the critical window of opportunity to save lives from cancer by eliminating barriers to timely care between the point of suspicious finding and the point of resolution by diagnosis and treatment. The program compared 5-year survival rates of breast cancer patients who were navigated to those who were not. The study demonstrated a 5-year survival rate of 70% for patients who worked with a Patient Navigator to that of 39% for those who did not.[ii][iii] 

Since its inception as a community-based intervention program, Patient Navigation has expanded and transformed into a nationally recognized model that extends well beyond cancer care to include the timely movement of an individual across the entire healthcare continuum. 

The Business Case for Patient Navigation

Patient navigation is not only the right thing to do; it’s the smart things to do. In addition to the many benefits it can provide to patients, families, and communities, robust programs can also provide many benefits to the organization. 

For example, by reducing no-shows, cancellations, and redirecting ED patients to more appropriate resources, hospitals that took part in a pilot program in Cleveland, OH, saw a return on their investment of anywhere from 2.5 to 6 months. After this time, the patient navigator’s work contributed solely to the bottom line of the organization. 

Learn More about Patient Navigation

We invite you to learn more about Patient Navigation and its impact on your organization and patients. Carol Santalucia, MBA, Vice President of CHAMPS Patient Experience will be presenting on the topic of Patient Navigation during our July Webinar. Carol will also speak about the benefits of patient navigation at one of the many exciting breakout sessions at HealthStream Summit 2013 in Nashville, TN, October 15-17.    

In the meantime, for more information on developing and implementing patient navigation programs please visit www.champspatientexperience.com. And get your questions on patient navigation answered by leaving a comment on CHAMPS Patient Experience’s blog: www.pxperspective.com.

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[i] ²Freeman HP. Voices of a Broken System: Real People, Real Problems. President's Cancer Panel: Report of the Chairman 2000-2001. Reuben SH, ed. Bethesda, Md: National Institutes of Health, National Cancer Institute; 2001.

Healthcare Talent: Successful Change = Empowerment/Empowerment = Successful Change

By Marie Manthey , FAAN, MNA, FRCN, PhD, (hon) President Emeritus, Creative Health Care Management

When dealing with healthcare talent management, positive and sustainable change requires involvement on the part of the “changee.” Without some level of participation by those who will operationalize and live with the changes, change comes through coercion rather than through the agreement and commitment of those involved. Coercive change, no matter how great the power base, seldom lasts. Coercion causes resistance. Empowerment on some level, no matter how little, reduces resistance. 

People are empowered when responsibility, authority, and accountability are meted out in equal measure: 

• Responsibility is the clear allocation and acceptance of assignment so that everyone knows who will do what and when it will be done. The clear assignment of responsibility must be visible within the organization.
• Authority consists of the right to act in the area for which one has accepted responsibility. Authority must be commensurate with responsibility. If people are given responsibility but insufficient authority to carry out their responsibilities, it creates system dysfunction and personal dis-ease.
• Accountability involves the retroactive review of decisions made and actions taken to determine whether or not they were appropriate. If they were not, corrective (not punitive) action must be taken. 

Once responsibility is truly accepted, a person becomes keenly aware of the authority necessary to carry out that responsibility. Many innovations are defeated by staff and managers who refuse to accept responsibility, which results in the absence of perceived authority.  This in turn creates a victim mind-set that is exacerbated by feelings of powerlessness over change, which is then reinforced by the refusal to accept responsibility, thus perpetuating a victim mind-set. Only by accepting responsibility and exercising authority can we break this cycle. 

A well-designed and carefully supported change process does more to empower healthcare staff than months or even years of traditional staff development. Management must demonstrate its belief that those who perform the work know more about the work than anyone else; therefore, they are the right people to make decisions about how the work should be done. 

A well-designed healthcare talenet management process to implement a new model or system for care delivery is founded on four points: 

1)     Informal leaders—those who will lead by benefit of their ability to influence others without being in positional leadership roles—should be identified and included on the team that designs the change. Believe it or not, it is important to have leaders with both negative attitudes and positive attitudes on the team. The best way to identify informal leaders is to ask every group member to identify the people they would like to see as members on the design team other than the manager (a formal leader). For true empowerment to be achieved, managers should encourage the leadership of others rather than steer the change themselves. 

