ISSUE 5: The Patient Takes the Lead
In his article written for Health Affairs (19 May 2009) titled, "What ‘Patient-Centered’ Should Mean: Confessions of an Extremist," Don Berwick noted that “patient centeredness” has a long intellectual pedigree. Most of us who are or have been providers of care recall hearing at some point that "the patient comes first." However, as Berwick notes, traditional professionalism (“Trust us, we know best what will help you.”) and the consumerist approach (“Tell us what you need and want and that is what we will offer.") are demonstrably worlds apart.
If the conversation isn't new, why now? Certainly, the price paid for health care by consumers/patients is undeniably under scrutiny. An article in the Washington Post recently reported that a benefits provider refused to pay billed charges because they were considered exorbitant and unjustifiable.
Lately, along with a resurgence of terms used to denote a “new” direction for health care services (value driven care, not volume; community health; population health improvement; and accountable care) comes renewed interest in partnering with the patient.
People, many of them Boomers, are vocal about being involved in care. In the May 2015 issue of an airline magazine, an article, “Patient Uprising,” details ways in which technology connects patients to data, which can in turn lead to finding better treatments for illnesses.
Health care in America is about choice. It seems logical that providers and purveyors of health care services who do not do more to adapt designs incorporating the patient perspective on value and benefit should perhaps become obsolete.
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In this issue,
An article and video by Kellie Bryant (NYU) takes the reader into the world of standardized patient actors and their usefulness in educational settings.
Fran Ludwig and Bonny Kehm (Excelsior College) illustrate ways to integrate the “Art of Nursing” into 21st century, patient-centered, AD to BSN online nursing student curricula.
Practicing nursing professional, Marty Brock, who also is a member of an IT department in a large health system, discusses different kinds of technology used by nurses and the support or interference of technology when establishing connections to the patient.
Amy Zwygart, Heidi Shedenhelm, and Adam Holland, staff at the Mayo Clinic, look at the institution's history of patient-centered care and how it has evolved to be a sustainable part of all aspects of its corporate culture.
An RN offers a personal account of a nightmarish odyssey through her own experience as a recipient of care, asking us to recognize the conditions she experienced and how we might improve them.
And finally, nursing leader Joann Rickley, shows how UCSF, a major medical center, has redesigned its surgical services (traditionally a bastion of professional control in organizations ), blending patient input with the implementation of robots, smart phones, healthy food, and humane architecture to create a more patient-focused experience.
We hope this issue will spur ideas that will lead to conversations and improvements in patient-focused care at the facilities and in communities and systems to which you contribute your expertise and time.
As was said in the sixties, and is still a good idea today, “Power to the People.”
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About Dr. Maureen Boshier
Maureen Boshier, FACHE, LPD, is Visiting Associate Professor and Track Coordinator Health Promotion and Education, Eastern Virginia Medical School/Old Dominion University a joint Master’s in
Public Health Program.
Enhancing Patient-Centered Care through the Use of Standardized Patients
Since the early 1960s, Standardized Patients (SPs) have been used widely in the field of medicine. However, the use of SPs in nursing education is a relatively new teaching modality (Bornais, Raiger, Krahn, & El-Masri, 2012). An SP is a person who has been trained to portray a patient in a standardized manner for the purpose of teaching and/or evaluating students. SPs enable students to practice patient-centered nursing care in a safe learning environment, without risking the safety of a “real” patient. SPs can be used to develop and/or evaluate core nursing competencies, including patient care, nursing knowledge, critical thinking, interpersonal and communication skills, and professionalism. As described in this article and video, the incorporation of SPs into our nursing curriculum in 2013 has improved our delivery of nursing education and our effectiveness evaluating students.
NYU College of Nursing (NYUCN) has an innovative clinical model that utilizes simulation for close to 50% of the student’s clinical experience. Every week, students rotate between a hospital-based clinical and a simulation session at the Clinical Simulation Learning Center. Every other week, students are provided with a simulation scenario that uses either hi-fidelity Human Patient Simulators or an SP to meet clinical course outcomes.
Although the use of Human Patient Simulators continues to play an important role in the highly technical hospital environment, SPs have proven to be highly effective for enhancing students’ psychosocial behavioral skills for several reasons:
- They allow students to focus on patient-centered care with the goal of improving the quality of health care.
- They teach students how to better care for patients by simulating real interpersonal interactions.
- They are trained to evaluate the effectiveness of student’s history taking, communication, physical assessment skills, and overall attitude during the encounter.
- They can provide useful immediate feedback on student’s interpersonal skills, techniques, and professionalism.
- Since incorporating SPs into our curriculum, we have found our students have excelled at demonstrating a caring demeanor and level of professionalism.
Some of the common areas SPs provide assistance to novice students include: more effective patient education, increasing comfort levels while performing a physical examination, avoiding the use of medical jargon during a patient encounter, and accurately performing nursing skills in the context of a simulated clinical environment. Students value the feedback and will frequently demonstrate improved performance during subsequent SP encounters due to previous SP feedback. Most importantly, SPs assist with teaching our students patient-centered care by being the voice of the patient and emulating the nurse/patient partnership.
NYUCN began using SPs during the spring 2013 semester. Due to implementing a new Electronic Medical Record system, the hospital was completely focused on training its staff nurses. This meant that students were unable to administer medication in the setting, and, in order to ensure patient safety and proper medication administration, were only allowed to observe the nurse administer medications. To ensure students had sufficient time to practice and develop their medication administration skills, we decided to create several medication administration simulations using SPs. The simulations not only enabled students to practice administering medications but also enabled them to perform a physical assessment, and work on communication, critical thinking, and dosage calculation skills.
Students were required to attend one session with an SP each semester, and were evaluated by both the instructor and the SP. Students who did not successfully complete critical competencies during the simulation were required to attend a remediation session. Due to the overwhelming positive feedback from the students, and the identification for the need for additional opportunities for students to practice safe medication administration skills, NYUCN soon required every student to complete a medication administration simulation each semester. After observing the positive clinical outcomes from the use of SPs, we brought them into our health assessment course as well as into numerous graduate nursing simulation sessions.
Some of the anecdotal comments from an informal survey distributed to students who performed their health assessment evaluation using an SP include: “Although I was nervous, using a standardized patient was definitely helpful and realistic. He very accurately portrayed the patients we see every day in the hospital.”
Another student stated: “The use of SPs forced me to use a critical thinking thought process as opposed to just completing steps on someone.” Across the board, students agreed that SPs created a more realistic learning experience and their use required an increased level of critical thinking skills.
Hiring and Implementing SPs into the Curriculum
Building a repertoire of trained SPs requires as great deal of time and resources. NYUCN was fortunate to obtain a listing of experienced SPs from a nearby medical school that had an established SP program. Other sources for recruiting SPs are retirees from the community, retired nursing alumni, and students from local acting schools.
Our goal was to hire SPs of various ages, ethnicities, and of both genders. All prospective SPs were required to submit a resume and headshots. Potential candidates were invited for an in-person interview. Our preference was to hire actors with SP experience, great communication skills, who were comfortable exposing their body for a health assessment. Once an SP was hired for a session, they were required to attend training 1 week before their scheduled simulation. During each training session, the simulation staff reviewed the script, evaluation form, expectations of the SP, and level of formative feedback required for the assigned case. A practice of each case was performed, and the simulation staff offered feedback as needed to the SPs. All SPs were paid an hourly rate, which included training plus a 30-minute prep before each session.
Currently, SPs are evaluated each semester by the simulation center staff. Some of the obstacles with hiring SPs are frequent last minute cancellation due to acting auditions, loss of SPs due to an acting job, and lack of experience providing feedback to students.
Conclusion and Future Considerations
This interview with one of our SPs, Chris Northrup, demonstrates his integral role in the delivery of our nursing curriculum and how he and others have helped improve our methods for evaluating course outcomes. Patient-centered care requires effective communication and a partnership between the nurse and patient to improve patient care outcomes and satisfaction. The use of SPs can create a more realistic clinical experience and enhance the therapeutic interaction between the nurse and patient. Results from our student surveys (at the end of each semester) showed that the majority believe SPs have enhanced the learning experience. Students suggested they would like to see SPs incorporated into more of their simulation sessions. Although the research is limited, there is evidence that the use of SPs in nursing education can enhance student communication skills, increase self-confidence, encourage critical thinking, and decrease student anxiety (Bornais et al., 2012, Raiger, Krahn, & El-Masri, 2012; Gibbons et al., 2002; Yoo & Yoo, 2003).
In addition, students who were exposed to SPs performed better on their performance evaluations as compared to students who practiced on peers (Bornais et al., 2012; Gibbons et al., 2002). In the Bornais et al. study (2012), the intervention group that used SPs scored 10 points higher on OSCE exam that students who received traditional health assessment education. Although the limited research has shown multiple benefits of using SPs, one of the biggest obstacles to higher levels of implementation is the significant cost associated with hiring and training. Additional research is needed to determine if using SPs in a nursing program actually translates into improved patient care in the field.
