Outlines elements of a strategy for high patient satisfaction focused on patient-staff interactions and patients' needs, including a culture of customer service, shared governance, better data collection, more visible leaders, and evidence-based practice

Sharon Silow-Carroll

English

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The mission of The Commonwealth Fund is to promote a high performance health care system. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy.Case StudyHigh-Performing Health Care Organization • December 2008To download this publication and  learn about others as they become available, visit us online at  www.commonwealthfund.org and  register to receive Fund e-Alerts. Commonwealth Fund pub. 1205 Vol. 4Hutcheson Medical Center: Focusing on Personal InteractionsJennifer edwards, dr.P.H. HealtH ManageMent associatesVital SignsLocation: Fort Oglethorpe, Ga., near ChattanoogaType: Community, nonteaching, nonprofit hospitalBeds: 179Distinction: Hutcheson Medical Center scored among the top five hospitals in the country on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey among hospitals eligible for the analysis. Timeframe: October 2006 to June 2007. Its rank is based on the percent of patients who rated the hospital very high overall and percent of patients who would definitely recommend the hospital to family and friends. See the Appendix for full methodology. This case study describes the strategies and factors that appear to contribute to high patient satisfaction at Hutcheson Medical Center. It is based on information obtained from materials and interviews with key hospital personnel during May 2008.    SuMMaryBy focusing intently on patient–staff interactions and patients’ needs, Hutcheson Medical Center has turned around its quality and financial indicators in the last two-and-a-half years. Under new leadership, the hospital moved from a position of financial losses and shrinking census to being competitive again in its region. Scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey show that Hutcheson is now a leading hospital nationally on measures of patient satisfaction. Five components of the hospital’s strategy may be behind their success:fostering a culture of customer service; •	empowering nurses through shared governance;•	For more information about this study, please contact:Jennifer Edwards, Dr.P.H.Health Management Associatesjedwards@healthmanagement.com2 the CoMMonwealth Fundcollecting and tracking data to chart progress;•	visibility of leaders; and•	implementing evidence-based practice.•	OrganIzatIOnHutcheson Medical Center is a nonprofit, 179-bed community hospital located in Fort Oglethorpe, Georgia, eight miles southeast of Chattanooga, Tennessee. Hutcheson serves a three-county region—Catoosa, Dade, and Walker Counties—with its hospi-tal, nursing home, three family practice sites, home care agency, and an after-hours clinic. In response to deep financial losses, migration of patients to competi-tors in the region, and lagging staff morale, the Board of Directors replaced the hospital CEO in September 2005. Charles Stewart, M.S., M.A., the new CEO, has since built an entirely new leadership team that has begun a journey to achieve the highest-quality health care. The thrust of their strategy is to focus on patient satisfaction. “People want a good personal experience in the hospital. They are sick and scared,” says Stewart. “They want to know ‘if anyone is looking out for me.’” The leadership team believes that the focus on personal interactions has resulted in across-the-board improvement in quality measures. Stewart was predisposed to focus on improving quality through patients’ eyes, having come from a hospital in Tuscaloosa, Alabama, where he learned that excellent customer service drives business and builds loyalty. He also attended the Baptist Leadership Institute in Pensacola, Florida, which teaches hospital leaders a strategy for quality improvement based on the experiences of Baptist HealthCare, Inc., a hospital that showed a remarkable turnaround in the last decade using these methods. Stewart handpicked leaders from other hospitals where customer service was also a priority and who shared his philosophy of organizational turnaround. The team developed a strategic plan based on a model of service and operational excellence they learned from The Studer Group, also in Pensacola, Florida. It focuses attention on five “pillars” by which to set goals and measure accomplishments: customer service, people, quality, growth, and finances. The Board and executives have set goals for each, and Stewart himself is evaluated by the Board on his suc-cess in improving each priority area. Stewart’s goals have been used to set divisional goals and unit goals, including those related to frontline workers. People want a good personal experience in the hospital. They are sick and scared. They want to know ‘if anyone is looking out for me.’Charles Stewart, Hutcheson CEOStrategIeS FOr SuCCeSSOver two-and-a-half years, Stewart and his leadership team have been focused on promoting staff buy-in to the hospital’s strategic plan and driving change throughout the organization.  