2)     Establish a healthy group process based on open communication, mutual respect, and at least a functional level of trust. Clear, consistent response to group members’ needs and requests begins the process. Sometimes a person skilled in facilitating groups can be used to develop a healthy group process. If the group process falters, or a few individuals dominate, the quality of the group’s decision making will drop. 

3)     The group must have the authority to make final decisions about the way their own work is handled and the way their own units operate. Consensus decision making can be achieved using several techniques, but “voting” generally is not desirable because it often polarizes a group. Consensus is a negotiated agreement, achieved through the use of process skills to be learned if not already in place. 

4)     A formal communication network must be established between every member of the design team and every member of the staff. Every staff member needs access to both the information available and the decision-making process. If the design team’s considerations and activities are perceived as secret, trust will be undermined. 

When these four key steps are carefully followed as the basis for a change/empowerment process, the right decisions will be made. No one knows more about how work should be organized than those who are doing it every day. As the attitudes of the design team begin to evolve—as open communication, trust, and respect become the norm for the informal leaders who comprise it—those “process changes” are transmitted to the rest of the staff via the communication network.  When the change process itself includes those who will be working the change every day, everyone involved becomes empowered and transformations are positive and sustainable.  A change process of this magnitude will result in an empowered staff which creates energy, thus expanding capacity. The entire process inspires trust among team members and increases the level of staff nurse professionalism and effective teamwork. 

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Saying Marie has seen it all is either literally true or an understatement. The founder and president emeritus of Creative Health Care Management, Marie has been a nurse since, she says, “practically age five.” And through that time, she’s been motivated by the same burning passion: focus on the nurse-patient relationship and its potential for healing.

 

Fixing the Emergency Department to Secure HCAHPS Reimbursement

By Bo Hansen, RN, MBA, Consultant

Like it or not, first impressions are lasting; and, if they are negative they can be difficult to overcome. We don’t get a second chance at first impressions! They are deeply embedded in our memories and often turn into a lasting prejudice with hefty price tags attached. The cost of being indifferent, unkind, careless, non-communicative, or unprofessional may cost someone the opportunity of a great job or thwart a new friendship. In the case of patients’ first impressions of a hospital, a negative one may cost the hospital hundreds of thousands of dollars in CMS reimbursement, and it may take the hospital years to regain the trust of its community. 

First impressions Count

First impressions to patients admitted through the emergency department (ED) are powerful. Visits to the ED are always unplanned and disruptive of lives, and they may be life altering. Whether patients suffer minor injuries, unexplained illnesses, or severe trauma, they arrive at the ED, often alone, in a state of fear and worry about what is going to happen to them. They are not in control of their life; they feel helpless and vulnerable. How they are received by the first person of contact is critical to their impression. Is the person friendly, making the person feel like he is in good hands? Trusting that we will be safe when we are vulnerable is critical. Patients trust that the doctors and nurses will treat their physical illness and injuries. Equally strong is their trust that the same physicians, nurses, and ED staff will comfort them, calm their fears, and reassure their loved ones. Violating that trust can be a serious mistake in terms of damage to the hospital’s reputation, patient loyalty and HCAHPS scores. 

High scores in ED equates to high H-CAHPS scores

We know 50 to 60% of all inpatients are admitted to the hospital through the emergency department. Since the inpatient HCAHPS survey asks questions of discharged patients that are prefaced by the words “During your hospital stay,” it means that more than half of all inpatients include their ED experience in their feedback in the post discharge survey. 

In an effort to better understand the relationship between the ED experience and the inpatient experience, HealthStream completed a study of 551 hospitals that surveyed both their inpatients and their ED patients. One important finding of the study showed that patients admitted through the ED scored significantly lower on all HCAHPS measures than those who were not! 

The study also revealed that hospitals that score high on ED Overall Satisfaction also tend to have high HCAHPS scores. This relationship is stronger in higher-performing hospitals than in lower-performing facilities. We can conclude that hospitals with high patient satisfaction scores in the ED are likely to see that satisfaction carry over to inpatients who are admitted through the ED. Consequently, hospitals that want to maximize their chances of high HCAHPS scores and associated reimbursement should take a close look at how their EDs are performing. 

First Impressions That Pay (We Are Talking $Millions!)

The degree of care, kindness, timely information, and attentiveness that the patient and family receive from ED staff determines the first impression of the hospital. Beyond the best practices most commonly discussed, such as rounding, smiling, clear explanations of pending tests and results, etc., what else could the ED staff contribute to meet the patients’ expectations of hospital experience? 