Bornais, J. A., Raiger, J. E., Krahn, R. E., & Masri, M. M. (2012). Evaluating undergraduate nursing students’ learning using standardized patients. Journal of Professional Nursing, 28(5), 291-296. doi:10.1016/j.profnurs.2012.02.001
Gibbons, S. W., Adamo, G., Padden, D., Ricciardi, R., Graziano, M., Levine, E., & Hawkins, R. (2002). Clinical evaluation in advanced practice nursing education: Using standardized patients in health assessment. Journal of Nursing Education, 41(5), 215-221.
Yoo, M. S., & Yoo, I. Y. (2003). The effectiveness of standardized patients as a teaching method for nursing fundamentals. Journal of Nursing Education, 42(10), 444-448.
About the Contributor
Dr. Kellie Bryant DNP, WHNP, is currently the Director of Simulation Learning Center and Clinical Assistant Professor at NYU College of Nursing. She oversees the day to day operation of NYU’s Simulation Center where she works with faculty in the development, implementation, and integration of over 100 simulation sessions a week for both the undergraduate and graduate programs.
Person-centered care (PCC), identified as a fundamental unit for improving the quality of health care by the Institute of Medicine 2003 report, “A Bridge to Quality,” has begun to be incorporated into educational philosophy and course structure. In addition, the IOM call for eighty percent (80%) of RNs to be BSN prepared by 2020, combined with new nursing educational methods, has further intensified the need to step back and review how we are educating RNs who are returning to school to pursue their baccalaureate degree.
AD and Diploma nurses who have been practicing for years, and in some cases decades, bring varied educational and professional experiences, and influence how we shape our baccalaureate education program. Their prior knowledge regarding person-centered care (PCC), holistic health assessment, and the vision of population health is valuable and has been used as a springboard toward designing effective, relevant courses.
This article addresses a creative approach in which emphasis is placed on the provision of PCC from the onset of an online RN to BS in nursing curriculum.
The idea of the patient as the center of care is not new. In fact, it dates back to the days of Florence Nightingale, “who differentiated nursing from medicine by its focus on the patient rather than the disease” Lauver et al. 2002 (as cited in Morgan & Yoder, 2012, p. 7). And, while written about extensively, the actual concept of person-centered care has only recently begun to be integrated more widely into nursing curriculum. PCC alters the educational focus to “highlight the importance of knowing the person behind the patient – as a human being with reason, will, feelings, and needs – and engages the person as an active partner in his/her care and treatment”(Ekman et al., 2011, p. 249). This chart demonstrates that moving away from a “disease-focused, acute-care, and illness-based management to a more person-centered care approach requires a paradigm shift in the profession beginning with nursing education” (Battie, 2013, p. 1).
Application and appreciation of PCC is now being integrated more broadly into nursing curriculum, as well as into other healthcare professionals’ educational programs. One example is the University of Maine’s RN to BS integral-holistic curriculum, which emphasizes the same humanitarian, patient-centered values Nightingale spoke of when she said, "We must not talk to them or at them but with them." The American College of Osteopathic Internists has developed the Phoenix Physician, which is a training program defining a pathway between physician and patients. (Good et al., 2012). These programs are addressing the changes in health care delivery and providing health care providers and nurses with an appreciation and understanding of PCC with the goal of improving care and empowering the person.
Involving the “hearts and minds of staff in the shared value of PCC” (Small & Small, 2011) is critical, and nursing practice at an increasing number of health care institutions have already begun to demonstrate this commitment. In Oregon, Three Rivers Community Hospital has seen a sustainable result in the areas of increased patient and nursing satisfaction due to implementing person-centered practice (Thornton, 2005). The Cleveland Clinic is “raising the quality of nursing care by adopting a Patient Centered Practice Model to guide nurses and practice.” Naturally, the implementation of PCC will differ from institution to institution, but the message is clear: PCC impacts not only patient satisfaction and outcomes, but staff as well.
Current Practice in RN to BS curriculum
The authors of this article, faculty in an RN to BS nursing program, have re-designed two courses, The Profession of Nursing and Holistic Health Care across the Life Span, which together provide the framework for learning activities directly shaping how students learn to provide high-quality PCC.
The courses introduce the following elements:
- reflective practice
- introspective perceptions
- Chinn’s model of knowledge domains
- holistic health
- the art of communication
- cultural competency/awareness
- health literacy
- technology integration
At the foundation of our new paradigm, students are introduced to several different ways of knowing in order to provide safe, high-quality, PCC to individuals, families, communities and populations. Within an RN-BS in nursing course--through the early introduction of Chinn’s theory and process of knowing and knowledge development--students can be introduced to various fundamental patterns of knowing, then identify those most challenging to them in practice. With further discussion, students gain a deeper appreciation of their own needs and what they will need to develop to meet the challenge that a particular pattern provides. While gaining an understanding of the separateness of each domain, students realize “the complementarity of the processes within each pattern and their contribution to the whole of knowing” (Chinn & Kramer, 2015, p. 3). Through this process, the student begins to appreciate the uniqueness of her or his own background and experiences as well as the patient’s. The knowledge gained from this serves as a foundation upon which to build a person-centric practice.
New Courses for Returning Students
Returning to college can be a daunting transition for many returning AD and diploma nurses who are already RN licensed. Content previously obtained in pre-licensure nursing education could also be viewed as redundant. Therefore, the decision was made to transform the focus of the current RN to BS course to the new role of a baccalaureate prepared nurse, which in essence required moving from a review of the historical and theoretical aspects of the profession, to one that actively focused on the power of influence, reflective practice, and the role of advocate (professionally, personally, and patient care). The overarching theme of this course, The Profession of Nursing, compares the baccalaureate education (and the course content) to preparing to go on a journey: the journey being “embarking” on one’s career.
Each module's content is parallel to a different part of a journey’s preparations. The activities were developed to be both intriguing and applicable, and to encourage lifelong learning. The course combines creativity and innovation with practicality and clarity, which makes the content interesting and understandable.
The clinical aspect of this course asks students to complete a written Person-Centered Care Project in which they explore the expanding role of the nurse advocate.
Applied nursing theory was incorporated into this project, allowing students to see the importance and influence nursing theory has on professional practice and PCC. At the end of the course, one student, referring to her PCC client, said, “By taking the time to connect with her, I have learned information about her personal life that allows me to improve the care I give her, and she in turn has taught me some valuable lessons.”
Holistic Health Care across the Life Span
The second course, Holistic Health Care across the Life Span, continues to address topics such as health promotion, illness, and cultural competence, as well as the importance of population health, and helps students recognize that “the philosophy of holistic nursing supports the tenants of PCC” (Flagg, 2015, p. 75). The teaching and utilization of PCC within the classroom/simulation experience has served to serendipitously reinforce the students’ capacity to distinguish individual values and to critically cogitate. It provides students with an opportunity to integrate, synthesize, and use learned knowledge and skills in the application of PCC.
The essence of this course is to view the person as a whole being. Watson (1989) stated that “the ethic of caring provides an expanded context for nursing education by calling upon the highest ethical self in the process of an evolving consciousness” (p. 53). Students are able to formulate a holistic and culturally competent nursing plan of care in collaboration with the person, thereby achieving PCC. As affirmed by Daley (2012), “Person-centered care means designing care delivery in a way that ensures individuals and families are engaged and that their goals for health and care outcomes are identified and prioritized within the plan of care” (para. 3). Patients are therefore asked: What are you experiencing that has not been addressed?
Since implementing these courses, and as part of critical and analytic reflection, instructors have noticed a marked increase in personal knowing, ethical knowing, empiric knowing, aesthetic knowing and emancipatory knowing. When asked about their experience within the educational activities, students provided examples of what they felt care of this nature involved. Two student respondents noted:
“Providing cultural competent care is important for survival and well-being (Parker & Smith, 2010). Our cultures are an important part of who we are. I found it fascinating to learn about different cultures. Once you learn about different cultures, it provides an opportunity to provide better quality care. Actually, I have found that most patients enjoy sharing about their culture. Culture is a part of the uniqueness in each of us. As caring nurses we desire the respect and honor the uniqueness of each individual." — MA
“As an admission nurse, utilization of genograms allows me to establish hereditary disorders since there is no limit on the information that is included in the genogram. This will also help me acknowledge reasons behind a patient’s refusal of medical treatment or why they do not understand their medical diagnosis with the addition of cultural information in the genogram. This could be why some clients never talk about the past health issues in the family. It was not culturally permitted.” — MA
Person-centered care resonates with the idea of cultural context being central to the care of the person. Leininger’s (1991) Theory of Culture Care Diversity and Universality assert that for PCC to occur, students have to understand “therapeutic nursing care can only occur when cultural care values, expressions, or practices are known and used explicitly” (ANA, 2010, p. 25). The ANA Code of Ethics for Nurses (2010) states that nurses should “show respect for the values and practices associated with different cultures and use approaches to care that reflect awareness and sensitivity” (p. 115). Through various aspects of the course, students had to sensitize themselves to cultural diversity by developing their cultural understanding and respect by scrutinizing their own cultural characteristics and beliefs, evaluating ethnocentrism, recognizing that cultural and religious values are deeply ingrained and therefore very difficult to change, and being willing to adapt the plan of care to accommodate the person’s cultural and spiritual practices (Jarvis, 2012).
