Infrastructure & Governance

Improving the Patient Experience through People

On the Road with Texas Health Presbyterian Hospital – March 2012

by Jason A. Wolf

Our March On the Road took us to the campus of Texas Health Presbyterian Hospital Dallas and a story of patient experience grounded in the efforts of 4000 employees. It is a story of a systemic effort of active engagement of staff at all levels and across all roles. The power of the effort shared at Texas Health Dallas was that while they were engaged in many of the practices emerging as standards in addressing the patient experience, such as leadership support, rounding, discharge calls and strong culture, to name a few, a clear foundation of their effort was the focus on engagement itself. This was not a drive to implement practices to make people “happy,” or increase individual satisfaction, but rather shows the implementation of processes that support staff in being more actively engaged in the experience of care overall. By helping people engage in why they chose healthcare in the first place, you find the greatest engagement of all.

A recently released grant paper from The Beryl Institute, Impact of a Collaborative Re-structuring of New Hire Hospital Orientation on Employee Engagement, reinforces the thought that the engagement of employees across a healthcare organization is a significant factor in positive patient experience. The team at Texas Health Dallas reinforced this in almost every action they shared. Building on a core experience effort grounded in rounding across functions, supported by seven Service Excellence teams that have specific accountability for areas of improvement and HCAHPS domains, and bolstered by a robust leadership development and training effort, the organization created a few unique and powerful focal points that have contributed to increased patient experience performance.

A Commitment to Rounding – Making time for “Sacred 60”
Many organizations have built rounding into their care efforts and experience programs. Rounding was also identified as one of the top five priorities for those addressing the patient experience in The Beryl Institute’s study, The State of Patient Experience in American Hospitals (link). At Texas Health Dallas the team has implemented a process entitled “Sacred 60”. This effort was actually named as a result of a contest among employees. It captures the important meaning of the sacred nature of the time. It also reflects the faith-based foundation of the organization.

Every morning from 9 – 10 AM is designated as a no meeting and no email hour in which leaders at all levels from Manager to Senior Executives round in the organization. As Laura Weber, Director of Quality and Patient Safety, explained, “While the time is set and the expectation is unwavering, how the leader chooses to conduct rounding is adaptable to the their style or current focus.” This does two things, ensureLaura Weber, Director of Quality and Patient Safetys that rounding is happening throughout the organization while at the same time it takes on the personality of leaders and guarantees a focus on the priority issues of units. Every leader we spoke to on our visit mentioned the fundamental nature of “Sacred 60” and its importance to the efforts of the organization.

While a handful of organizations focus on this idea of committed time for rounding, it often is just a time set aside to go through the motions of rounding. When done in a mechanical or meaningless way rounding may have little impact at all. Instead, at Texas Health Dallas they are clear that this effort has a significant impact on the engagement of employees and as a result on communication, service, and ultimately experience overall.

An interesting twist on rounding was shared by Cole Edmondson, Chief Nursing Officer. Aside from the importance of ensuring the best encounters, or “wow” moments for patients, one staff member suggested, “If we want patients to find wow moments, then we need staff to also have wow moments.” “Wow Rounds” were implemented to do just that. When a unit or team has a positive achievement or a significant outcome in scores, for example, the leaders will bring in dinner for that team. They let the members take time in the break room to eat and the leaders actually spend time on the floor covering the shift. It is this combination of recognition and support that reinforces the very value of engagement as fundamental to providing wow experiences overall for patients.

Reconnecting Leaders to the Bedside: The Leader to Patient Program
We also learned of another exciting program from Cole Edmonson that was focused on reconnecting clinical leaders to why they chose to become nurses. The Leader to Patient (L2P) program is designed to help nurse leaders stay connected to the bedside.Cole Edmonson, Chief Nursing Officer Reinforcing that the importance of time with patients not only supports the engagement of nurses in helping remain focused on why they chose care as a profession, but ultimately supporting patient experience by expanding the presence of care givers. As Edmonson shared, “Nurse leaders and managers can make or break a facility. They are the front line to your patients and represent your vision, mission and values in every interaction.”

The L2P program combines a few key elements. The first, clinical leader rounding, reinforces the importance of the presence of leaders not only to engage with patients, but to connect with staff. The second component is grounded in the work of Barbara Mackoff, director of the Leadership Laboratory at New York University Langone Medical Center. Mackoff discusses nurse management engagement and suggests that nurses who view their management role as administering care often are more satisfied in their position. She stresses that nurse leaders must keep a line of sight to the patient and Edmonson stressed how engaging nurse leaders by supporting line of sight again reinforces the connection of engaging employees to ultimately provide a superior experience. Lastly, a full leadership curriculum has been put in place to further develop nurse leader skills and strengthening them in their roles overall. “Bringing nurse leaders closer to patients, is a significant contribution to our ability to provide a positive patient experience”, Edmonson concluded.