From my days as an ED staff nurse and manager, I have a few examples of how the ED staff can enhance patients’ ED experience. There are many more than the ones I have listed, but these address some of the areas of opportunity that I see in EDs today:  

• Hire the right people with the right attitude to greet your patients and families.
• Replace silos with bridges. Know the value of reaching out to other departments. Let them know you are friendly. (ED staff sometimes has a reputation of being grumpy with their colleagues in other departments). Ask what you can do to help speed up the transfer of patients from the ED to their unit. Would it help if the ED nurse starts the care plan, the doctor’s orders right away?  Getting the patient transferred to a unit is not THEIR (the unit’s)problem, it is OUR (everyone’s) goal to make it happen!
• Adopt an attitude that tells patients you understand their sense of urgency. Once admitted, your patient wants to get out of the ED and into a bed to start treatment, recovery, rest, and healing. He doesn’t understand why it can’t happen right now!  Be empathetic and keep your patients updated at least every half hour on how long it will be before they can get to their bed.
• If your patient is spending extended time in the ED, treat them like guests. Keep up with the comfort measures. Offer extra pillows, blankets, ice, juice, or snacks.
• Start the care plan if your patient is held more than two hours in the ED after being admitted. It is the right thing to do for your patient.
• Being one team with a shared goal is one of the fundamental requirements for creating a positive patient experience. Include ancillary and support staff in department meetings. Make sure your phlebotomists, IV team, radiology technologists, housekeepers, and registration staff have the attitude and training that provides the first class service experience that you intend for your patients.
• Act in a way that makes the patients glad they chose your hospital for their care.
• Every time we are in front of our patients, we are “on” or as Disney describes it, we are “on stage. ” How well we perform determines the lasting impression with leave with our patients.
• Pretend you are a patient in your ED. How would you rate your ED experience? 

Learn More About HealthStream Patient Insights/HCAHPS.

Learn More About HealthStream’s HCAHPS Preparation and Improvement Library.

 

Top 3 Tools to Assess Critical Thinking Competencies for Healthcare

By Donna Wright, MS, RN, Consultant and Traci Hanlon, MN, RN, Consultant

Many of our techniques for competency assessment are geared toward technical skills, but critical thinking skills require other assessment methodologies.

According to the work done by Peter Facione, a leading expert in critical thinking, self-regulation is one of the core cognitive skills involved in critical thinking. Self-regulation is basically the ability to think about how we arrived at certain conclusions, to evaluate our own cognitive activities by self-examining, and then correcting our thoughts, actions, and perceptions based on information being filtered through the higher reasoning centers in the brain. The only way to effectively do this is to use the skill of reflection.

Reflective exercises are the only way to assess how a person came to a certain set of conclusions or judgments. Reflection requires an individual to think about data in relationship to their assumptions, biases, prior knowledge, and the environmental context of the data. Therefore, it is very logical to use “reflective” tools for assessment of critical thinking skills.

Here are the top three tools for assessing critical thinking:

1) Case Studies

The case study method presents the person being assessed with a scenario that describes a certain situation. The person being assessed should be given questions to help them explore their own problem-solving, prioritization, ethical responses, and assessment of the scenario. Case studies can be purchased or created by the assessor.

One of the mistakes made when using cases studies is the individual being assessed is asked to write his/her own case study. Although this may cause the individual to reflect on a past experience or to design something that best represents a type of patient he/she might care for, the goal of a case study should be to cause the individual to think through a set of pre-determined contexts and data and explain, based on the data presented, why he/she came to the conclusions he/she did. This will help the assessor get inside the “thinking” of the person being assessed and highlight a person’s ability to make clinical connections between multiple sets of data where an obvious connection is not always made.

To do this, every case study should have explicit instructions on how to respond. For instance, a patient scenario might include the following questions: 

• Given the patient information presented, describe the top three priorities for this patient and why you prioritized them in the order you did.
• What interventions would you recommend to the physician and why?
• What clinical signs or symptoms are most concerning to you and why?
• Are there any environmental, social, or family issues you would take into consideration when prioritizing care? What are they? Describe how they are relevant to the care of this patient. 