While there are many essential nursing competencies required of nursing graduates, PCC is a fundamental aspect of nursing practice and therefore needs to be incorporated within nursing courses allowing students to integrate it into their practice. It is important to recognize that additional education is essential in the provision of quality safe care (Aikens et al., 2002).
RN to BS in nursing programs highlighting person-centered care as well as holistic care are able to take these skills forward adapting to the changing health care environment and nursing roles, embrace new opportunities, and fully integrate this new knowledge into their practice.
As faculty members, it becomes vital and essential for each of us to carefully consider the message we are providing our students in regard to PCC. Each faculty member should develop a firm understanding of PCC and relate that to the educational activities. St. Onge and Parnell, (2015) asserted that faculty members must be prepared to facilitate thinking about PCC. As faculty members, it is our responsibility to present an effective role model for person-centered behavior based upon a solid understanding of the competencies and standards of nursing practice thereby producing reflective knowledgeable practitioners.
We believe the following quote from a student captures the essence of incorporating person-centered care in RN to BS in nursing education:
“I learned that just stopping for a minute to speak with a patient about what is on his or her mind can offer so much more insight to the plan of care. It is important for me to remember that acknowledgement of the whole person, body, mind and spirit, is the most important part of what nursing care is about.” –MA.
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Battie, R. N. (2013). Perioperative Nursing and education: What the IOM future of nursing report tells us. AORN Journal, 98(3), 249-259. doi:10.1016/j.aorn.2013.07.004
Chinn, P.L., & Kramer, M.K. (2015). Knowledge development in nursing: Theory and process (9th ed.). St. Louis, MO: Elsevier Saunders.
Daley. K. (2012). Person-centered care –What does it actually mean? The American Nurse Retrieved 12 April 2015, from http://www.theamericannurse.org/index.php/2012/12/03/person- centered-care-what-does-it-actually-mean/
Donadio, G. (2005). Improving healthcare delivery with the transformational whole person care model. Holistic Nursing Practice, 19(2), 74-77.
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Flagg, A. J. (2015). The role of patient-centered care in nursing. Nursing Clinics of North America, 50(Transformational Tool Kit for Front Line Nurses), 75-86. doi:10.1016/j.cnur.2014.10.006
Good, RG., Bulger, JB., Hasty, RT, Hubbard, KP, Schwartz, ER, Sutton, JR, Troutman, ME, Nelinson, DS, (2012) The phoenix physician: Defining a pathway toward leadership in patient-centered care, The Journal of the American Osteopathic Association, 112(8), 518-520
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About the Contributors
Fran Ludwig, MS, RN, is a Faculty Program Director in the RN-BS program at Excelsior College. Her background in baccalaureate nursing education, as well as Community Health Nursing, is extensive. She has published and presented nationally on the role of Faith Community Nurses in providing holistic care in the community and the importance of patient-centered care.
Dr. Bonny Kehm, PhD, RN, is a Faculty Program Director in the RN-BS program at Excelsior College. She has many years of experience in pediatric nursing, as well as 13 years’ experience in higher education. She gives seminars and presentations on various educational topics for nurses, physicians, marketing groups and professional societies.
As a registered nurse in a large health care organization I have had the opportunity to lead and be part of a small innovation team inside a much larger information technology (IT) department. Nine years ago, when I was an open heart recovery nurse at the bedside, I never dreamed I would be part of such a ground-breaking group of thinkers looking for technology solutions to help our patients and our clinicians. Our team acts as liaisons between the clinicians and technical IT. We evaluate, implement, and optimize technologies with our operational partners. This role is difficult, rewarding, and necessary.
The Role of the Electronic Health Record
In 2005 our organization entered the planning stage for implementing the electronic health record (EHR). The executive leadership felt it was easier to teach clinicians IT than to teach IT clinical workflows, so a large number of clinicians from many disciplines were hired to build the EHR. The use of EHRs at this time was very limited and the percentage of adopters was very low. As organizations pushed to meet meaningful use, adoption rates nearly doubled for physician practices since 2009, and quadrupled for hospitals since 2010 (HHS.gov, 2014). The amount of change and process redesign involved in the adoption of a robust EHR was monumental. To help design the system and mitigate issues prior to go-live, clinical superusers from every discipline were involved in the process. As we are seeing, implementation of EHR is really only the starting line.
One of the major goals of EHR implementation is seamless exchange of information and a decrease in stand-alone technologies that have to be interfaced to the EHR. This means that no matter how fantastic and innovative a new technology may be, there has to be an evaluation of benefits, return on investment, and what added value new technology may bring. The expense and affects of an integrated EHR cannot be underestimated, and many technology solutions are and will be judged by how well they will integrate with these costly, complex systems.
Although the EHR is a great first step it will not meet all the needs of the ever-changing health care environment, particularly in regards to quality patient-centered care. Innovation teams are always on the lookout for technology to give the patient more control over her or his day in the inpatient and outpatient settings, and patients are starting to expect this.
Integrating EHR with Inpatient Scheduling and Ancillary Departments
We implemented a technology called Inpatient Scheduling, which allows patients to know when they have scheduled procedures during a hospitalization. Like every health care system we are looking to improve patient satisfaction and felt this technology would help patients know their itinerary while in the hospital, by allowing them to know when procedures and tests were being scheduled.
Ancillary departments schedule the appointment and the nurses can see the schedule in the EHR, communicate the time to the patient, and prepare them for the procedure before the patient is transported. Currently the communication is done verbally and is written on a white board in the patient’s room. The long-term goal will be to provide the schedule to the patient through an electronic white board that automatically populates from the order in the EHR, but we are not there yet. The patients like the technology, but have asked for more functionality.
This process is a huge culture shift for the ancillary and the inpatient staff. Historically out-patient departments fit their inpatients into their schedules wherever there is an opening which is not always convenient to the patient and their family. Due to the variability in the schedules inpatient nurses are not comfortable medicating their patients for procedures until transporters arrive to the floor. This is not ideal for the patient and can delay the procedure even longer. A key component to successful implementation is a clear expectation that this is a tool to improve the patient experience.
MyChart Beside - A Patient App
MyChart Bedside is an application within our EHR used by patients, not clinicians. The application is displayed on a mobile tablet that is given to the patient upon admission.
This device allows patients in the hospital to look up lab results, see their procedure schedule/itinerary, review education related to their diagnosis, communicate to their care team, and provides games and music through mobile applications. Nursing or administrative personnel will set the patient up with the device and educate them on the use of the device. Outpatients have access through a web portal called MyChart that gives them very similar information and allows them to self-schedule outpatient appointments.
This technology is used to improve patient experience by keeping them informed, entertained, and educated during their hospitalization. Our patients are embracing and using the technology, but it is difficult to sell to the clinicians because it is an added task to their already hectic and complicated day. Once again, culture plays a role in whether certain technologies are adopted or not. Once a technology is proven successful, accountability, ownership, and leadership expectations are important for adoption.
Orchid - A Rounding Tool for Nurses
Measuring patient experience is not always an easy task when you look at the many factors that can affect how the patient feels about their experience. Putting tools in the hands of the clinical teams to resolve issues at the time they occur makes this easier. We partnered with Cipher Health to pilot a rounding tool called Orchid. It is a nurse rounding tool that is displayed on an iPad mini and provides the nursing leaders the ability to round real-time on patients in the hospital.
Rounding is simply the nurse leaders asking questions of the patients to ensure they are satisfied with their care and the environment within the hospital. The patients are asked a series of questions related to cleanliness of their rooms, how the food is, and how the physician and other staff are caring for them. The nurse uses the iPad mini to enter the answers into the application and if there is an issue or complaint, the nurse leader can immediately send a message to the appropriate team for resolution.
Our patient experience scores have improved using this tool and the patients feel as though they are being heard. Leaders have real-time reports that allow them to see how many patients are rounded on, what the issues are, if there has been resolution, and if patient experience is improving
Other technologies that we are looking to implement are those that improve transitions of care and help the patient navigate through a very complicated health care system. Our goal is to partner with the patient to ensure continuity of care across the continuum, while providing tools to help our patients engage and manage their care. We wanted to find ways to help patients that would not qualify for home health monitoring manage their chronic conditions (the patient has to be home bound to have a care giver come to their home).