An Integration of Process and Technology: Ensuring a Focus on the Important Things
A fascinating and unique addition to the conversation is the use of technology to impact the patient experience. Texas Health Dallas has implemented Real Time Location Service (RTLS) in an effort to begin to track the use of equipment in the facility. Jim Jim Berg, SVP and Chief Operating OfficerBerg, SVP and Chief Operating Officer, shared this idea is driven by focusing on efforts to impact the primary point of service. More simply stated, Berg said, “We need to identify what is in the way of caregiving and remove it.” In the example of equipment where this concept was launched, by identifying where equipment is located in the facility thousands of hours of time lost simply tracking down needed resources is recouped, according to Clint Abernathy, Administrative Director of Operations. When you can give staff back time used on non-interactive efforts, you provide the opportunity for more time at the bedside, ensuring quality of care, attentiveness to patient and family needs and ultimately impact the patient experience for the better. The RTLS is a virtual web that encompasses the campus, mapped out by strategically placed sensors, which read chips or cards attached to equipment and can pinpoint items to an exact location in the building.

The next step in this implementation is to tag patients and staff. The power of this resource is the ability to begin to track and streamline patient flow, manage and maintain immediate information on patient location and status for fClint Abernathy, Administrative Director of Operationsamily and friends, measure interaction time between patients and staff, and have the ability to determine opportunities for improvement. “By understanding the processes in our hospital,” Abernathy said, “we can actually trigger proactive responses to patient situations.” For instance if a sensor indicates that a patient was just admitted to a room, the signal that this occurred could trigger the requisite process steps across the facility to ensure this patient is receiving everything they need. For example, it could trigger a visit from a Unit Director to welcome someone to the unit or even a visit from food service to explain dining options. The system provides Texas Health Dallas the ability to monitor and streamline the process in real time, not with a punitive eye, but with a focus on improvement, supporting the staff ability to offer the best care encounter possible and thus a positive overall patient experience.

A Quick Look at a Comprehensive Effort
While the short form of an On the Road cannot capture all that is taking place at Texas Health Dallas, there is a real tangible feeling that staff at all levels understand and leadership is committed to the careful integration of efforts to ensure team members have a top experience and therefore support the delivery of an unparalleled experience. Jim Berg reinforced how the organization was continuously learning and intentionally focusing on the sharing of key stories, whether gathered through rounding or as a result of score improvement. Berg stressed that this open and transparent environment provides for a place that everyone can learn from one another in any given moment. They have groups report on their results, both good and bad, not to chastise, but to celebrate and support. In some cases lower performing units are provided direct feedback from leadership and even paired with a leader from a high performing unit who acts as a support and coach. This process exemplifies how to most effectively turn outward and provide the best of experiences for patients and families, Texas Health Dallas turned inward to ensure it is creating an actively engaged team of caregivers and support teams that wow one another. Cole Edmonson supported this thought as well, sharing that it is important for the team to hear and learn about the successes they were having. Edmonson’s Door Decorated in Letters of AppreciationHe challenged the team that he would cover his door in letters from patients about their great experiences in two weeks. In fact it happened much faster than that…and now the doors of nurse leaders around the facility are also starting to be decorated with these kudos and letters of appreciation. This is a celebration of the care Texas Health Dallas provides, recognition of the service they offer and ultimately reinforces the very power of the organization’s people to achieve these results.

The outcomes are now visible. As Berg shared, in just 3 years of focus on engagement, the experience scores have seen a sharp rise. In 2008, Texas Health Dallas was in the 51st percentile for engagement based on their survey vendor’s national database. Less than two years later, in 2010, they were in 81st percentile and in 2011 they climbed to the 93rd percentile for engagement. This rapid ascent was not due to fancy bells and whistles, massive programs or large-scale change, instead it was about the effective implementation of some fundamental, but significant ideas and having a leadership team at all levels who supported and drove these outcomes. It is interesting here to note that The Beryl Institute’s 2011 benchmarking study found the top roadblock to patient experience success was “cultural resistance to doing things differently”. Texas Health Dallas challenged this and instead made a conscious decision to do things differently, engage their workforce and drive for great results. The outcome, a likelihood to recommend score in their survey vendors database that started in the 15th percentile, climbed to the 50th and then leaped to the 90th percentile in an overall two year period. Berg was clear in reinforcing that the organization did focus on some of the very fundamentals we mentioned at start, but it was a commitment to focused, measurable and consistent action that reaped the greatest results. It is in fact part of the day-to-day conversation of the organization now: how to create a culture that engages staff and creates a positive experience. Clint Abernathy added that Britt Berrett, CEO of Texas Health Dallas, likes to reinforce the point that what you talk about gets done. In the case of Texas Health Dallas they have certainly put their money where their mouth is and the results are there to show it works.

Our thanks to the team at Texas Health Dallas for their gracious time for this month’s On the Road including Jim Berg, Cole Edmonson, Laura Weber and Clint Abernathy. And thanks to Emily Hoad for helping to arrange our interactions with this powerful team of leaders. Also in thanking the team at Texas health Resources we also wish to acknowledge the Texas Health Resources Center for Learning who is supporting The Beryl Institute Patient Experience Conference 2012 and our offer of CNEs this year.