2) Exemplars

Exemplars can be an impactful self-reflection tool. The exemplar method asks the person being assessed to write or tell about a situation. The situation can be one he/she may have had or one that he/she may one day experience. For example, “Tell me about a time when you provided good customer service,” or “Describe a time when you de-escalated a patient or family member’s explosive behavior.”

Be sure to provide instructions that ask the respondent to be very specific in what he/she said, thought, and did. Responses such as: “I saw they were angry and de-escalated the situation enabling me to provide better care,” are too vague and do not get to the thinking or actions that help those assessing the exemplar determine whether or not the individual used good critical thinking skills.

The completed exemplar report can be given to unit practice councils or another group for peer review so they can weigh in on whether the criteria for competency is met. This is a better approach than just having one educator assess it alone. 

3) Discussion/Reflection Groups

Your health care organization may be using discussion or reflection groups already. Are you doing a debriefing session after a code or mock event? This is a discussion/reflection group. They take some time to do, but they can be well worth it. Not only can they assess critical thinking skills, but they can also develop critical thinking skills. 

Using open-ended questions (versus “yes/no” questions) will help the group stay focused and require them to think about their responses. For example, one organization we’ve worked with debriefed all falls with the entire team within minutes of a patient fall. Rather than the manager asking rote questions such as: “Did the patient have fall precautions in place?” she started the debrief huddle with: “What would have had to happen for this patient not to have fallen? and “What are some practices we can do that would make this patient safer?”

Case studies, exemplars, discussion/reflection groups all use the skill of self-reflection and therefore exercise “cognitive muscles.”

Many of these tools can both assess critical thinking skills and develop them. Give these methodologies a try, and you may create a more professional team environment.

Learn more about HealthStream's Competency Center.

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A staff development specialist known for her irreverent wit, Donna brings a global perspective to her work. In this country and in the over two dozen others, Donna’s best known for the work she does based on two of her books, The Ultimate Guide to Competency Assessment and Relationship-Based Care (co-authored with several CHCM colleagues). The Ultimate Guide has become the industry standard for HR departments in establishing and assessing competency, and Donna specializes in setting up systems for organizations to ensure accountability and measure competency.

Traci is a registered nurse with clinical experience that spans 20 years in critical care, PACU, telemetry, and med/surg. The past 10 years of her career have been spent in staff development with a focus on preceptor and leadership development. People who have worked with Traci as a facilitator are quick to describe her as inspirational and funny, and on further thought, they often point with appreciation to her deep foundation of knowledge and the fact that her work is so well grounded in research.

What Exactly is “Top Box” Service for HCAHPS and How Do I Get There?

By Hayden M. McKaskle, Consultant (HCAHPS and Other Surveys)

Soon after I joined HealthStream several years ago, I had the pleasure of reviewing HCAHPS patient satisfaction scores for a client hospital.  I had spent considerable time preparing for this review and had run a number of special reports in addition to the lengthy quarterly report they receive.  Their scores were ok but not great, and they had seemingly plateaued over the last few quarters.  Since they really didn’t have an issue with negative scores, I simplified the strategy for them as best I could.  This hospital only needed to move a handful of patients each month from “Usually” to “Always” and from “7s or 8s” to “9s and 10s.”  In other words, if they could “wow” and move a few more each period to Top Box, their scores will steadily improve and in time, prove to be exceptional.

Thinking About the Meaning of “Top Box”

Just when it seemed like the CNO and the CEO were buying into this approach, the CEO asked a simple yet profound question, “What makes a score Top Box”?  Interestingly, another CEO had recently asked a similar question during a review of their employee satisfaction results.  The timing of these questions sent me on a quest to find a better answer to this question.  In part one of this blog, we will explore this question from a patient perspective.  In part two, we will attempt to address this question from an employee viewpoint.  After delivering several hundred report reviews for Patient, Employee, and Physician surveys, I have found numerous insights within the data. These have helped a number of clients.  As helpful as the data can be, it was within the verbatim comments of patients that I really began to find an answer to my question.

Top Box: What Do Patients Say in HCAHPS Surveys?

• ” Nurse A____ was very attentive like I was the only person in the hospital that mattered to her.”
• “They made me feel like I was at home.”  “…they took care of me like I was a king.”
• “It was wonderful, like staying in a hotel.”
• And a personal favorite of mine, “They took care of me like I was a newborn baby.”