By use of in-home monitoring devices (blood pressure cuffs, scales, and 02 sat monitors) patients are able to be monitored for blood pressure, weight, heart rate, and oxygen saturation remotely. A technician or nurse will educate the patient on the use of the devices in their homes as well as the expectations on when and how frequently the patient will take their vital signs. The values are sent via phone line and monitored by a nurse. If any of the numbers are outside of the protocol parameters the nurses will call and coach the patient and determine a course of action. If the patient values are within range the nurses will still call and talk to them weekly to provide education and a listening ear.
Early results are showing a decrease in ED utilization, readmissions, and costs. This technology gives patients who do not qualify for other services a safety net in relation to their chronic condition. If for example a congestive heart failure patient was gaining weight the nurse could educate them on salt in their diet or suggest that they may need to see their physician to adjust their medications. If they were not part of this program the weight gain might go unnoticed by the patient until it became severe enough to cause a visit to the emergency room or even an admission to the hospital. It engages the patient in their care and provides a place to ask questions and receive education.
Improving health of populations, patient experience and outcomes while reducing costs, is the challenge of the Triple Aim. We have to understand how consumers/patients want their health care delivered as we move to value-based reimbursement and consumers/patients have to engage in their care. The triple aim will challenge both patient and provider to think outside the box.
Value-Driven Quality Health Care through Patient Centeredness and Collaborative Care
Value-driven health care is based on quality, transparency, standards of care, and evidence, and should spark competition (HHS.gov, 2015). It allows consumers to make better informed choices, select quality providers, and shop comparatively for the services they need at the price point they need (HHS.gov, 2015). Consumers are involved in comparison shopping in all other aspects of their lives and health care should not be the exception. Government sites, like this, can give the consumer more information abut their ability to take action and expect accountability for their care, and that being proactive should be rewarded by lower premiums (HHS.gov, 2015).
If patient accountability is a major factor in patient-centered care, what expectations are required and how do you measure the results? As the country looks to lower health care costs consumers must become more involved and the health care system must provide solutions that support these efforts. Technological advances are occurring rapidly, so how can these technologies be used to move us toward value-based health care where the patient becomes part of the solution?
Collaborative partnerships are needed between disciplines such as primary care, specialty, urgent care, nursing etc., to share information and evidence and guide the consumers to the best care at the best cost. These collaborations can prevent things such as duplicate testing and unnecessary procedures that add costs and risks for the consumer. As a country we have to understand the populations we serve, the needs of these populations, and how we educate and assist them to become more involved in their care.
Engaging patients in their care through the use of technology will be challenging and there has to be expectations for both the provider and patient. As providers, hospital systems, and patients begin to use new technology, there are many things to consider. What are the rules of the road for the provider and the patient? What expectations will be placed on the patient and how do you educate the patient on the technology, as well as monitor and measure the results to determine whether the technology is making a difference related to outcomes?
Technological Barrier to Patient-Centered Care
There is still a culture of proprietary information on both the provider and vendor side. Exchange of information between systems and providers is complicated. Strict security rules and heavy fines further complicate the open exchange of information. For example, the Department of Health and Human Services has complex rules and protocols governing data breaches.
State and federal laws also impose barriers related to reimbursement. Traditional health care visits require face-to-face appointments with providers, and in many cases is required for reimbursement. Telehealth and non-traditional methods are challenging the norm and the outcomes are starting to prove to be as effective as in-person visits. HRSA (2015) defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.” Although telehealth is a strong alternative for traditional visits by providing access and decreasing non-emergent ER visits, culturally it has not been fully embraced.
Disruptive technologies that create new markets by changing the way we normally provide care are essential. Patients will expect convenient scheduling to decrease wait times, improved access to care, the ability to comparatively seek care, and assistance for engaging in their care. As an industry our focus should be on removing these barriers.
IT for Nurses – Education for Patient-Centered Care
Nursing curricula are starting to include foundations in technology, informatics courses, and a broad understanding of healthcare reform and the political environment. Hospital systems are educating nurses on the current political environment to include required documentation elements. Clinical information technology user groups are working to ensure that required documentation is built and engrained in practice. Initiatives are in place to improve the care of certain patient populations such as those with pneumonia, heart failure, and sepsis. Educating and changing workflows to improve and incorporate best practices for population management to improve readmission, reimbursement, and outcomes for these populations.
As leaders, nurses will constantly review the evidence in order to provide the best and safest care. Part of their emerging roles will include how to understand, how to incorporate, use, and suggest new technologies that enhance patient-centered care. It is not only physical care of the patient, but seeing the patient as a whole and changing practice to enhance the patient experience while providing safe quality care. New nurses and students are partnered with experienced nurses to provide a solid understanding of the political, clinical, and technological environment within health care environments. Technology will be a tool to help manage these goals and nurses will be expected to lead and facilitate care using many different technologies. Each new technology will be supported and implemented via a partnership between the technical and clinical teams. Nurses and other disciplines will be called to give input as the clinical experts and to determine the educations aspects for the clinical masses.
The cost of health care is challenging the traditional Fee-For-Service model of health care delivery. The future of health care will be very different and new models are being created to improve quality, access, and lower cost. The patient has to be at the center driving the care and collaborating with providers to manage care in a new way. Technology and culture collide and challenge the world to look at new and different models to improve access and create partnerships that encourage open exchange of information for the benefit and health of the population.
HHS.gov, (2014). More physicians and hospitals are using EHRs than before. Retrieved from http://www.hhs.gov/news/press/2014pres/08/20140807a.html
HHS.gov, (2015). Value-based health care. Retrieved from http://archive.hhs.gov/valuedriven/
HRSA, (2015). Telehealth. Retrieved from http://www.hrsa.gov/ruralhealth/about/telehealth/
About the Contributor
Maureen R. Brock, MSIT, BSBA, RN, is an Information Systems Manager for Clinical Innovations and Med Systems Support at Sentara Healthcare in Virginia Beach, VA.
All images in this articles are used with permission.
Driven by a Mission
Today’s healthcare environment is fast-paced and multifaceted. Patient acuity and complexity of healthcare is growing as Americans are living longer with chronic co-morbidities. In recent years, organizational focus on patient satisfaction has grown with the implementation of quality metrics linked to reimbursement as the United States’ healthcare system moves from fee-for-service to a pay-for-performance era. In today’s competitive healthcare environment, organizations are faced with the challenge of providing high-quality care with limited resources in a manner that ensures a positive patient experience. In direct response, organizations have made a dramatic change toward promoting a positive patient experience through use of care delivery models focused on a multidisciplinary, patient-centered approach (Epstein & Street, 2011; Bodenheimer, Chen, & Bennett, 2009).
Patient-centered care was brought front and center in the Institute of Medicine’s (IOM) “quality chasm’ report as one of the six aims in providing high-quality care (IOM, 2001). Patient-centered care is defined by the IOM as “care that is respectful of and responsive to individual patient preferences, needs, and values” and that ensures “that patient values guide all clinical decisions.” The IOM definition showcases the value of the provider-patient relationship and the need to include the patient in clinical decisions to achieve the best possible clinical outcomes (Barry & Edgman-Levitan, 2012). The quality of personal, professional and organizational relationships, and the focus on the patient, was the primary foundations on which Mayo Clinic was founded.
William J. Mayo, M.D., in his 1910 Rush Medical College commencement address stated, “The best interest of the patient is the only interest to be considered” (Mayo, 1910). Dr. William J. Mayo (Dr. Will) and his brother, Charles H. Mayo, M. D. (Dr. Charlie), along with the Sisters of Saint Francis (the first nurses at Mayo Clinic Hospital – Saint Marys Campus), demonstrated a commitment to patients that has endured over 100 years. This patient-first philosophy evolved into Mayo Clinic’s primary value, “The needs of the patient come first,” and guides Mayo Clinic’s mission and vision. The commitment to this value by the organization and employees has created a culture unlike any other and has been identified as a key factor in Mayo Clinic’s success (Berwick, 2009).
A Longstanding Culture of Teamwork and Mutual Respect
A common question often asked is, “How has Mayo Clinic been able to focus on the needs of the patient for over 100 years?” It dates back to the 1800s when a tornado destroyed a large part of Rochester, Minnesota, leaving 37 dead and many others injured.
Dr. William W. Mayo, and his sons, Drs. Will and Charlie, worked with the Sisters of Saint Francis, a local teaching order, to care for the injured in a local dance hall as there was no hospital (Keeling, 2014). This early teamwork and mutual respect between the doctors Mayo and the sisters eventually led to the building of Saint Marys Hospital, today known as, Mayo Clinic Hospital – Saint Marys Campus (Keeling, 2014). The partnership was unique as in the early 1900’s it was uncommon for individuals of Protestant and Catholic faiths to work together in the opening and operations of hospitals. In many towns across the United States, each religion built and operated their own hospital (Clapesattle, 1969).
