Infrastructure & Governance

The Importance of Culture and the Power of Intention in Impacting the Patient Experience

On the Road with Scripps Health – July 2012

by Jason A. Wolf

Our July On the Road took me to the Scripps Health and the blue skies and ocean breezes of San Diego, CA. The visit included hospitals driving new care processes and those living through the strains of construction and growth, from emergency care redesign to the central strategies of a systemic approach for driving patient experience success. Two significant themes that emerged at the core of the conversations I had with nurses and physicians, patients and administrators were the power that culture plays in driving patient experience success and the importance of a purposeful, yet genuine intention to ensure patients are at the center of the healthcare experience.

While culture was not the explicit focus of my inquiry into efforts at Scripps, it showed up in every stop and was part of every conversation I had with individuals across the system. There was a powerful recognition that the very nature of the organization providing care has a significant impact on experience. What was also evident was a great curiosity and a willingness to explore what was best for the people, process and patients in the system. Ideas are seen as opportunities and successes are quickly translated into learning that is ultimately shared across the system.

Underlying this is the recognition of who Scripps wants to be as a provider of care. There is not a search for quick fixes, or a need to plug in packaged solutions. Instead there seems to be an intentional commitment to engage in efforts that represent who Scripps intends to be as a provider of care. As with the discussion of culture, the word genuine emerged in a number of the conversations, from the genuine nature of care nurses looked to provide to the genuine way of approaching an issue in ensuring as one nurse said, “we work to find ‘our’ way of doing it.” This combination of cultural impact and genuine effort was exemplified in a pilot program launched at Scripps Memorial Hospital Encinitas.

Restructuring the Care Process
At Scripps Memorial Hospital Encinitas they recently initiated a care redesign process that essentially turned the model for care inside out. Rather than processes of convenience to the hospital, it was built with the intention of putting the patient at the center of the care experience. The process is grounded in providing clarity of expectations and the care plan for a patient and family, while more efficiently engaging primary care physicians. The premise, while simple, has had significant and expanding impact.

The care delivery process was redesigned to focus on a team approach that includes a unit based bedside nurse, a hospitalist, a newly created role of care navigator and a pharmacy representative. There are some unique characteristics of this team structure. First, the team follows a patient through their time at the hospital. Second, the use of hospitalists provides a consistent physician presence while providing greater flexibility for the primary care physician. Third and most significantly was the creation of the care navigator role. This role, filled by a registered nurse plays the part of creating a coordinated and integrated care plan from the moment the patient is admitted. More importantly this care navigator currently works to build the post discharge care plan for the patient, helps translate this information to the primary care physician or home health and stays connected with the patient for 30 days post discharge. This ensures a consistency of information and considerable follow through on the in-hospital care experience. It also creates a seamless transition from hospital setting to primary care providing the physician with the information they need and saving them time in transition as well.

The intention of the process redesign was that it would lead to a reduction in readmissions, better-managed length of stay and greater patient satisfaction. The significance of the effort impacted well beyond those key indicators. “The care process redesign put the patient back at the center of care,” said Bella Kaufman, Senior Director Clinical Service. The team engages with the patent in a whole new way, preparing clear care agendas that allow patients and families to know and engage in the entire care plan including when the doctor will be in to visit the patient on rounds.

I had the opportunity to observe these team rounds and as described the family member was present. The team first ran through its protocols before entering the room to ensure a shared and coordinated awareness of the patient’s current situation. They then entered the room – hospitalist, nurse, navigator and pharmacy rep – to engage the patient in the steps of their plan for the day. The patient’s spouse was at the bedside and together they were able to engage with the team. The care board at the foot of the bed was updated with any pertinent information from the discussion, outlining the commitments for the day. In just a few engaging and efficient minutes the patient felt that he and his team were aligned and on plan.

As the meeting was built into the schedule as part of the care plan, the spouse was able to schedule time to attend, she shared how impressed she was with the team effort and how she and her husband felt that there was a coordinated effort that help her and her husband feel great confidence in the care. The patient added how important it was to him to see a well-integrated effort by the team. He didn’t need to repeat himself or worry someone missed something. He added, ” I can sleep at night knowing they are in synch and focused on my care.”