Fostering a Culture of Customer ServiceHospital leaders believe that patient satisfaction is closely tied to employee satisfaction, so a stepping-off point has been to learn what employees need to be happy in their jobs. A staff satisfaction survey led to the creation of teams, which identified four standards of behavior that staff felt would help them achieve job satisfaction and patient satisfaction. The four behaviors spell the word TEAM: T = Take ownership and pride in HutchesonE = Everyone demonstrates leadership and commitmentA = Always respect and support all team membersM = Model excellent customer service in every- thing we doBeginning with the orientation of new staff, Hutcheson has begun to train all clinical and non-clini-cal staff about the importance of patient satisfaction and customer service. The four behaviors are posted throughout the hospital where they are visible to both staff and patients.hutCheSon MediCal Center: FoCuSing on PerSonal interaCtionS 3empowering nurses through  Shared governance The culture shift at Hutcheson has also been achieved through shared governance, an organizational model in which staff nurses are given a voice in determining clinical practice, standards, and quality of care. Shared governance has been endorsed by the nursing Magnet program as a feature of quality care.1 Nurses at all levels have helped to improve patient satisfaction by redesigning and implementing better care strategies.For example, staff nurses created a care stan-dard: nurses would visit every patient every hour and check on four fundamental needs, based on The Studer Group’s principals of patient rounding. These are easy to remember as “the four Ps”: Pain, Potty, Privacy, and Positioning. Before leaving the room, staff have been instructed to ask patients and their families, “Before I leave, is there anything else I can do for you?” and telling them when they will check back. The consis-tency with which this interaction occurs has gone a long way to reassure patients and manage their expec-tations about being able to reach someone if a need arises. Adherence to rounding schedules is tracked using a log kept at the bedside, and data are compiled and given to unit managers and charge nurses. At each visit to the room, the floor nurse asks the patient, ‘Before I leave, is there anything else I can do for you?’Hutcheson has also introduced whiteboards in each room to alleviate the common complaint of patients not knowing who is taking care of them. When a patient first arrives, they are shown the board, which lists the name of their doctor, nurse, and patient care technician. In addition, the unit manager’s name is shown, and patients are instructed to contact him or her if their needs are not being met. To keep the infor-mation current with each shift change, a process was 1 The Magnet Recognition Program® was developed by the American Nurses Credentialing Center to recognize health care organizations that provide nursing excellence. The program also provides a vehicle for disseminating successful nursing practices and strategies. See www.nursecredentialing.org.established for regular updates. Patients have said they appreciate knowing who is looking out for them throughout their stay.Prior to the leadership change, staff had become negative about the hospital and their jobs. Chief Nursing Officer Debbie Reeves, M.S.N., has sought to cultivate professionalism among the nursing staff to overcome this negativity. Nurses identified a need for education about evidence-based nursing and translating research into practice, and are beginning to go back to school for additional training. Reeves predicts that the quality of care will continue to improve as a result. Collecting and Feeding Back Data Hutcheson collects data on patient satisfaction and other outcomes measures on an ongoing basis and pro-vides weekly report cards to all departments to help them track their progress against their own goals and other hospital units. Results are discussed at all meet-ings to help maintain a sharp focus on improvement. Additionally, data are posted on the hospital’s internal Web site, enabling managers to compare their unit to others and promoting learning opportunities.Hutcheson uses a survey firm to conduct weekly surveys of a sample of recently discharged patients. The data are reported back to the hospital  and benchmarked against similar hospitals throughout the Southeast.Another important data source is a series of five questions that unit managers ask of a sample of patients prior to discharge. These questions mirror ones from the HCAHPS survey. The goal is to elicit views from 30 percent of patients before they leave the hospital. The data go to Carol Courtney, M.S.N., the chief quality officer, and are included in unit and divi-sion reports. Managers have results on their desktop daily. They track the percent of patients saying their care was very good (the top category) compared with the percent saying their care was good. In this way, they focus on moving patients’ experiences from “happy” (good on the survey) to “delighted” (very good on the survey).4 the CoMMonwealth FundVisible LeadershipNot long after undertaking this transformation, hospi-tal leaders checked with staff to see how the changes were being received. Feedback was positive, but staff noted they would like to see and hear more from top leaders. Stewart and other administrators began mak-ing weekly rounds, during which they spoke with staff, patients, and families. Stewart believes that interaction with staff in formal and informal meetings has helped create an atmosphere of transparency and trust. Hospital leaders also began holding weekly patient safety rounds. The administrator on call and five other senior hospital leaders visit a unit and ask staff to identify issues that may harm a patient or impede patient care. Leaders also speak with patients during the rounds. Staff concerns are usually able to be addressed, making staff happier and more effective at their jobs. “In the last six months,” according to Carol Courtney, “we’ve seen an increase in teamwork on the units. The staff know us and recognize us. We believe staff response to better teamwork has contributed to patient satisfaction.”Hutcheson has also added a second directors’ meeting each month, so that more time can be devoted to discussions of patient satisfaction. The additional meeting focuses on issues such as rounding and com-munication with patients.Finally, Hutcheson has sought to increase attendance at quarterly all-staff meetings. CEO Stewart reads patients’ letters at the beginning of each meeting