However, at Mayo Clinic, with teamwork and respect between the Doctors Mayo and the Sisters, the hospital was a success. Over time, these concepts have been passed down from employee to employee through what has become known as the Mayo Clinic values. This organizational culture, shared values and mission allow Mayo Clinic to focus on the needs of the patients and is the key driver in the multidisciplinary patient-centered care team model (Keeling, 2014).
As the organization has grown and works to ensure a fully integrated practice, the primary value “the needs of the patient come first” has continued to drive all decisions around patient care. Barry and Edgman-Levitan (2012) highlight decision making that involves multidisciplinary team members and the patient as the optimal shared decision making process. Across the organization, Mayo Clinic’s values drive its culture. It is the culture that supports a true multidisciplinary team approach in providing patient centered care. Mayo Clinic employees value the contributions of every member of the multidisciplinary team in putting the needs of the patient first. Each member of the team is encouraged to have a voice, which includes the voice of the patient and the patients’ family that has created the unprecedented patient experience that Mayo Clinic has become known for.
Mayo Clinic Nursing Professional Practice Model
In the Department of Nursing, the Mayo Clinic Nursing Professional Practice Model (MC NPPM), based on the Theory of Human Caring, is the framework that supports Mayo Clinic nurses in putting the needs of the patient first (Keeling, 2014). In 2012, a team of Mayo Clinic staff nurses and nurse leaders from across Mayo Clinic reviewed the previous professional practice model’s strengths and opportunities. The team re-affirmed relationship based care as the care delivery model and supported the MC NPPM alignment with the Mayo Clinic primary value, “The needs of the patient come first,” as the central component of Mayo nursing. The MC NPPM was updated, adopted and placed into practice across all Mayo Clinic nursing sites.
The MC NPPM framework emphasizes the patient as the center of care and the nurse’s relationship with the patient and family that tie the caregiver to the patient, “resulting in appropriate, dedicated, and personalized care” (Keeling, 2014). In the MC NPPM, nursing care is based in both the science and art of nursing. The model allows the nurse who knows what to do and who cares about the patient to deliver relationship based care that is compassionate, holistic and ensures the involvement of the patient and family at its center.
In actualizing the MC NPPM, the registered nurse is accountable for providing nursing care to assigned patients throughout the continuum of care. During every encounter, the nurse develops a therapeutic relationship with the patient and family.
This relationship is central to the nursing process. The model is based on four nursing core values that include continuity of care, professional practice, evidence-based practice, and accountability to the patient (Mayo Clinic, 2014a).
Core Values of the MC NPPM
The core value of continuity of care is based on the nurse patient relationship and respect for the individual. This continuity is promoted through daily practice including nurse assignments, nurse to nurse bedside handoffs, and coordinating and communicating care across the continuum. Nursing professional practice is facilitated through a shared governance model that promotes decision making by those directly at the point of care. Professional practice is demonstrated through nurses’ involvement in scholarly activities, education and professional development that encourages individuals to develop all realms of their practice. Evidence based practice is the foundation of nursing practice as it supports patients receiving science-based nursing care. Additionally, nurses’ involvement in nursing research promotes new knowledge that is generated and shared across the nursing community at large. Registered Nurse (RN) accountability is the commitment to patients having a competent RN assigned to every patient working to their full scope of practice. The RN serves as the coordinator of nursing care and promotes collegial interdisciplinary practice (Mayo Clinic, 2014b).
Roles of the nurse in the MC NPPM
The MC NPPM is comprised of seven roles: caring healer, problem solver, transformational leader, pivotal communicator, teacher, navigator, and vigilant guardian. These seven roles, actualized across Mayo Clinic sites, reflect an integrated practice “where nurses use a shared language to define, describe, and evaluate their practice” (Keeling, 2014).
Patient centered nursing practice is built through relationships with patients by each nurse in the role of caring healer and is the foundation for nursing practice at Mayo Clinic. The nurse establishes a therapeutic relationship through presence, listening, trust, knowing the patient story, and the patient’s family role in care. The nurse pays close attention to the patient’s primary language, implementing specific cultural practices, based on individual’s need and preferences to ensure a patient centered approach in the nursing process.
Problem solving is a role nurse’s play as they use critical thinking skills and knowledge to create an individualized plan of care. The nurse then innovates how care is delivered based on patient needs, and evaluates the effectiveness of nursing interventions (Keeling, 2014). Mayo nurses are key individuals in the patient experience and are empowered to meet unique patient needs through problem solving on the patient’s journey throughout the continuum of care.
Mayo nurses function as transformational leaders. They are involved in interdisciplinary teams, embrace change, and develop new models of care and ways of working. The voice of nursing at Mayo Clinic is a collective whole achieved through an integrated nursing practice (Keeling, 2014). This collective voice allows the Mayo nurse to function effectively in a team environment. Nurses use the following hierarchy to help guide decision making:
- Is this best for patient care?
- Is this best for Mayo Clinic?
- Is this best for the profession?
- Is this best for individuals?
Nurses play an important role in patients’ safety and satisfaction as pivotal communicators between nurse-to-patient, nurse-to-nurse, and nurse-to-provider communication (Caruso, 2007). Mayo nurses function as pivotal communicators during interactions with patients, families, and the multidisciplinary team. They listen closely to concerns, questions and goals, while promoting understanding of medical terms and disease processes. Mayo nurses are patient advocates empowered to speak up on the patient’s behalf and recognized for their efforts of collaboration as members of the multidisciplinary team (Keeling, 2014).
Imparting knowledge through teaching patients, families, and colleagues is a key role of the Mayo Clinic nurse. Nurses develop an individualized educational plan based on patients’ or colleagues’ needs, learning styles, and goals (Keeling, 2014). Teach-back is used to evaluate effectiveness of teaching strategies. Nurses are engaged in educating their peers related to changes in nursing practice, medical innovations, and knowledge transfer.
Mayo nurses serve as navigators for patients and their families in every episode of care. Throughout the continuum of care, Mayo nurses guide patients through journey of illness, wellness, restoration, or end of life. The nurse creates individualized plans of care to ensure continuity, life style changes, and goal setting reflective of the patient needs and desires.
As vigilant guardians, Mayo nurses’ promote patient safety. Nurses are key team members in interdisciplinary rounds where they engage in the exchange of information about the patient’s plan of care. Nurses monitor, respond and evaluate physiological data, intervening as necessary to prevent harm (Keeling, 2014).
In today’s healthcare environment, where organizations are continually charged to create the most efficient and effective care delivery model, it is often easy for organizational culture to become an afterthought. Mayo Clinic recognizes that it is the Mayo Clinic values that drive the organizational culture. It is this culture that creates a supportive environment for multidisciplinary care team models, that allow for the actualization of true patient-centered care and contributes to an unparalleled patient experience for the patients and families served. The essence of Mayo Nursing in putting the needs of the patient first is achieved through the patient-nurse relationship. This relationship is enabled by the seven roles of the nurse that drives nursing care. The MC NPPM provides a venue by which the best nursing care can be delivered to Mayo Clinic patients, supports nurses as valued members of the multidisciplinary team and leads Mayo nurses to provide an unparalleled experience to every patient through practice, education, and research.
Berwick, D. (2009). What 'patient-centered' should mean: Confessions of an extremist. Health Affairs, 28, no.4 (2009):w555-w565 (published online May 19, 2009; 10.1377/hlthaff.28.4.w555)
Barry, M. D., & Edgman-Levitan, S. (2012). Shared decision making: The pinnacle of patient-centered care. N Engl J Med. 366:780-781 March 1, 2012, DOI: 10.1056/NEJMp1109283
Bodenheimer, T., Chen, E., Bennett, H. D. (2009). Confronting the growing burden of chronic disease: Can the U.S. health care workforce do the job? Health Aff January/February 2009 vol. 28 no. 1 64-74, doi: 10.1377/hlthaff.28.1.64
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Caruso, E. M. (2007). The evolution of nurse-to-nurse bedside report on a medical-surgical cardiology unit. Medsurg Nurs, 16(1), 17-22.
Clapesattle, H. (1969). The Doctors Mayo. Rochester, Minnesota: Mayo Foundation for Medical Education & Research.
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Koloroutis, M. (2004). Relationship-based care: A Model for Transforming Practice. Minneapolis: Creative Healthcare Management.
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About the Contributors
Adam T. Holland, MS, RN, NE-BC, has been a professional nurse for 13 years and is currently a nurse manager on a hematology inpatient unit. Previous experience includes nursing administration, acute care, and long term care.
Heidi J. Shedenhelm, DNP, RN, NE-BC, is a Nurse Administrator and Assistant Professor of Nursing, College of Medicine, Mayo Clinic.