Scripps Memorial Hospital Encinitas – Care Team in Action
Debra Fore, Supervisor, Case Management/Social Services, who is helping lead the pilot of this process, shared her observations on the benefits and impact of this effort on the organization and on patient experience. First, the connection and collaboration among members of the care teams has been strengthened leading to a better-coordinated and consistent effort overall. “This team approach builds bridges,” she said, “and has had a significant impact on how the different roles interact.” In fact the staff reaction has been overwhelmingly positive. They have felt stronger connection, ensured greater coordination, and expanded opportunities for learning. Debra added, “The program generated such great enthusiasm that the staff broadly expressed how much they missed it as they were moving through pilot phases.” She added, “There was such great interest in the navigator role and its impact in the pilot that we were overwhelmed with applications.”

The greatest outcome from the pilots reinforced the very hopes of the effort, namely patient satisfaction on the pilot units increased significantly. The synergy between team members, the greater coordination with primary care and the integration of patients in the process in providing a clear, understandable plan solidified this care process as one that was truly patient centered. There were also a number of unintended consequences that emerged as well.

In asking about some of the biggest lessons so far in this care model, Debra offered that the patient now feels a greater sense of control. They are aware of their plan and are part of the process. More important she added the patient could now say “this is really about me” and the actions reinforce that at every step. More significantly perhaps is that the effort has had even broader impacts on the hospital itself. As Bella Kaufman offered, “The implementation of the pilot has positively changed the culture of the organization overall.” To create defined schedules requires the coordination of much more then the direct care team. It aligned all aspects of the organization from food service to lab, nursing to hospitalists and created energized and committed alignment around the idea that the patient must be at the center of the care process.

This well orchestrated effort was not complicated in design, but did require shared commitment and consistent effort. It also has shown to have significant impact on patient experience overall, while building a stronger culture of service and greater collaboration throughout the hospital. The broader impact; due to the success of the program every hospital in the Scripps system will begin to implement this process as of September 2012. The power of patient experience has been realized and reinforced through this effort.

Redesigning the Emergency Department Experience
This care redesign effort has been paralleled by an effort focused on redesigning the experience in the emergency departments (ED) and urgent care settings across the Scripps system. I had the chance to visit with Cathleen Faulkner, Manager of Scripps Torrey Pines Urgent Care, which operates in essence as a level 2 ED. The process redesign focused on ensuring reduced “door-to-doc” times, was exemplified in both the passion shown and process shared by Cathy. Her redesign to reduce wait-times started with the patient first. Questions were asked about the types of patients that would show up at the door and only then were the systems and processes created to ensure the best experience for those individuals. Valerie Walsh, VP/Chief Nurse and Operations Executive of Scripps Green Hospital added, “The redesign process itself included staff, physicians, and leadership from both Scripps Green Hospital and Scripps Clinic. This exemplified the positive relations of the team and contributed to the excellent outcomes of the redesign. It truly takes a team to make a difference.”

The Urgent Care process was simple, but again significant, as it allows patients to be quickly processed, triaged and routed to the most appropriate locations of the unit. From fast track patients who could be quickly accommodated, to more serious needs requiring monitoring and even eventual admissions, defined process flows were created to ensure the most effective use of staff and physicians all with the patient at the center of consideration. You could sense the urgency of care wired into Cathy’s very words. She reinforced this urgency by saying, “You must put your best nurses up front!” In fact the process she has built allowed for such a speedy registration and tracking of patients she was able to convert half of her initial waiting room space into a step down unit of sorts as patients were readying to leave the center. She added six additional spaces for patients by giving up her waiting room. Cathy grinned, saying, “If we do our job and take care of our patients, I will take beds (or recliners) to waiting room space any day.” It is clear the result of her and her team’s efforts have proven this true.

In redesigning the process for this urgent care center, Cathy also acknowledged the value of both expertise and culture. Having the right people capable of operating in this model was crucial, she added. Most significantly was that as the redesign took hold, the culture shifted as well. Here too this example focused on patient centered design and reinforced a culture that supported greater patient experience. In fact, Cathy proudly shared the center has been consistently “in the green” on her patient satisfaction scores since October of last year.

