Patient Experience 2.0

Why Nice Is Not Enough and What to Do About It

"I can't do all that patient experience stuff!" nurses sometimes say when leaders try to engage them in improving the patient experience. They think it's fluffy stuff...stuff they don't have time to deliver on.

Some still believe that the CAHPS family of standardized patient surveys (HCAHPS, CG CAHPS, ED PECS, OAS CAHPS) are just focused on customer service. After all, the surveys ask patients if they were treated with courtesy and respect and how their nurses and doctors communicated...so if we smile more, scores will go up? Patients will be happier?

CAHPS is About Quality

But here's what some of your leaders may be missing: the government (Centers for Medicare and Medicaid Services) is actually measuring how consistently you communicated effectively with patients. The surveys measure the patient's perception of quality care. And that's tied directly to quality clinical outcomes. The CAHPS surveys are largely a frequency analysis; very few survey items are 'yes or no' questions.

So, it's not about satisfaction, it's about the consistency of the patient's care delivery experience. When we speak to large groups of nurse leaders, we like to pose the question: "Why do you suppose an organization with high quality clinical outcomes also enjoys great performance on the CAHPS surveys?" In response, there's often complete silence. Nurses aren't sure at first.

But when we explain that the reason is because patients are recognizing through their survey responses that they're receiving highly reliable care, it seems immediately obvious. Of course patients would rate a hospital highly when they say their pain was always well-controlled, they always got help when they needed it, and their post-discharge instructions were clear. Every clinician recognizes that patients who understand how to take their medication correctly and when to report side effects have fewer readmissions and heal faster.

(graph) Hospitals with higher patient experience ratings realize lower readmissions.

An Engaged Culture is Non-Negotiable

Delivering a memorable patient experience isn't just about nursing though. The whole team has to consistently deliver with every patient, every time. On-the-spot service recovery is everyone's job. It can't be relegated to a special department like the office of patient experience or department of customer/guest services. Dieticians need to deliver the right meal to the right patient on time. Every time. Everyone who interacts with the patient-including students and volunteers- is part of the patient experience team.

As we know from their feedback, patients have high expectations. They deserve staff and clinicians who deliver care with concern for a safe environment and behaviors that embody expertise with a caring, respectful approach. Exceeding those expectations is the goal...and the right thing to do.

Engagement Starts with Leaders

Engagement flows to physicians, caregivers, and employees and only then to patients. Without it, quality suffers. To hardwire engagement in your organization, be sure to connect the hearts and minds of your care delivery team first. We call this "connecting to purpose."

Patient stories, among other strategies, help us do this effectively. Explain how that thing you're asking someone to do directly impacts the patient. Open your meeting by celebrating a patient win or recognizing staff. Then connect that back to the opportunities for improvement that you're currently working on.

To help improve patient experience, consider these six ways to build and hardwire a culture of engagement for consistent care delivery in your organization:

1. Set the stage for the patient experience daily.

Use short shift huddles to set the tone for the day by opening the huddle with a value or standard that contributes to patient experience (e.g., what right looks like). Share patient experience results and feedback in an area you want to focus on.

Perhaps you want them to better "manage up" the expertise of other departments during hand-offs or better bundle care with Hourly Rounding® so staff think in terms of continuous instead of episodic care. Recognize staff individually and provide very specific recognition, tying it back to your department or unit's patient experience improvement plan. Remember, what gets recognized, gets repeated!

Instead of telling staff, "Don't forget your AIDET®!" be specific and connect back to why. Say, "Let's focus on AIDET today because it reduces anxiety and contributes to a better patient experience. I want to know that the 'D' of AIDET is understood by every patient...their plan of care for the day and approximately what time they will have their radiology study or be seen by the hospitalist. When I round on patients, I want to hear that you've articulated the 'D' of AIDET with each patient and family member."

2. Use behavioral standards.

Studer Group finds that just telling people to be courteous and respectful isn't enough. It's a leader's role to "show what right looks like." In most organizations, behavioral standards that are employee-driven and endorsed spell out clearly how to act and are usually tied to the organization's mission and vision. For example, standards that drive courtesy and respect include: "I will greet all visitors and patients with a 'hello', smile, and eye contact" and "I will use open-ended questions, such as 'How may I help you?'"

3. Commit to validation.

Improving patient experience requires validation of the consistency and frequency of care delivery; you must ensure that your staff are doing what you've asked them to do-every patient, every time. Just ask Neal Loes, CNO at Mary Greely Medical Center in Ames, IA.

"We'd get results and then they'd fall off and then we'd get results again until I finally committed to relentlessly validating performance," Loes explains. "Now we've sustained our HCAHPS overall rating at the 86th percentile for three years. It's not about getting to a number, but about creating a culture of execution. As a nurse leader, you can never stop."

4. Give timely and constructive feedback.

Consistent feedback tied to specific behaviors that enhance or detract from the patient experience improves performance. Imagine a nurse leader validating that his nurses are rounding hourly, for example. While it's tempting for him to just toilet a patient who explains she had to use a call button, it's more important to coach the nurse to do it proactively.

That's why Leader Rounding on Patients is critical. It is a powerful way to validate where both excellence and gaps are occurring in care delivery. By coaching staff directly and then validating that gaps are no longer occurring, nurse leaders can truly create a culture of "Always". Remember, recognizing staff for what is going well is just as important as highlighting what needs improvement.

5. Onboard agency nurses.

Organizations often overlook the undesired impact that agency or traveling nurses can have on the consistency of care delivery. Do you quickly and thoroughly onboard the agency nurses you use to ensure they understand performance expectations, organizational values, and culture? If you don't, you'll have a major performance gap that patients will recognize. And, this gap will be directly reflected in patient perceptions on the survey. (Just think about how many patients a single nurse touches over three 12-hour shifts in a week.)

6. Use appreciative listening in service recovery.

Although we try our best, at times we will disappoint our patients and this causes frustration. When patients are frustrated, what they desire most is to feel truly heard. Resist the impulse to provide an on-the-spot solution in favor of truly listening. (Behavioral standards for courtesy and respect work here too!)

Repeat back to the patient what you just heard. If a patient received conflicting information about discharge from two caregivers, for example, you could say, "I imagine that's confusing. I'm going to make sure we do better than this." Then circle back the next day (or later that day) and provide clarity.

The #1 Way to Improve Patient Experience

How can you help improve performance on your CAHPS surveys? It's easy. Stop talking about CAHPS surveys with your staff! Just remember that your care delivery team members don't kiss their spouses and wives goodbye in the morning because they're excited about improving survey scores that day at work.

It's all about engagement. When you talk about surveys and scores, you move your team further away from their true purpose, from work that is absolutely worthwhile, and from making a difference with their patients...the very reason we do get up in the morning and give it our best.

The surveys are a post-care delivery report of how well we provided consistent, high quality care from the patient's perspective, based on the patient's actual experiences. Remember, it's not a "happiness" survey. The CAHPS surveys provide us important consumer feedback on our ability to deliver on our organization's mission and values.

How to improve patient experience.
  • Vikki Choate

    Vikki Choate, MSN, R.N., NEA-BC, CCM, CPHQ

    Coach Leader, Studer Group

  • Colleen McCrory

    Colleen McCrory, MBA, FACHE


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