eTable2. Description of patient-level interventions employed at the majority of high performing hospitals, implementation issues, and how addressed.
Intervention(% hospitals) / Intervention Description * / Implementation issues and how addressed /
Proactive nurse rounds (83%) / This type of rounding involves having a nurse ‘check-in’ on the patient on regular basis to ensure that their needs are identified and addressed in a timely manner. Most often these rounds focus on patient basic needs and their comfort (e.g. toileting, pain, position in bed). At some organizations, the rounds are also utilized to ensure that safety measures are in place esp. fall prevention measures. The nurses performing the rounds and their frequency varied between organizations from primary nurse and nurse assistants alternating rounds on an hourly or two hour basis , to charge nurses and nurse managers checking in on every patient once a day.
“ Purposeful rounding – Prompted by staff suggestions, our patient care units are working to implement a program on all units where nurses and LNAs (Licensed Nursing Assistants) visit each patient hourly, except at night, when sleep is important. During hourly rounds, nurses attend to a patient’s pain, positioning, bathroom needs and safety concerns which, in turn, can lessen a patient’s anxiety, reduce the risk of falling and increase patient satisfaction”-TRa hospital in NCb, SRc, PMd.
“ Nurse Managers and/or their Clinical Nurse Leaders round on inpatients daily. During the rounding they acknowledge the patient’s pain score from the white boards. With respect to pain, we have coached them to ask questions such as “Has your medical team discussed pain management with you?” and “In the last 12 (or 24) hours have you had to use your call bell to ask for pain medication?” If yes “We want to have adequate pain relief available when you need it and I want to be certain we are meeting your needs. Do you call because we haven’t told you when to expect your next dose, or we haven’t asked you about pain when we’ve been in your room?” It give the patient the space to say they deliver the meds too late, or I try not to take the meds, etc. and the Nurse Manager or Clinical Leader can then have a more robust discussion with the patient regarding their specific pain control needs”-TR hospital in PM
“ Hourly Rounding - we added "with purpose" because just stopping in the room did not make a difference in our scores. Staff needed to be fully present and demonstrate caring to the patient when they inquired about their needs”-TR hospital in SR. / Main issues with implementation included initial employee buy in, performing the rounds as intended, and monitoring so they occur on a regular basis. To address buy in, leaders engaged local teams in deciding how to best implement (e.g. alternating nurses and nurse assistants), and highlighted that proactive rounding reduces the patients’ calls to the nurses. To ensure consistent implementation, nurse leaders rounded on patients and directly inquired whether their nursing team is performing the rounds as intended. Having ‘logs’ on which nurses checked whether they rounded was less useful as it did not monitor the quality of the rounding.
“Hourly Rounding - Some staff were extremely resistant because they felt it was "another thing". Explaining the why and tying it back to the best interest of the patient removed most of that resistance. Explaining the importance, why, and sharing the evidence with staff makes a difference. Units with unengaged employees were a major barrier. So instead of implementing based on previous methods we know work, the staff were entirely responsible for figuring out the method to be used, and back-up processes. Having the front-line staff have the responsibility for figuring out the problem and coming up with solutions, gets them more involved and engaged in the entire process. There were a couple of units that had staffing issues, such as 1/3 of their positions being open. We did not implement on those units until their basic needs were being met - staffing, major processes, no other major software implementations occurring such as computerized provider order entry. A major lesson learned was that not every unit can be the same. There MUST be variation (the 'loose' part) to allow for the needs of individual units”- TR hospital in SR.
Executive/ Leader rounds (62%) / These rounds involved an executive rounding on the patients to assess whether they have any concerns, and whether their needs are being met. This rounding helps bring leaders closer to the patients and the local teams, help leaders identify issues that patients and employee face, and engages them directly to help problem solve those. Furthermore, by taking the time to round on patients and directly ask them for their concerns, leaders demonstrate by action that the organization is truly focused on putting patients at the center of care and that this is a high priority endeavor.
“Senior Administration rounds weekly on patients to assess patients' perceptions of the overall acute care experience, opportunities for improvement, as well as compliments/individual recognition [which are] then shared with staff and leaders.”- TR hospital in DCe, PM, DIf.