These are actual comments selected from thousands made during 2012.  These are not isolated occurrences; similar ones appear scores of times in reports for high scoring hospitals as well as lower scoring ones.  Most of these exceptional comments have the staff member’s name included, and these have been edited for the purposes of this blog.  I believe that it takes great effort to remember the names of caregivers during moments of great stress and sickness, so the mere mention of actual names adds even more significance to these comments.  Although the above patient comments may appear to be very general and perhaps difficult to mine for improvement strategy, consider the following comments:

• “She did everything possible to make me comfortable and even sent me a note after I got home. I couldn't find a better hospital.”
• “Nurse J___ was off on the day of my discharge, but she came in the day before and thanked me for letting her take care of me.”
• “(The CNA) would come and hug my neck and cry with me those times when I was down. She wasn't just there for a paycheck or only what was medically required from her.”
• “The nurses were very fast, very prompt, and they did things that weren’t on their job description. They did things below their status, and that was very nice. They do things that RNs usually don't do.”

Although comments about nursing make up the majority of patient comments, the exceptional ones are not limited to just nursing.  Someone once said that everyone impacts patient satisfaction.  The following comments illustrate the truth in that statement.

• “The person who came in and cleaned my room just asked me how I was doing. I said gee I would like somebody to get me some ice. She brought me two bags and I just thought that was awesome.”
• “The housekeeping supervisor asked me if I needed anything, and she would get it for me. Having her there was very nice.”
• “The technician, John, was great. He talked me through my test. I was really scared and crying, and he was very good and had a good bedside manner.”
• “Dietary came every morning and asked if I enjoyed my meals and asked if there was any way that they could make it better for me. I have never had anyone treat me this way. They treated me like royalty.”

Even though all of these comments come from inpatient surveys, often a high percentage of admissions come from the ED.  That initial experience in the ED can influence an inpatient’s expectations for care in the hospital - for good or for bad.  Even in the hectic and crisis oriented atmosphere of the ED, patients are often touched by personal and exceptional care.

• “Dr. S_____ in the ER is very good. I have never had a doctor call me after I was in the ER.”
• “Dr. John, I met him in the emergency room, and he followed with me all the while I was in the hospital. He was there every morning and he was good to me. He was like my son.”
• “Melissa and TJ were in the ER. They were both equal, as far as hanging with me, keeping me informed, and making sure I had anything I needed. They kept my wife informed about what was going on.”
• “The ER staff had just heard that my son had passed away. They all gave me hugs and that made me feel better.”

Doctors are also mentioned for providing exceptional inpatient care.  Here are just a few:

• “Even the doctors came in and sat down to talk to you as if you are a real human being.  The hospitalist pulled up a chair and sat down and talked with me several times.”
• “Dr. A_____ made sure I understood and he makes you feel like you are the only patient he has. He is wonderful.”
• “He didn't seem in a hurry or a rush to get out of my room. I really appreciated that. I just loved the way he approached me.”
• “I appreciated that she had conversation with me rather than just as a patient. She listened to what I had to say, instead of me being just a patient.”
• “I was really surprised that the doctor who discharged me called me at home and talked to me about my health. I have never had that happen to me before.”
• “He is very attentive and listens. He is calm and explains everything. I think he is a wonderful doctor.”

The Secret to Great Patient Experiences

After reading so many more comments like these, I am convinced that the secret in the sauce is really very simple.  Those caregivers that make a difference for patients do so in small yet profound ways.  They listen.  They take time.  They look for ways to take just one more step than required during a round - something that connects with the patient as a fellow human being. 

There is so much that needs to be done each and every day, indeed so much professional noise that can get in the way of providing an exceptional care experience.  Paperwork, shift reports, hourly rounding, and the like all must be done but each of us must make an effort to add value for the patient, in our jobs, and in our lives each and every day.  Often that added value comes from things that may seem small at first glance but can make all the difference in the world for a patient.  We have to make an effort to look for these “extra steps” in spite of the professional noise.  

Exceptional patient perception is never about professional credentials, education, or the like.  It is about people connecting with people - not patients. As I wrote in one of my first blogs, Healthcare is after all, a people business.  Getting to “Top Box” then, is no different.  It is all about people doing more, going farther, paying more attention, and listening intentionally.  There is certainly a bit of prescriptive medicine somewhere in there for all of us.

Learn more about HealthStream Patient Insights/HCAHPS.