This reinforces as well that when you build processes and organizations that allow staff to focus on the patient, the impacts are significant. More so, Cathy added, the changes also made us a family. This is powerful as in my research on high performing healthcare organizations, and more so those that sustained high performance over time, that feeling of family, which I translate to connection, support, aligned efforts and shared care and compassion was central to those organizations. It is clear in this situation that Scripps Torrey Pines Urgent Care didn’t simply redesign process; they made lasting decisions to change the nature of care and their organization all with the patient in mind.

Managing through Change
In the midst of these strong efforts, Scripps as a system is undergoing other changes that both challenge and provide opportunities to address the patient experience. Once situation I know many healthcare organizations are currently facing is that of physical change, either in new construction, retrofitting, or renovation. I was impressed by the fact that Scripps didn’t just see this as a necessary evil, but also as a means to reconsider the patient experience overall. I had the chance to visit Scripps Memorial Hospital La Jolla, which was undergoing both renovation and new construction. It provided the perfect storm for patient satisfaction to plummet and experience overall to falter. In fact as I learned from Cindy Steckel, VP/Chief Nursing & Operations Executive, the opposite has occurred .

Perhaps this perspective is no better exemplified than in these words from Cindy, “In the end we do not get a write off because of construction!” Some might be asking why is this important to discuss and I would reply that for many healthcare organizations I have had the chance to engage with, a large number throw up their hands in defeat in these situations with little effort. Cindy instead saw it as an opportunity to reinforce the importance of experience. It was clear there was an attitude of “if we can do it well in this environment, we can excel in any other…so we need to prove we can do it here.”

In talking with Cindy and Holly De Falco, Patient Care Manager of the Surgical Acute Units, it was clear that one of the greatest strategies in positive patient experience was the management of expectations. I share this story not simply as it presents the challenge of managing experience in the midst of chaos, but it truly reinforces the need to look at how we manage expectations of patients in even the most serene of settings.

A comprehensive communication campaign was enacted to provide patients with advance apologies, clear information on what was happening to cause the noise, and the efforts to mitigate it during the stay. More importantly this setting of expectations was reinforced by continued core patient experience efforts, from reinforcing service standards and an active service recovery process to active and engaged staff reinforcing the importance of experience to patients and their families. The team took it to the greatest extent even testing construction tools to select the quietest ones possible to be used in renovations. The greatest discovery in this effort of setting, reinforcing and addressing expectations is that the facility has not seen what some might have anticipated as a reduction in patient satisfaction, in fact they has seen an increase while the noise has reigned. This does not mean every patient is happy at every moment, but it means the team has identified an important component in improving overall experience, the power of expectation.

What asking Cindy what patient experience was for her institution and for Scripps overall, she paused and said with a smile, “We are going to ensure we do for our patients like we would for our family. We are going to ensure that across our system you have that same consistent experience in how we care for you and you know the patient and family is always central to our commitment in delivering care. We are going to ensure genuine commitment to this effort…that patients know they are getting us fully at our best, not some regurgitated model or tool, but rather who we are as caregivers, as people providing care.” It is this central focus on the patient that was evident in the commitments of all the members of the Scripps team with whom I interacted.

Reinforcing Accountability
While focusing on these significant efforts of experience-centered redesigns that will truly change the nature of care and patient experience overall, Scripps is also driving some core practices to reinforce and engage staff throughout the system on the importance of patient experience. Kristin Hoefling, Director, Cultural Excellence, shared that this starts with the effort to reinforce service standards under the theme “Making a Difference, One Patient at a Time”. The service standards implemented across the system are based on the acronym ICEA (pronounced IKEA), which represent the key components of the service encounter. ICEA stands for:
I – Making a positive first and last impression
C – Communicate effectively
E – Create a safe, clean and private environment
A – Make amends to ensure patients and families are satisfied with their care

The standards provide clear and powerful guidelines for staff across the system to not only focus on the critical components of a positive service encounter, but also to be aware of the broader considerations and even an understanding of the importance of service recovery. Each of these items also has associated key words that help staff focus on the critical questions and interactions central to ensuring these service standards are met.