“Department directors are encouraged to round frequently during the week to connect with patients and engage staff by setting an example.” - MIghospital in NC, DC, PM, CAMh, DI.
“Rounding is completed daily by the COO/CNO, Inpatient Director or one of the Directors/Managers. During those rounding activities, patients are asked about their care, and are asked to provide one suggestion as to something that could be done better. Business cards are provided so patients are able to contact us privately if they choose.”- TR hospital in DI / Main reported issue involved securing the executive time to round on patients. Frequency of visits to patients varied. At some organizations this was addressed by creating some scheduling rules ( e.g. no meeting between 9-11) to block time for rounding.
“ Nursing Leadership - no meetings between 9am and 11am ”- MI hospital in NC.
“Senior leaders round monthly in departments - there is a rotating schedule to ensure all departments are visited.”-TR hospital in NC, DC, SR, PM.
Setting Behavioral Standards (60%) / Setting behavioral performance standards involves identifying a minimum set of specific behaviors which are expected of every employee and clearly communicating these standards to all staff. These standards are often included as part of the human resources processes (e.g. hiring, orientation, annual evaluation, and termination) and are constantly reinforced by leadership through communication and exemplification. Staff are held accountable to these standards.
“Education on patient-centered care begins at Employee Orientation, with a focus on __ Hospital’s 10 Service Behaviors. These behaviors are also part of every employee’s performance evaluation and account for 35% of their merit increase.”-TR hospital in NC, SR, PM.
“[We have] well developed Standards of Behavior which is a document used in both hiring and termination. Each employee signs the standards and we highlight a standard once a month to keep them top of mind.”-MI hospital in PM, CAM, DI.
“Service Standards: Smile and Make Eye Contact / Greet Each Patient and Visitor / Seek Out Patient and Visitor Contact / Display Appropriate Body Language at All Times / Take 5 Minutes Each Day to Go Above and Beyond for One Patient or Visitor / Honor Diversity / Thank Every Customer.”-TR hospital in SR. / Main reported challenges include educating new employees on the behavioral standards, establishing accountability, and constant re-enforcement and verification of the behaviors. To address the education of new employees, many organizations include the standards directly as criterion during the hiring process and include these standards in new employee orientation and performance reviews. Behaviors were reinforced through consistent and clear communication of the standards and role modeling by organizational leaders.
“[T]he personal transformation of our CEO … was the single most important factor in getting the organization to buy in. He evolved from a very distant and unwelcoming personality type to a much friendlier and approachable person. His effort to personally model the changes expected of the rest of the employees was the essence of true leadership.” - TR hospital in NC, DC, SR, CAM, DI.
Multidiscip-linary rounds (56%) / These rounds involve a multidisciplinary team rounding on the patients to improve communication and collaboration across different disciplines and improve the patient experience. Multidisciplinary teams may incorporate the physician, primary nurse, pharmacist, respiratory therapist, charge nurse, case manager, dietary, physical therapist, occupational therapist, speech therapist, and social work and can occur at the bedside with patient and family members engaged.
“Institution of interdisciplinary team rounds that included nursing, care management and physicians. This allowed all to gain a greater appreciation of the discharge plan and, in turn, relay a common goal the patients.”-TR hospital in SR, DI.
“We also developed multi-disciplinary rounding (MD, Nurse, Case Manager, Pharmacist,.. ) who all do a standardized rounding process together in the patient room, with the patient hearing all of the conversation.”-TR hospital in DI. / Main challenges reported include engagement of multiple disciplines, time constraints, and communication across disciplines. To address time constraints, the frequency of these rounds varied from several times a week to once a day. At some institutions, multidisciplinary rounding were implemented at a few units first before its implementation was expanded to other units. Some institutions focus their multidisciplinary rounds on specific goals (e.g. pain management and discharge).
“A challenge at first was finding time when the Hospitalist and Nurse could round together. So we focused on increasing internal communication between the nurse and hospitalist to increase consistency and hardwire the practice.”-TR hospital in DC, SR.