Amy M. Zwygart, MS, RN NEA-BC, is the Vice Chair, Department of Nursing in Rochester, Minnesota. She is responsible for the overall management and coordination of the clinical practice divisions within the Department of Nursing. Additionally, Ms. Zwygart provides leadership to assure consistent models of nursing care across the clinical practice while working closely with division/department practice chairs and other senior administrators. In her 28 years at Mayo Clinic, she has held multiple positions in Nursing including Nurse Coordinator, Nurse Manager, Clinical Nurse Specialist and Nurse Administrator.
All photos: Used By Permission of the Mayo Historical Unit, Mayo Clinic, Rochester, MN. Permission has been granted for use in this article. Individual images may not be altered, copied, or used for personal, educational, or other purposes without explicit permission from the Mayo Clinic.
As an RN, I am used to taking care of people, sick people. I specialize in body fluid clean-up but also in respect, comfort, educating for self-care needs, safety, and care effectiveness. I am not an unsophisticated health care consumer. When I became a patient, I did not like it. At all. Not one bit. It wouldn’t be an exaggeration to characterize the overall experience as traumatizing.
The Odyssey Begins
My body processes began to break down as I moved past middle age, and, over time, my metabolic conditions deteriorated until I became seriously ill. I know now that I ignored subtle signals along the way and kept up with my high-stress life when I should have eased back. Eventually, though, my body gave out. I had a good job, good insurance, and the opportunity for regular medical care, so access was not an issue. As I well know, it’s easy to ignore vague symptoms when they present. I also know that those same vague symptoms can leave traditional medical providers in ambiguous territory.
The Crash and Initial Encounters
Barely able to get out of bed or stay awake for long, tired and with flu-like symptoms, I was taken by my husband to a community hospital ED, which resulted in immediate hospitalization. I was ill, vulnerable, and lacked the metabolic strength to process or function as a person, much less as a nurse. My hospitalization lasted 6 days, and during this time, I experienced almost immediately how protocol seemed to contradict the healing process. Hospital routines contributed to sleep deprivation, and I soon came to dread the loud IV pump alarms and the rude awakenings for AM lab draws. A week later I was discharged, and while I was a bit more stable, I had a diagnosis of probable renal cancer. The next step was transitioning to an academic medical center to see specialists.
Outpatient Trials and Tribulations
After discharge, my encounters (with care providers, and most often specialists) were as an “outpatient,” primarily in clinics. It wasn’t long before I learned that I did not actually have renal cancer (to great relief). My diagnosis was for correctable conditions requiring several procedures I was familiar with, procedures I knew to be relatively routine. After a 6 month period for “healing,” a specialist physician did the first corrective procedure.
Right away, the physician encountered complications, which were not communicated to me. Unintentionally, they caused further pain, damage, and the need for additional corrective procedures. As I journeyed through this array of corrective procedures, to my frustration, the specialist physician was often not available for long periods. I had multiple conscious sedation procedures, including general anesthesia 3 times in 4 months, all amounting to temporary fixes until the MD could schedule surgical procedures.
In all, I endured many months of stressful encounters in the outpatient setting at an academic medical center, which included impersonal encounters, inaccessible providers, long wait and standing in line times, lack of basic courtesy and information, unsafe care situations, unresponsiveness to pain, and lack of protection of basic personal privacy. I saw clearly how their system was set up from the provider and organizational perspective. Instead of healing, I was exhausted, confused, and scared.
When medical interventions passed beyond a certain point, and I was not pleased or comfortable with what was happening, I knew enough to intervene and make 2 self-actualized decisions, which dramatically altered the course of my care: 1 - to pursue medical management from a physician in private practice and 2- to pursue a referral to an ARNP (advanced registered nurse practitioner) who specialized in integrative health. Both of these decisions put me in the care of practitioners who set a course of treatment that addressed and resolved the original vague symptoms, the unintentional complications, and helped nurture me back to health without surgery. I am now healthier than I have been in years. The private-practice physician also worked with me on a long but successful course of medical management. The ARNP paid attention to my vague symptoms and corrected the metabolic imbalance. Her care was the most significant influence in my return to health.
Viewed only from a purely monetary perspective, many more dollars went to the multiple procedures at the academic medical center. The medical management MD and ARNP were paid vastly less for the work that actually restored me to health. It is important to know that I am grateful for the ultimate outcome and for the intervention and support of the providers who got me there. So, what are the barriers to making all patients central in patient care?
Patient Care Settings
As I journeyed from illness to health, I saw first-hand some amazing “systems disarticulations” in patient care settings. They illustrated— to me — on almost every level, what non-patient-centered care delivery looked like. As care shifts more and more to outpatient settings, the way that systems structure the patient’s care experience needs urgent attention. Here are some observations about what—for me—mattered in the outpatient setting.
Ancillary Departments Matter
When a patient is ill, vulnerable, compromised, or not fully functioning, care providers often do not consider or think about the patient’s circumstances getting to service, and how he or she is treated once there. What a difference it would make for our patients if we considered these simple points:
- Will traveling to the clinic be a simple or difficult task?
- Is there sufficient, accessible, and inexpensive parking, especially if the patient has low mobility and may potentially have limited financial means?
- Will navigation from parking to point of service be a challenge? Are directions clear and easy to follow?
- Will the patient be taking time off from work, and are we sensitive to that?
- If the patient is accompanied by a care companion, does that person have any limits or special needs?
Once the patient arrives, does the receptionist give eye contact to acknowledge the patient or keep eyes diverted onto the computer screen and ignore the patient? If there is a line waiting for service, is there a mechanism for keeping the line moving, or at least an eyeball assessment of whether the patient might be in distress? In one instance, I waited in a line for 25 minutes while in bladder spasms, with pain and bleeding. The two reception staff seemed too busy looking at their computer screens. In another instance, I observed a patient walking out of a clinic because her (shared) ride home was scheduled to pick her up at the entrance. The patient proceeded to tell the frantic nurse assistant she had to leave and had already waited over an hour and a half in the exam room.
I encountered what seemed to be a general lack of a culture of awareness considering patients’ and families’ needs. For example, when a patient is placed in a clinic room and prepared for an exam or procedure, are they checked frequently to be sure they are comfortable, ensured privacy, and managed in a respectful environment? I can attest to the fact that often times they are not. Patients are left too long in awkward, compromising, and uncomfortable situations, which leaves us feeling ignored and vulnerable, even embarrassed, especially if we have not been prepped properly or have been left exposed and within view of others who are not attending to us.
Technology Implementation Matters
Technology can be used for great positive effect or can be a factor in poor patient care. I found out late in my odyssey that at the academic medical center where I received treatment, the MDs were not required to complete their notes for as long as a month after care delivery. A lot happened to me in that month before the (sanitized) procedure notes appeared in the electronic medical record (EMR) portion that the patient sees. Incidentally, this was one of the initial procedures that had generated complications. Too much time had passed and continuity of care was compromised by my lack of knowledge. In a case like this, the EMR can give a false sense of security.
Other technology implementation issues surround the point of patient contact. Once, when checking in to a clinic where the computer screen faced the receptionist, I was asked to sign an authorization form, which was apparently on her screen, but was not shown to me. How can that be a legal or proper transaction?
In another instance, the whole computer system went down. The clinic staff just stopped processing information, but patients in the waiting room (including me) were not informed. The receptionist/desk staff packed up and went home at 5, and when the nursing staff finally put me in a room, the MDs were confused as to how to process anything. They would come to the door and ask who I was.
Patient Flow Matters
Why do providers behave as though it is completely reasonable to make patients wait? Certainly there are parts of care delivery (obtaining and processing lab results, for example) that create wait times. This can be anticipated, however, and systems can be created to manage patient waits (starting with telling them what to expect and when things will occur or why the wait time is so long past the appointment time so that they can go get food or attend to personal needs) and about information lag times. If the system was designed to manage patient flow for the benefit of the patient, then maybe wait times could be taken advantage of to complete health screenings, deliver patient education, teach about medications, or to accomplish any number of important health-related functions. There are statistical methods to help with staffing adjustments to then improve patient flow. This needs to become widespread best practice.
It is easy to say that communication, both written and oral, needs to be clear. Just rapidly talking to a patient is not sufficient. Some patients have hearing loss, cognitive changes, lack of basic health knowledge, and many other issues such as fatigue, metabolic changes, and the stress of illness. Pain alone blocks the reception and retention of information, and many of the medications prescribed alter cognition. Yet we as providers puzzle over why our patient teaching, delivered when the patient is most compromised, is not retained. At one point I was so ill that I could not figure out, once home, my own medications (they were constantly changing during this period).