to drive home the importance of their experiences. A staff person or group is recognized, either because a patient has written about them or their manager has recognized a contribution they have made. One of the standing agenda items at these meetings is to share  and discuss the most recent patient satisfaction scores and trends. results Hutcheson’s efforts have proven successful in many ways. Increased inpatient volume has driven up reve-nue: the hospital went from a $6 million deficit in 2005 to an $800,000 positive net income in 2007. HCAHPS scores for 2007 exceeded national averages on every measure, as shown in the Table on page 5. Though longitudinal HCAHPS data are not available, other internal satisfaction measures have also risen since 2005.LeSSOnS LearneDAs many other institutions have found, quality improvement is a journey, not a race. Hutcheson’s leaders say it is important to maintain focus—both their own and their employees’—on the priorities. They believe small hospitals can achieve as much suc-cess as large hospitals, though they must be creative with their limited resources. Experience has taught them that focusing on patient satisfaction is the right thing to do for patients, staff, and the bottom line.FOr MOre InFOrMatIOn  Contact Debbie Reeves, M.S.N., chief nursing  officer and vice president of patient care,  dreeves@hutcheson.org or (706) 858-2000. hutCheSon MediCal Center: FoCuSing on PerSonal interaCtionS 5Table. Hutcheson HCAHPS Scores Compared with National Average, CY 2007Percent of patients who reported that: Hutcheson National AverageTheir nurses “always” communicated well 91% 74%Their doctors “always” communicated well. 96% 80%They “always” received help as soon as they wanted. 70% 63%Their pain was “always” well controlled. 87% 68%Staff “always” explained about medicines before giving it to them. 80% 59%Their room and bathroom were “always” clean. 83% 70%The area around their room was “always” quiet at night. 79% 56%Yes, they were given information about what to do during their recovery at home. 97% 80%Gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest). 89% 64%Yes, they would definitely recommend the hospital. 93% 68%Source: http://www.hospitalcompare.hhs.gov/Hospital/Search/compareHospitals.asp, accessed fall 2008.6 the CoMMonwealth FundaPPenDIx. SeLeCtIOn MetHODOLOgySelection of hospitals for inclusion in this case study series is based on data voluntarily submitted by hospitals to the Centers for Medicare and Medicaid Services (CMS). Between October 2006 and June 2007, hospitals or their sur-vey vendors sent a survey to a random sample of recently discharged patients, asking about aspects of their hospital experience. The survey instrument, called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), was developed with funding from the Agency for Healthcare Research and Quality (AHRQ). CMS posts the data on the Hospital Compare Web site (www.hospitalcompare.hhs.gov). The survey contains several questions about nurse and physician communication, the physical environment, pain management, and whether the patient would recommend the hospital to family or friends. One question inquires about the patient’s overall experience: “Using any number from 0 to 10, where 0 is the worst hospital possi-ble and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?” HCAHPS is a relatively new survey, and hospitals across the country are not yet achieving very high scores across all of the questions. Nevertheless, some hospitals are scoring significantly better than others. By profiling hospitals that score within the top 5 percent (among those that submitted at least 300 surveys) on the question con-cerning overall experience, this case study attempts to present factors and strategies that might contribute to and/or improve patient satisfaction.  While high HCAHPS ranking was the primary criteria for selection in this series, the hospitals also had to meet the following criteria: ranked within the top half of hospitals in the U.S. on a composite of Health Quality Alliance process-of-care measures as reported to CMS; full accreditation by the Joint Commission; not an outlier in heart attack and/or heart failure mortality; no major recent violations or sanctions; and geographic diversity.HutcHeson Medical center: focusing on Personal interactions 7about tHe autHorJennifer Edwards, Dr.P.H., M.H.S., is a principal with Health Management Associates’ New York City office. Jennifer has worked for 20 years as a researcher and policy analyst at the state and national levels to design, evaluate, and improve health care coverage programs for vulnerable populations. She worked for four years as senior program officer at The Commonwealth Fund, directing the State Innovations program and the Health in New York City program. She has also worked in quality and patient safety at Memorial Sloan-Kettering Cancer Center, where she was instrumental in launching the hospital’s Patient Safety program. Jennifer earned a Doctor of Public Health degree at the University of Michigan and a Master of Health Science degree at Johns Hopkins University. acknowledgMentsWe wish to thank members of Hutcheson Medical Center’s leadership team who generously shared their time and experience with us: Charles Stewart, president and chief executive officer; Gerald Faircloth, chief operat-ing officer; Carol Courtney, chief quality officer; Debbie Reeves, chief nursing officer and vice president of patient care; and Agnes Cloud, chief marketing officer.Editorial support was provided by Martha Hostetter.This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution.The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.

Hutcheson Medical Center: Focusing on Personal Interactions

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Hutcheson Medical Center: Focusing on Personal Interactions

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