Emergency Care Center
Parkwest Medical Center is a 307 bed community hospital located in Knoxville, Tennessee. The Emergency Care Center (ECC) is a 40 bed unit consisting of a 10 bed fast track area, a 10 bed telemetry-observation area, and a 20 bed main department of which 4 beds are configured as critical care rooms. The Emergency Care Center has received PRC's 4 star award patient satisfaction for the past three years.
Long History of Systems Improvement
For almost 10 years, the Parkwest ECC has worked to improve its processes both in the clinical area as well as the patient satisfaction arena. In late 2005, the ECC began a journey to raise its customer satisfaction from the 4 star level to the 5 star level. Doctors, nurses and ancillary staff met in the last quarter of 2005 to evaluate and set goals for moving from good to excellence in the following year. The team looked at the 2005 PRC data and decided what key drivers and snap shot questions we would focus on for 2006. The following questions were selected after conducting patient interviews on what they felt was important to them:
Nurse's understanding and caring (key driver)
Doctor's understanding and caring
Overall teamwork between
Doctors, nurses and staff (key driver)
Going from "Good to Great"
In January 2006 a team of doctors, nurses, support staff and directors met with The Studer group for a presentation on change in the emergency department to seek ways to meet our 2006 goals. The group met collectively to implement suggestions from Studer which would impact patient's perception of providing excellent care. Three initiatives were selected from the seminar that we felt could be implemented quickly with effective results.
Multiple Focused Initiatives
The first initiative was to provide change of shift reporting by doctor's and nurse's at the patient's bedside which would impact the patient's perception of the doctor's/nurse's understanding and caring and teamwork. Those of who attended the Studer seminar started teaching the staff the new process. Both doctor's and nurse's went into the patient's room and introduced the next staff member who be providing their care. Report consisted of key indicators for patient satisfaction such as explanations of what the patient was waiting on, evaluating their pain management etc. We began bedside reporting at the end of January. Initially there was some resistance from staff members as this was very new to them. In March, 2006 we began measuring bedside reports and posting the results for the staff members to observe. Bedside reporting has promoted confidence and continuity of care from the patient's perspective and the staff has increased teamwork between physician's and shifts.
The second initiative was to begin rounding interviews on patients each shift. Rounding forms were created utilizing Studer input, key drivers and snapshot questions, and JCAHO standards for pain and safety. The shift leaders, clinical educator, and management met to discuss the process prior to implementation in February, 2006. Each shift a member of the above team rounded with a small group of patients and families to discuss the care they were receiving in the ECC.
The patient was asked the following questions:
Did the doctor and nurse introduce themselves by name?
Has your pain been addressed?
Did we provide explanations regarding tests or procedures?
Call light available and did we perform two patient identifiers prior to tests/procedures?
Is there anything I can do for you now?
Did anyone provide excellent care to you today?
Rounding provided feedback on what we were doing well as well as areas we could improve on. Rounding also provided information on nursing staff and doctors as to who was providing excellent care to their patients. Recognition was given to those performing excellence customer services which reinforced the behaviors. Patient rounding began being measured on a monthly basis in March 2006 and results are shared with all staff members.
The third initiative was to perform patient follow-up calls within 24 hours of their initial visit. The purpose of the phone calls was to provide a clinical check to the patient, inquire about service provided by the doctors and staff, and to reward individuals who provided excellent customer service. A call back form was developed utilizing the format for patient rounding. Scripting was utilized in order that calls being placed by staff members were uniform in nature. The receptionist referred as greeters and other staff members received training in February. An additional form was developed to ascertain the patient's telephone number and receive permission to leave at message on their answering machine if they were not home.
The greeters began making calls the third week of February. The response from the call backs was immediate. The patient's/family member expressed gratitude that we cared about them enough to call and check on them the next day. The same opportunities were available from call-backs as patient rounding but we were able to reach several more patients utilizing this technique. Follow-up calls have been measured and graphed since March of 2007 and are reviewed with the staff.
Other strategies were developed to support the three primary initiatives. Plans to improve the quality and consistency of discharge instructions were developed by the staff. A team of physicians, nursing personnel, and registration staff met to discuss ways to improve the discharge process. Based on this discussion, discharge instructions were changed from a brief information format to a Micromedex computerized discharge form personalized with patients name, physician, and prescriptions. These instructions provide extensive information regarding diagnosis and plan of care. The physician initially presents the discharge information verbally to the patient and discusses discharge planning with the primary nurse. The nurse then provides both verbal and written instructions to the patient and seeks confirmation of patient understanding. The nurse walks the patient to the discharge center and at that time the registration personal provides a scripted message. The scripted message is as follows:
"Do you have any questions about your care today?"
"Are there any issues or concerns we have not addressed?"
"If you have any further problems concerning today's illness or injury of if you have healthcare concerns please return to Parkwest for re-evaluation."
If the patient answers yes to question one or two the nurse is called to discuss any problems or concerns the patient may have prior to discharge. This process has provided increase clarity in patient understanding and comprehension of discharge instructions. The process supports the patient's perception that the staff at Parkwest ECC work in a teamwork environment. This model also provides the staff ability to perform service recovery, if necessary, prior to the patient leaving the facility.
Parkwest ECC focuses on patient satisfaction indicators, improving communication techniques and teambuilding at a yearly retreat which is developed by the staff education council. This council is composed of nursing personal at all levels which includes RN's, CNA's, unit secretaries, and the departmental educator. The council developed the retreat in conjunction with the learning and organization development department for Covenant Health (Parkwest's parent company). Physicians, PA's/NP's, RN's, LPN's, CNA's, departmental secretaries, departmental assistants, unit coordinators, and directors attend the Emergency Care Center's retreat.
Half of the staff attended the retreat in April and the other half of the staff attended in May. The retreat is facilitated by a staff member of the Emergency Care Center. The first part of the retreat was taught by specialist from our internal learning and organizational development department. All staff members were given a pretest regarding communication style prior to the retreat. The presentation at the retreat involved discussions regarding how people have different communication styles, what the staff's personal style meant, and how we can communicate more effectively with co-workers and patients.
The second part of the retreat was focused on service initiatives based on the Studer principals. The education council developed a video presentation which utilized staff members and physicians demonstrating both appropriate and inappropriate behavior for providing excellent customer service. The last part of the retreat was based on team building and communication games and techniques. The retreat provides meaningful information for physicians and staff and helps us to achieve excellent satisfaction scores while enhancing a teamwork environment.
Overall Quality of Care by Month