Privacy with patient communication is another critical area. In some clinics, the patient’s full name is called out, then asked to state a date of birth. These are 2 of the 3 identifiers needed to steal someone’s identity! I experienced this more than once, including in transit through hallways and other non-private situations. I have been asked for this information with other persons standing almost next to me at the waiting room desk. My only defense was to drop my voice to an inaudible level. One private radiology suite offered a nice solution; after check-in I was given a restaurant-style vibrating buzzer which alerted me when it was my turn.
Nurses and nursing staff must become aware of talking to each other over the patient and among themselves with the patient present. I understand that colleagues like to “talk shop.” However, it truly is distressing to be the patient on the exam or procedure table and have to listen to staff complaints about being understaffed. I heard that discussion a lot. It does not inspire trust, confidence, or healing. In fact, it is scary.
I hope my experiences were unique and unusual and that I never have to go through anything like this again. If it was possible to change practice everywhere, I would offer 2 key recommendations that are based on shared values:
Safety first, from the patient’s point of view.
This means that we structure our work in a way that preserves safety (do no harm). For example, in a patient with diabetes, who may also be NPO, we need to manage glucose and fluids, and control pain. This mindfulness also needs to extend to caregivers and those who may accompany the patient. What if a care companion has diabetes or important health issues? What if the companion has medications of his or her own to take, but is stranded in a waiting room? Long periods of waiting disrupt structured food, fluid, and medication intake and can be dangerous. For a hospitalized patient, noise may disrupt sleep. Communication gaps can cause self-care and home management problems.
Structure care delivery from the patient’s point of view.
This means it is not ok to make patients wait, to violate their privacy, to make care difficult to navigate, or treat them as an annoyance on a busy day. Buffers need to be built into systems to take care of staffing and other bottlenecks in processes and procedures. This can be done with better systems engineering. Walt Disney World moves large volumes of people seamlessly. We should use statistical techniques to improve throughput and reduce wait times.
Think about what is happening to the patient as if it were going to happen to you or your family. How would you want the experience to go? We must do better, and we certainly can.
All Things Considered
What are the barriers to making the patient central in patient care? Certainly the logic is there: the patient leads the way. If the goal is to optimize the patient’s state of health, wellness, and self-care ability, then the provider needs to leverage his/her expertise to solve health-related problems for patients. Yet we know that health care organizations are consolidating and forming very large, interconnected organizations that need structure to operate efficiently. More and more, providers are becoming employees of these large networks. Are technology and workplace the culture barriers to be overcome?
I have had occasion to reflect on this phenomenon. Here is my first reaction about hospitals as care delivery sites:
I think the barriers to making the patient central come from the almost automatic (unquestioned) way care has been structured for provider convenience/from the provider’s perspective. LDR (Labor and Delivery room) rooms in birth places highlighted and attempted to address the inefficient ways we have moved patients from place to place to suit the structure, not the patient’s needs after birth.
Wait times in the OR (rather than using queuing theory) are another example. In fact, in any setting: why do we make patients wait? In the Emergency Department (ED) or the provider’s office (clinic), what would happen and how could we behave differently if we determined that it was not ok to make the patient wait?
Why do we put diabetics on NPO after midnight then make them wait all day (with no meds, fluids, or blood sugar stabilization) for procedures or surgery? The same is true for persons in pain, who smoke, or are used to a glass of wine. We take all that away suddenly and do not re-calibrate for the biological effects.
In addition, there are the many indignities we foist upon patients. Try getting rest in an alarm-blaring environment where the IV pump alarms (next to your head) are set to maximum screech because “the nurses do not answer them."
Should you happen to fall asleep after the alarms screech at 1:30 AM, the lab tech will push open the door without knocking, flip on the overhead lights and draw labs at 5 AM. How does this reconcile with the knowledge from sleep studies about adults’ need for 6-8 hours of sleep at night?
These phenomena can be remediated with targeted problem solving and evidence-based practices that restructure the work environment and processes of care delivery. It will not be easy, but improvements have to be made. If this is an artifact of volume-driven fee-for-service reimbursement, then the future looks bright as population health management strategies become more prevalent and the focus on the patient experience as a part of quality and safety reaches into the outpatient and all arenas.
Take note and ask yourself: Do we, as providers, pay attention or dismiss unresolved symptoms, untoward occurrences, and ignore the patient’s conversation about their concerns and issues for which we cannot locate an immediate cause despite the patient’s repeated pleas for help?
There are known solutions and a need to foster creativity and innovation for those issues without a known solution. We all HAVE to be receptive and listen to the patient. We have to believe, teach, and practice patient-centered care.
Research has shown that engaging patients and their family members in decisions about their care can lead to better patient experiences and outcomes (AHRQ, 2014). Patients can improve their understanding of their condition when actively involved in making decisions about their care.
The process of involvement starts with talking to patients about ways to stay healthy and teaching skills to readily identify what makes them sick. Patient engagement can also be enhanced by offering patients opportunities to suggest alternative approaches to how care and service can be improved in hospitals and clinics. Healthcare systems are often seen as complex and care is fragmented. Navigating through the health care system can be daunting for patients and families.
Treating patients as partners can provide insight into ways to improve the patient’s experience that makes sense to the patient. Patients who participate in frank discussions about their experiences when sick can help providers identify ways to work through the challenges of being hospitalized. True engagement of patients and families in the design, implementation and evaluation of healthcare services should be a national undertaking.
At the University of California San Francisco (UCSF) providing patient-centered care and optimizing the patient’s experience is a priority for all who work here. This article is about how patients and families were actively consulted at the University of California San Francisco when planning for new centers of care.
What’s It All About?
The Institute of Medicine (IOM) recognized the need for patient centered-care to be responsive to the patient’s individual beliefs by advocating for solicitation of the patient’s own preferences. (IOM, 2001). If a goal to increase the patient’s participation in their own healthcare is desirable, why not offer opportunities for patients to be involved in redesigning healthcare in several areas?
At UCSF, even before the plans for new care centers were begun, several initiatives to improve the patient’s experience resulted from discussions with parents of hospitalized children. Patient-centered care in a pediatric center is about allowing parents of a sick child to educate medical staff about the importance of listening. Small group discussions between parents and medical students at UCSF help prepare future physicians to listen and learn about the best ways to care for patients. For example, ways to communicate difficult news in an empathic and supportive manner has been a subject of such small group meetings between medical students and families. It is important that providers understand what it is like to have a sick child who is hospitalized as seen through the eyes of the parents. Such awareness adds depth and credibility to the experience for the clinician and the patient.
In the new care center design, parents were consulted as experts. For each patient room, Wi-Fi was installed with sleeper sofa and lockable cupboard to store personal belongings. Another support for parents and siblings is a spacious Family Resources Room where families can learn about their child’s disease, make phone calls, and utilize computers, printers, and scanners.
In an effort to support healthy nutrition for children all sugar drinks and donuts were removed from the cafeteria. Initially this was met with fierce resistance from the employees. However, additional communication to all employees about the reasons behind the decision seemed to decrease the opposition surrounding the change. (Nutrition Services eased up on the restrictions and provided pastries in the Express Coffee Café in the hospital.)
Fresh fruit and organic meals are now available. On-demand menu options are available 24-hours so that parents may order and request meals to be delivered directly to the child’s room. This allows parents to stay with their child for meals.
Requiring patient experience measurements in employee performance evaluations is an important aspect of patient-centered care. Improving the patient experience is an organizational goal scored via patient feedback on care and service. Monthly scores are published and finalized the end of June each year. Incentive bonuses are given to the entire staff and to medical residents should the goal be attained.
The hospital delivers 100% fresh outdoor air with no recirculation throughout the buildings. There are outdoor terraces on every floor. For families from out of town, there is a Ronald McDonald house on site equipped with laundry services and kitchens all integrated with the hospital. In addition there are family lounges with showers, laundry facilities, and kitchens located on every floor.
The New Care Centers
At the new Benioff Children’s Hospital at Mission Bay in San Francisco, providing patient-centered care and optimizing the patient’s experience is an acknowledged priority. The design of the new hospital involved patients, families and parent advisors from the start. The goal, to provide patient-centered care, meant that the mode of care would be responsive to patient preferences and values and these values would influence clinical decisions and the design of the new facility.
Beginning the Work
UCSF began developing plans to build a new 289-bed academic medical center for women, children, and cancer patients in 2000. Using the latest technology and improving the delivery system, the plan intended to move health care in the San Francisco community to a higher standard of excellence. In February 2015, after five years of planning, the new Benioff Children’s Hospital, the Betty Irene Moore Women’s Hospital, and the Baker Cancer Hospital opened at the UCSF Mission Bay campus. Combining these three hospitals at UCSF Mission Bay campus created a singular approach to guiding and structuring care concentrated on the patient experience.