To reinforce the important nature of these standards, the Scripps team also added 6 questions to the overall patient survey to measure performance across the system. These simple and direct questions are allowing the team to gather data on the impact of action and also ensure that team members are focusing on these central aspects of the service encounter. The questions include:
* How often the nurse visited every 2 hours?
* How often the care board was updated?
* How often the care plan was reviewed?
* How often the patient was asked to provide input on their care plan?
* How often new caregivers introduced themselves by name?
* How often a nurse leader visited?
The power of these questions is that they move the organization beyond desired action to measurable outcomes. They are providing the Scripps team the means to gauge progress and improvement over time.

Central to these questions was the consistent presence of caregivers and leadership. At its core, effective rounding supports this effort. The Scripps team worked hard to evaluate the multiple rounding situations that were occurring and recognized an opportunity to design a consistent multi-purpose rounding process. The goal was simple, “to establish a common rounding practice and ensure each leader is looking at their areas from a broader scope”. The result was a comprehensive rounding plan that was rolled out across the system just this spring.

Multi-purpose rounding follows a standard format and has a common checklist for observation and follow-up for all leaders. (Download the Rounding Tool) The rounding now encompasses seven critical areas focusing on patient first, safety, communication, patient satisfaction, employee engagement/morale, systems/processes and environment. Guidelines were established to help leaders know what you look for and how to engage in these areas. It also takes on a perspective I see as central to patient experience success – a systemic point of view. By providing the leader a framework to look across the broad spectrum of areas that influence experience, the leader is ultimately assessing for issues related to quality, safety and service, with the addition of engaging staff. This systemic perspective is a critical step in ensuring an effective and comprehensive patient experience effort.

Aside from clear standards, questions to measure and a consistent and system rounding effort, reinforcing accountability touched on one more area, that of rewarding for performance. Through a program called “success shares” staff across the system have certain performance targets for satisfaction and experience. The team at Scripps not only created the process to address what they believed was important, they built a system by which actual performance to goals was incentivized and rewarded. Staff across the system are aware of the components of their performance bonus tied to patient experience overall. They collectively reap or lose this incentive based on performance across the system. This is not simply about individual performance or behavior; it is about a system-wide effort that is clearly defined, clearly measured and ultimately rewarded when objectives are realized. This framework of accountability truly represents what I experienced across Scripps. This perspective as so many shared has been reinforced under the leadership of System CEO Chris Van Gorder. That when people encounter Scripps regardless of what corner of the system or what area they encounter, that the experience is consistent, positive and patient centered at every touch point.

Conclusion: The Power of Intention
There is great power in intention and even greater power in follow-through. The story of the Scripps effort from designing patient centered care processes to reinforcing and incentivizing desired actions and behaviors is based on this idea. In closing the day I spent time with Vic Buzachero, Corporate Senior Vice President for Innovation, Human Resources and Performance Management and the executive champion for Scripps’ patient experience effort (pictured left). He spoke to the very item we found to be the top driver of patient experience success through our research at The Beryl Institute – leadership and culture. Vic talked about the importance of leadership alignment and intention, supported by a culture committed to executing on these intentions.

“It is important,” Vic shared, “that we build a culture that drives consistency in our effort. We must have the infrastructure to show the genuine nature of our organization, reinforce our focus on the patient and shape the balance of systems, processes and behaviors that will help us realize our goals.” He expressed the importance of consistently reinforcing behaviors, communication and understanding the perceptions of those in your care. The challenge he expressed is that organizations all too often take baby steps into big changes and this often leaves them vulnerable or has them fall short of their goals. Rather he offered, “We need to set aggressive goals at the system level to build the muscle we need to succeed. We need to be willing to push our people and our efforts in order to do what is right for the people and community we serve.” This is intention at its very core and it is with this intention that Scripps has taken on its patient experience journey.

As we ended the day I was reflecting with my host Kristin Hoefling about the consistent story of culture and intention we had experienced throughout my visit. She and her colleagues RJ Salus and Barbara Bates have been hard at work to ensure these system-wide efforts move forward. The impact of this effort was reflected in the pride the entire Scripps team had in their efforts to drive system-wide improvement. It was also clear as she reinforced that they were truly just underway. “This is just the start of our journey,” she said with a warm smile, “this is not about chasing numbers, we know they are important. For us this is about doing the right thing.” It is clear that at Scripps the right thing is definitely happening each and every day.