Post-discharge phone calls (54%) / Post-discharge calls involve proactively calling patients after discharge. The calls aim to surface and resolve questions and issues patients may have after being discharged, check whether prescriptions have been filled, and assist in the transition to care out of the hospital. It is also used to understand the patients’ experience in the hospital and helpful for real-time service recovery. These calls are mainly made by nurses, pharmacists, or case managers.
“…has instituted a discharge phone call program where nurses call patients who have returned home within 48 hours to see how they are doing and to clarify and questions about discharge information and self-care. Since the program was instituted …about a quarter of the calls resulted in clarification of discharge instructions.”- TR hospital in DI.
“Our pharmacist also make discharge phone calls to high risk patients with multiple medications.” MI hospital in PM, CAM, DI.
“We have instituted Patient Care Manager to do call backs on discharged patients to ensure they have understood their discharge instructions, are able to fill their prescriptions and have not had any set-backs. We take the opportunity to get feedback on the care they have received, and record this feedback to let staff know of both their successes and the opportunities for improvement.”-MI hospital in PM, CAM. / The main challenge with post-discharge call is staff buy in and organizing the work so that staff has the time to conduct the calls. At different facilities, depending on their staffing availability, different roles (e.g. nurse, pharmacist, physician, case management) take on this responsibility. Some facilities assign dedicated personnel to conduct post-discharge calls. Some facilities reduce the resource burden by focusing their discharge calls on high risk patients (e.g. patients on multiple medications.)
“…implementing new best practices or discontinuing longstanding ways of doing things (e.g. – starting discharge phone calls or changing the way rounds are conducted) always requires a lot of education and time for staff to learn and ask questions.”-TR hospital in DI.
Discharge folder (52%) / The discharge folder is a communication tool which contains a working package of discharge information accumulated throughout the patient’s stay for the patient to take home. It promotes consistent focus on patient education and a team-based approach to patient discharge.
“…discharge folder given to patient upon admission. This discharge folder has a short checklist printed in large letters on the cover and is addressed by each nurse taking care of the patient. The checklist states "What I need to know when I get home" and "discussed": Help I will need, How to care for myself, purpose of my medication, symptoms to look out for, when to see my doctor, my responsibilities, any worries or concerns”-MI hospital in PM, CAM, DI.
“We have discharge folders with specific patient education materials for each patient and we add to that folder throughout the patient stay. We refer to this frequently during the hospitalization and tell them how important all the information is once they have been discharged.”-TR hospital in CAM.
“Creation of a Discharge Information envelope – the envelop serves two functions. First – it is a container for all of the patient education materials and discharge information given to patients during an admission. The envelope organizes this critical information for patients in one place. Caregivers use the envelope through the admission. In addition, the envelope has a “going home checklist” on it. This simple checklist helps patients and families think about the items they will need when they prepare to go home – including everything from clothes to wear, a ride, keys to their house, etc. ”-TR hospital in DI. / The main issues reported is consistency in implementation. These were addressed through data feedback on patient experience and increased education and accountability. Timing for when to start working on this folder during the hospitalization was important. To improve implementation, some hospital started this for elective admissions even before patient got admitted to the hospital (e.g. prior to admission for orthopedic procedures) . Otherwise, the patient education on discharge/folder use was started early during the admissions process followed by reiterating and re-enforcing throughout the patients’ stay.
“We emphasize how important consistency is from each caregiver to the next…our Nurse Practice Council created medication information sheets based on the drug classification with a simple explanation of what the medication is for, what it does, and common side effects. Nurses always have the medication administration record (MAR) with them at the bedside to ensure they are giving the correct medication and explaining each medication as they administer the med to the patient. Handouts are generated … and provided as reinforcement for the patient. These handouts are placed in the Discharge Folder (which is provided to them upon admission) and kept in a mesh basket in the patient rooms for consistency.”-TR hospital in CAM.
“Discharge planning begins at the time the patient is scheduled for surgery and specific needs are communicated to the Case Managers so the process of discharge planning can begin even before the patient arrives for their surgical procedure.”-TR hospital in DI.
a TR = Top ranking; b NC= Nurse communication; c SR= Staff responsiveness; d PM= Pain management;