Utilizing the existing Family Advisory Council and establishing a Teen and Adult Patient Advisory Council to participate in the discussion about improving the patient experience and optimizing safe patient care was a priority. Advisors selected for the Council had received care at the hospital and expressed the desire to help improve services and care for others. Impending improvements were based on what mattered to patients and families. Input was obtained from the advisory council on designing system processes, new technology diagnostics and services, better communications tools and improving the physical layout of the facilities. For example, with the assistance of the advisory council the decision was made to build private rooms for all patients so families could be part of the healing process. The Advisory Council also recommended more collaborative interaction and teamwork between staff from all disciplines. As a result, instead of traditionally separate rooms for nurses, physicians, and ancillary support staff, multi-functional rooms were installed throughout the building to support collaborative teamwork. Every staff member can access and work in any team lounge. Touch down spaces are available throughout the facility for use by staff and also for families and visitors.
Humanizing the Physical Space
Families expressed concerns that the hospital needed to have a less sterile look and more of a home-like atmosphere. It was stated that it was important to have a child-friendly and welcoming setting throughout the building. At UCSF Medical Center at Mission Bay, art plays an essential role in creating a pleasing ambience, which not only improves the patient and family experience but also supports healing. Artwork is displayed in and around the facility in many forms: metal, paper, statues, ceramics, motivational sayings and sculptures. Art is the foundation of the new hospital’s design.
In addition, interactive play stations are located in the pediatric surgical waiting area. Patient stories are viewed on video screens in the cafeteria hallway. There are 16 unique gardens. Gardens can be seen outside the first floor and have play areas for children. Meditation rooms with low light, color everywhere, calming music and lighting are located throughout all the waiting areas. The entire building draws upon the healing power of nature which is represented throughout the structure.
The new UCSF Medical Center at Mission Bay covers more than 600,000 square feet. The building spans horizontally which prompted clinicians to consider using robotic technology. Robots were selected as couriers to perform daily tasks throughout the hospital and clinics to maximize efficiency. Self-directed robots known as TUGs by Aethon were investigated. A TUG is a mobile robot designed for hospitals.
These robots transport medications, blood, lab specimens, instruments, supplies, linen, and meals. They are computerized and navigate through halls and even doors by using Wi-Fi. The paths they travel have doors specifically designed to open for them. Programming the TUGS took months and results were overwhelmingly positive.
Eighteen of the robots were activated when the medical center opened February 2015. We are now up to twenty-seven. Robots are used by the Blood Bank, Pathology, Operating Room, Pharmacy, Hospitality, Materials Service, Food and Nutrition Services, and Sterile Processing. Every day they average 40 miles and 180 trips. Deliveries average 220 a day. The robots have quickly become family to the staff who depend on them every day.
Configuring technology systems to optimize patient flow and improve efficiencies was emphasized at every step. Taking the admitting process to the patient by using mobile devices is one such improvement. Patients having surgery proceed directly to the surgical waiting areas where an admitting clerk registers the patient and bypasses the general Admitting Department located in another area of the hospital. This convenience was an overwhelmingly positive success as reported by patients and families.
Formalizing the Conversation about Patient-Care Experiences
Members of the community were invited to attend several focus groups as patient experience advisors to recommend ways to improve the hospital experience. I attended several of the focus groups where patients stated they were less than satisfied with their care experiences. Their discussion caused me to re-evaluate how we communicate with families when their loved ones are in surgery. As a result, on the day of surgery each patient receives a confidential and unique tracking number so their progress can be followed by those waiting. This identification number helps loved one visualize where the patient is at any time during their surgical procedure.
Providing visual benchmarks relieves the stress associated with waiting for information. Before the availability of this electronic technology, loved ones depended on being updated by someone from the surgical staff coming to talk with them. Communication is now delivered in real time which reduces a number of questions families have about where in the process their family member might be at any given time. Hospital staff also track patients this way. Tracking devices can be offered as desktop computers, mobile devices, iPad, and iPhone applications.
The Results of Including Patients and Families
in Technology Choices for UCSF Care Facilities
The work of the Advisory Council launched in December 2013 and reached completion in August 2014. Parents and family members shared their perspective on the patient and family experience with hospital administrators. Their input gives families a voice in decisions that affect patient care and family experiences. Our patients and families became essential to the design and plan for the new facility. The workflow processes were designed to place patients and families at the center of care. One example illustrating Advisory Council input has to do with designing the home page for the “empowered patient media wall” which is a combination of an electronic whiteboard, complete with pictures of every member of the healthcare team, online menu options with diet restrictions taken from the electronic health record, entertainment choices including TV, on demand movies and video gaming, and educational content assigned by the provider. The educational content assigned allows the patients to view discharge instructions at their own leisure rather than at a convenient time for the provider. The 90-member Advisory Council found the original home screen too busy and difficult to navigate. The company selected to redesign the home page used this feedback to accommodate a less busy workflow navigation process.
A mobile device was selected for use by all healthcare clinicians, staff and ancillary support services personnel. The device integrates voice, text, alarm and alert notification from physiologic monitors and allows the healthcare team to work collaboratively, efficiently and to respond quickly to patients in a quieter healing environment.
This unified communication device replaced pagers used to connect the healthcare team with one another inside the hospital. The ability to text or call and have both roles and names in the directory accompanied by pictures has made making and receiving messages much easier without having to look up pager numbers. There is a feature that shows when someone has read a text which has prompted much quicker replies. This has been a big win with providers and ancillary departments.
As mentioned, patients and families, the consumers of our services, evaluated proposed patient status boards (the tracking tool), nurse on call systems, transport robots, communication devices such as smart phone apps, art work and furniture for patient care areas, and playground equipment. The shared decision-making experience in these examples and the involvement of patients, clinicians and hospital leadership in making decisions, was overwhelmingly positive in terms of problem solving and improved services.
Getting to the Nitty Gritty:
Implementation of New Smart Phone System
Here’s how the adoption of the Smart Phone system worked:
- Timelines were detailed along with a comprehensive project plan designed by clinical and technical teams.
- Pilot objectives and outcome metrics established.
- Hardware solutions and functionality demonstrated, first in patient rooms. There were eight demos over 2 days with greater than 100 participants from across the health system. Included were patient advocates, patients, family advisory council members, clinicians, nurses, executives, information technology colleagues, and ancillary personnel.
- Priorities identified: Getting quick text messages, having a presence-based resource directory, a dial-by-photo for phone calls, and immediate access to healthcare apps.
Testing and finalizing. When ready, the UCSF medical center set up a clinical simulation center so clinicians could experience how the device worked. The entire process was based on an innovative vision that combined technology with architecture to benefit clinicians in their daily work to optimize patient centered care. The entire process moving from planning to implementation was transparent to everyone affected and/or interested.
The entire process moving from planning to implementation was transparent to everyone affected and/or interested. More than 850 smartphones were implemented at Mission Bay on opening day. The combination for the clinicians to be able to call, receive alarm notifications, and text message on a touch-based smartphone has allowed connecting with others to be faster and seamless. Improved communications have reduced patient response times and increased productivity.
Additionally, providing opportunities for patients to participate as advisors, as demonstrated in the discussion about the adoption of a new home page and mobile device, enable an involved and dynamic patient experience overall.
Some Final Thoughts
One barrier within organizations to focusing more directly on the patient experience may be that clinicians will not fully embrace the concept of engaging patients or their family members in care decisions. The process to change from provider focus to a primarily patient focus takes time and commitment and can be a challenge. Likewise many patients may not feel comfortable participating in their care or giving feedback on their experience. Recent experiences with my elderly mother demonstrated that not every patient desires to make decisions about their care. When her physician asked her about treatment choices she expressed concern that it was a decision that should come from her physician. It is important to understand that patients may lack health literacy comprehension and may simply not want to participate in decisions.
As patient-focused care continues to evolve and transform, we must empower patients and their families. We can coach those who want to learn about how to participate actively and we can lend a voice to all. In a society where healthcare is often complex and fragmented, health systems can benefit greatly when patients are engaged in many opportunities to build better health. Mission Bay was designed by patients and families, a truly patient-centered medical center.
Hibbard, JH and Cunningham PJ. Research Brief No. 8: How Engaged are Consumers in their Health and Health Care, and Why does it Matter? Washington: Center for Studying Health System Change, 2008.
www.hschange.com/CONTENT/1019.pdf (accessed December 2013).
Internet Citation: Executive Summary: Guide to Patient and Family Engagement: Environmental Scan Report. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.
Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academies Press, 2001).
About the Contributor
Joann Rickley, RN, MBA, is the Director of the Perioperative Division at University of California San Francisco. Ms. Rickley has over 32 years’ experience providing leadership and direction for all aspects of perioperative services within complex healthcare systems. She has demonstrated her ability to develop a strong cohesive team of physicians, nurses, and support staff while ensuring organizational efficiency and satisfaction across multiple sites. She has practiced in New Mexico and California.
All photos supplied by Joann Rickely and are used with permission.
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