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Last year, nurses at Aurora Medical Center in Hartford, Wis., started an hourly rounding program that includes protocols for pain management, checking to see if patients are comfortably positioned within easy reach of their personal possessions and making sure their intravenous plugs are plugged in. Around the same time, all of the hospital's nurses made a service commitment to be "kind, respectful and courteous" to both patients and colleagues.

"We want them to be nice, kind and respectful not only to patients, but also to each other," says Karen Bialas, R.N., the hospital's nurse manager. "We're holding people accountable to that behavior."

Though vastly different in scope and purpose, both initiatives are part of a broader patient experience action plan under way throughout Milwaukee-based Aurora Health Care's 15-hospital system. Some of the new programs, like hourly, or "purposeful" rounding, are designed to improve specific aspects of patient care — for instance, how long patients wait for responses to their calls or how well they believe their pain is being managed. Other new initiatives, including the service commitment, are part of a broader organizational strategy to transform the system's culture, with the aim of improving both patient and employee satisfaction.

"We have strategies and tactics for the whole organization," says Kathy Leonhardt, M.D., vice president of patient experience and patient safety for Aurora Health Care. "We want to create a standardized, excellent patient experience."

The efforts come as hospitals and health systems work to improve performance on the 27-question Hospital Consumer Assessment of Healthcare Providers and Systems survey, given after discharge to a random sample of eligible patients. Starting in 2013, HCAHPS scores will be one of 13 measures used by the Centers for Medicare & Medicaid Services to calculate $850 million in payments from its new Hospital Value-Based Purchasing Program. Thirty percent of the VBP score will be based on HCAHPS and 70 percent on the 12 clinical measures. The survey includes 18 core questions about a patient's hospital experience, with topics that include communication with doctors and nurses, pain management, the quality of information given at discharge, cleanliness and noise in patient rooms.

Many hospitals and health systems are embracing a two-pronged HCAHPS strategy, with an emphasis on improving competencies around each of the 18 core questions alongside global efforts to improve the overall patient experience. The big-picture initiatives, which vary by hospital, range from comprehensive leadership training and employee satisfaction strategies to initiatives that identify potential new hires who possess both strong clinical and people skills.

The combined efforts are designed simultaneously to improve scores on individual HCAHPS questions and protect Medicare reimbursements, while also building the foundation for lasting patient loyalty.

"The [hospitals] doing well are doing HCAHPS, but they're really focused on the patient experience," says Janna Binder, director of marketing and public relations at the health care consulting group PRC.

Measure for Measure

In October, CMS will begin using scores from HCAHPS surveys to help calculate VBP payments for 2013. In the meantime, many hospitals are launching educational efforts to prepare their employees for the changes and keep them apprised of how their units are performing on individual HCAHPS measures.
Leaders at Carolinas HealthCare System, a 28-hospital system based in Charlotte, N.C., currently are training employees on tactics to improve performance for all 18 core HCAHPS measures. Carolinas is also building an online HCAHPS scorecard that employees will be able to use to track their performance in real time, says Bonnie Felts, the system's data management coordinator.

"In 2012, we're planning education for our administration and staff in terms of what HCAHPS and value-based purchasing mean to us," Felts says. "…But our ultimate goal is to create a scorecard for staff on what they need to know."

Throughout the Cleveland Clinic's network of eight hospitals in Ohio, all managers have access to HCAHPS scores that are broken down for different work groups and individuals, says James Merlino, M.D., the system's chief experience officer. Individual physicians are given data on their own HCAHPS ratings, as well as information on how their performance rates against other Cleveland Clinic doctors.

"We let physicians know how patients score them on their skills," Merlino says. "Physicians are highly competitive, so it's important to let them know how they compare against their peers and where they rank."

'Careful Listening'

Patient communication represents the largest single chunk of the HCAHPS survey; half of the 18 core questions directly relate to how patients perceive their interactions with nurses, doctors and other hospital staff. These questions ask patients how closely clinicians listened to their concerns and whether they clearly understood the explanations or directions they received.

To standardize the way clinicians interact with patients and their families, an increasing number of hospitals are training their employees to use scripted communication tools and keywords. The tactics, which some liken to the attention a diner might get from a waiter at a high-end restaurant, are believed to improve patient perspectives of the care they receive — and also may relax tense patients during times of anxiety.

