Research Activities, October 2013
Patients and families say "I do" to hospital engagement
For decades, the nurses at Advocate Trinity Hospital in Chicago met during shift changes to discuss their patient's condition, medications, and concerns. They always tried to be as thorough as possible as they spoke outside of the patient's room or at the nursing station.
But things changed in 2011—they started including the patient. They wanted their patients not only to hear them but to be involved. Bedside shift reports became a way for nurses to communicate with each other and their patients—and anyone else the patient wanted to be involved.
Patient participation in bedside reports was just one of four evidence-based strategies that Trinity tried as they tested protocols that are now included in AHRQ's Guide to Patient and Family Engagement in Hospital Safety and Quality, which was posted online in July. The other strategies involved patients and family members serving as advisors, better communication at the bedside, and different approaches to plan and track discharges.
"We know that patients and families are eager to participate in making health care safer," said Jeff Brady, M.D., associate director of AHRQ's Center for Quality Improvement and Safety. "This guide fills an important—and largely unmet—need and gives hospitals concrete ways to put this shared interest into action."
Under an AHRQ contract led by the American Institutes for Research, contributors to this guide included the Institute for Patient and Family Centered Care, Consumers Advancing Patient Safety, the Joint Commission, the Health Research and Educational Trust, and others with expertise in patient and family engagement. For 2 years before completion of the guide, three hospitals tested and evaluated at least two of the strategies and tools, which included sample brochures, letters, and slide presentations for patients and staff. The hospitals—Advocate Trinity, Anne Arundel Medical Center in Annapolis, MD, and Patewood Memorial Hospital in Greenville, SC—prided themselves on patient-centered care, but they each discovered that these strategies helped improve patient satisfaction based on their scores from the Hospital Consumer Assessment of Healthcare Providers and Systems survey.
The patient is part of the process
"If everything we do is for the patients, then we need to include the patient in the process and and design it with them as an active participant," says Susan Bocian, R.N., M.S.N., of Advocate Trinity, a 200-bed hospital. At Advocate Trinity, making the process about the patients includes everything from working with patients and their families as advisors who review brochures and recommend signage to involving patients in bedside shift reports.
"Looking back, it's ironic that we called it a bedside shift report when we didn't include the person in the bed," says Bocian, who coordinated the AHRQ project at Advocate Trinity. After the nurses at Advocate Trinity started including patients in their bedside shift reports, they surveyed their patients. "Some of the comments were, 'I always heard the nurses whispering at the bedside but I didn't know what they were talking about,'" explains Bocian. "When we involved the patients, several of them stated that by hearing the shift report every day, it made sense when it was time to go home. It is great that patients really enjoy the process and feel it is meaningful for them."
To involve patients' families, visiting hours at Trinity expanded to 24/7. The new times involved changes for everyone from the hospital's surgeons to the security team. "Surgeons round early in the morning, so family members who wanted to speak to them had to call and track them down. It's been more effective for them to talk in person," says Bocian. "The surgeons get everyone's questions answered at same time, which also helps with the discharge process." But it took time for the staff to get used to the new process, admits Bocian. "It was a big practice change. We heard, 'I don't know if I feel comfortable in front of the patient,' but the patient knows, for example, that he or she is diabetic," she says. "We don't have any secrets from the patients."
Just as the guide gives recommendations for opening up communication with patients, it also provides advice for appealing to the staff and physicians. "When we rolled out this project, we let the physicians know what's in it for them," explains Bocian. "We found that the patients used us as a sounding board before they spoke with their physicians. We helped them identify questions. Oftentimes, we could clarify things for the patient." Building rapport with families benefits everyone, says Bocian. "We had a knee surgery patient who needed rehab but was resistant and never explained why. After talking with her significant other, we learned that she cared for a son with a disability. We were able to change her plan of care upon discharge and arrange for her to have therapy at home so she could care for her son. That's a key example of why it's important to have the trust of the patient and her family," she says.
By improving communication, patient safety is enhanced in the process.
For Bocian, better communication with patients and families is part of keeping patients safe. She says, "Patients understand that we're doing a lot of things to keep them safe, like scanning their wristbands and their medications. Most errors occur because of errors in communication. By improving communication, patient safety is enhanced in the process." "We're having very good success. You can see it in our patient satisfaction scores," says Bocian. "We have 14 hospitals in our system, and after learning our results, the others are considering the same strategies we implemented from the guide."
Daily goals for everyone
Nurses have had daily goals for their patients at Anne Arundel Medical Center for a long time, but now patients have them, too. "Some patients want to walk down the hall, shower, or have a good bowel movement, which is a huge deal for the patient," says Jeanne Morris, R.N., at Anne Arundel Hospital, a 324-bed hospital with a mix of suburban and rural patients. Sometimes they just want to see their favorite team win. The most popular goal "is to get out of here," Morris says with a laugh. Whatever the patient's goal, the nurse writes it down on a white board in the patient's room.
Asking patients about their goals is just one change that Anne Arundel Hospital has made to improve communication at the bedside since using AHRQ's Guide to Patient and Family Engagement in Hospital Safety and Quality.
When Morris was asked to coordinate the guide's strategies at Anne Arundel Medical Center, she didn't hesitate. "It really dovetailed with what the entire hospital was doing to move forward and be more patient- and family-centered," says Morris, a nurse navigator at Anne Arundel's breast cancer center.
One story that stands out for Morris involves a mother whose child required two bone marrow transplants. "She told us how it felt to have the hospital team talking outside her room, not being able to hear, and not being included," says Morris. "She wanted to say, 'I know my daughter, I'm the one taking care of her, and I think I would be a great partner with you.' It was really just so powerful."
Another story from a patient advisor changed the way Morris addresses her patients. "She told us women of a certain age have a preference in how they want to be addressed and that when someone says, 'Do you mind if I call you Pat?' it puts the onus on her. She suggested asking, 'How would you like to be addressed?' Sometimes, there's something so simple we can do to help patients feel better. It's amazing what you can learn by listening."
"The guide was very easy to read and use," says Susan Ballew, B.S.N., R.N., a nurse for 37 years with the Greenville Health System (GHS). Ballew worked on implementing the guide at Patewood Memorial Hospital, a 72-bed hospital serving a rural population, which is part of the GHS. "With the exception of patient advisors, the strategies are not going to cost you more money or FTEs or time. We just had to reeducate the staff and set expectations for the staff and patients. Now more than ever it's important for patients and families to be participants in their own health care."
Bellew's colleague, Kerrie Roberson, M.S.N., R.N., agrees. "As health care providers, we want to do what's best for the patients and families," says Roberson. "This is simple communication. We've learned a lot from the guide, we're continuing to improve, and our patients are becoming active participants. We want them to know that they have a role, too."
Editor's note: The guide is available at http://www.ahrq.gov/research/findings/final-reports/ptfamilyscan/index.html.
For a video clip of Dr. Brady discussing the new guide, visit: http://www.youtube.com/watch?v=INzhyhY3e5E&feature=youtu.be&noredirect=1. AHRQ is working with the HHS Partnership for Patients, which has made focusing on patient and family engagement a priority for its 26 hospital engagement networks and other stakeholders to share the guide with hospitals across the country.