Nurses and physicians at Henry County Hospital in Napoleon, Ohio, employ the AIDET communication model developed by the Studer Group. AIDET — acknowledge, introduce, duration, explanation, thank you — requires clinicians to describe their educational background, listen carefully to patients and thank them after their consultation.

"Using AIDET effectively decreases anxieties, and decreasing anxiety decreases the patient perception of pain," says Kimberly Bordenkircher, the hospital's chief executive officer.

At Carolinas HealthCare System, employees are trained on tactics that include listening to patients for two minutes without interruption and regularly using expressions like "I want to make sure I understood you correctly."

"They're building that relationship through careful listening," says Patrick Ratchford, the system's human resources manager.

Even a clinician's body language can play a role; doctors who sit during consultations are perceived by patients to have spent twice as much time with them as those who stand during visits, the Cleveland Clinic's Merlino says.

However, some hospital leaders are wary of scripting and conversational tactics. Greg Johnson, D.O., chief medical officer at Parkview Health System in Fort Wayne, Ind., believes improvements in patient satisfaction from scripted questions and conversational tactics "are not sustainable. …[Scripting] is … really in a box by itself."

Leading by Example

Instead, Parkview focuses its patient satisfaction strategy on leadership training; selected physicians take up to 30 hours of class time on leadership principles that emphasize such values as curiosity, accountability and authenticity. Johnson believes the principles teach physician leaders to model the behaviors the organization wishes to spread to the rest of the staff.

"It's difficult to hold the physician or nurse accountable, but it's our culture that's holding them accountable," he says.

At Mount Sinai Hospital in Chicago, that point is driven home during Sinai Service: Simply the Best, a daylong training course all incoming staff are required to take. Using techniques first developed by the Broadmoor ski resort in Colorado, Sinai's top executives meet with new hires to drive home the importance of patient service as a clinical and business imperative. Regardless of their job titles, the new hires work together in teams as they learn Sinai's approach to customer service.

"Everybody's hearing the same thing," says Karen Teitelbaum, chief operating officer. "Whether you're a security guard or a neurosurgeon, you're going through this together."

Engaging Employees Pays Off

Many hospitals also are focusing on improving the way their employees talk and interact with their peers, in the hope that the benefits of a friendly workplace will trickle down to patients. At Henry County Hospital, employees now are being asked to identify colleagues who have recently performed well, and are encouraged to send each other thank-you notes. Bordenkircher says the peer recognition is part of an effort to reverse a longstanding tendency in health care to undervalue the importance of employee satisfaction.

"We're in the business of fixing people when they're broken," she says. "We're really trained to look for what's wrong. … But someone who feels supported by a team of other co-workers is going to be in a better position to provide exceptional care for patients."

Heightened employee morale and engagement can reap dividends beyond harnessing employee goodwill and passing it on to patients. Mickey Parsons, R.N., a professor for excellence in patient care with the University of Texas Health Science Center at San Antonio, argues that front-line staffers have a realm of expertise about the day-to-day life of a hospital that's hard to find elsewhere. If staff feel engaged and respected, Parsons argues, they are more likely to share their observations on patient care.

"There's an HCAHPS question about quiet at night," Parsons notes. "Who knows best about noise at night other than the staff?"

Many hospitals traditionally operate within a model "where the doctor is king," argues Richard Corder, vice president of the patient safety strategies division of CRICO/RMF, a firm that provides malpractice insurance and risk management services to Harvard-affiliated medical institutions. But a framework in which all employees play a role in decision-making may lead to breakthroughs around patient satisfaction. "It might be the front-line member of your housekeeping staff who has the answer," he says.

Financial incentives that nudge clinicians in the right direction can help, Corder says. When he previously served as senior director of service excellence at Massachusetts General Hospital, the hospital offered incentives to physicians who attended communication training, which led to 92 percent attendance for the course and a temporary increase in HCAHPS scores for physician communication.

"Anything we've done to make the life of a front-line care provider easier to care for patients has shown an uptick," he says.

Leadership is a key part of the patient satisfaction strategy at Aurora Health Care, where all of its 1,700 leaders receive specialized training on how to support caregivers to deliver care with "kindness, empathy and respect."

Lasting cultural change takes time and a consistent emphasis from leadership, Aurora Health Care's Leonhardt says. "Changing behavior is one of the biggest challenges for all human beings, and the culture in health care developed over centuries."

Haydn Bush is senior online editor for Hospitals & Health Networks.


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