Dartmouth-Hitchcock: Improving Adherence to Patient Communication

Added on Jun 22, 2017

Dartmouth-Hitchcock Uses Peer Ambassadors, Multimedia to Improve Adherence to Patient Communication Best Practices
By Whitney McKnight
Industry Edge June 2017

At New Hampshire’s Dartmouth-Hitchcock health system, “Culture of Caring” refers to both patient care and patient experience.

Until recently, consistent communication of this message to the thousands of employees throughout the system’s multiple locations had been a challenge. In Dartmouth-Hitchcock’s southern region, competition and collaboration with Boston-area health care systems had helped accelerate a more patient-centric approach to care, while at its main campus—the only academic tertiary care and Level 1 trauma center in the state—attention to the patient experience had not always been emphasized.

“We had developed legacy cultures at each location and began to excel in variation,” said Carol Majewski, RN, Dartmouth-Hitchcock’s director of the Office of Patient Experience. “There was great work being done in some areas of the organization, with little attention in other areas. It was time to put a stake in the ground and help our employees see the world differently.”

To place greater emphasis on patient experience and a patient-centered culture systemwide, Majewski and her team turned to providers with high patient experience ratings to coach their peers on how to connect more effectively with patients and one another. They also started employing videos and newsletters to facilitate discussion of the topic between unit leaders and staff. According to Majewski, these efforts have resulted in improved patient experience scores as well as more engaged employees.

Clear Communication is Key

The patient experience program was launched in early 2014, when, after considering whether to look toward the hospitality industry for help, the system’s leadership instead tapped Majewski, whose nursing career previously had led her from nurse manager to head of perioperative services systemwide. “It was a strategic decision to hire a clinician from the inside,” Majewski said. “I brought an understanding of our existing culture and could relate to the challenges that direct caregivers and operations leaders face in delivering excellence in patient experience.”

Majewski and the patient experience team devoted the program’s first year to building awareness. “We started having conversations about what the patient experience actually meant, and asked employees why they thought we’d gotten offtrack and how we might get refocused,” Majewski said.

After the team canvassed patients and employees for their stories, a theme emerged: The most satisfying relationships were not transactional, but qualitative, and always hinged on clear communication. “If patients trust us and feel cared for, they will come back. And they are more likely to partner with us on their health and follow medical advice,” Majewski said.

The patient experience team applied this insight to one of the system’s poorest patient-rated areas: During clinical visits, a majority of providers were failing to use electronic health records (EHRs) in a manner that didn’t alienate or upset their patients. So they enlisted a group of physicians with high patient experience scores to rate 61 of their peers in an observational study of 196 patient visits. The raters evaluated key behaviors associated with patient experience, such as greeting and engaging directly with the patient upon entering the examination room, asking open-ended questions, and seamlessly integrating the EHR into the visit. The result was that only 7% of clinicians followed all established protocols on every visit.

Because one of the goals for Majewski and her team is to avoid taking a top-down approach whenever possible, to address this poor rate of provider compliance they rely on provider “ambassador” volunteers with high patient experience ratings to help coach their peers on how to connect more effectively with patients and co-workers. Together, they review verbal and nonverbal cues that facilitate clear communication, such as greeting people by name while looking them in the eye, asking open-ended questions and asking patients whether they have any questions or concerns before ending their visit.

This program has proven popular with those who have sought help from their peers. Many have even seen their personal patient experience ratings improve by as many as 10 points, according to Majewski. “The providers like the peer-to-peer support where they get to evaluate each other’s interactions. Plus, they get to see how other physicians work. Normally, they don’t have the chance to watch each other because they are all so busy. But how can you learn what others are doing or not doing if you don’t actually see that firsthand?”

Rather than launching an email campaign complete with a series of meetings where lists of dos and don’ts are distributed, the patient experience team amplified their drive to improve how technology is integrated in the examination room by hiring actors and a film crew to create a video of a patient-clinician interaction gone wrong due to poor interpersonal skills. “It’s humorous but provocative,” Majewski said of the video. When she and her team showed it to the peer ambassadors, they agreed and roundly endorsed its message.

The video was distributed throughout the system, along with a list of conversation prompts to facilitate discussion between unit leaders and their staff as to how they might improve their use of technology in the examination room. These materials are reinforced by other videos, newsletters and peer ambassador activities. “Our goal is to shine a light on these successes and expand them throughout the system,” Majewski said.

A Work in Progress

The process of data gathering and determining which specific issues to address is still evolving, although an improved patient experience intranet with a dashboard for nurse and other leaders to use is under development, said Majewski.

“We’re using a couple of different measures,” she said. “We’re using the traditional patient satisfaction survey, because it lends itself to trends we can track.” Additionally, Majewski said that to capitalize on what she called “immediate service recovery and direct learning,” she and her team have been working with nurse managers to make time during their rounds so that they can meet with patients about their specific, real-time concerns. “The goal is real-time action,” she said. “We ask what is going on, and what can we do about it.”

She cites noise control—a common patient complaint—as an example of how to empower both staff and patients. Perhaps the noise is due to alarms, or to activity in another patient’s room—both instances where, even if the noise is unavoidable, the patient can be reassured that it is temporary. However, if the noise is due to loud conversation, for example, the nurse manager can work with staff to find a solution that works for everyone, while patients can be satisfied that their needs were heard and addressed.

“We mesh together multiple ways of getting feedback,” Majewski said. These include postings on internal social media, and reports from members of a patient relations team or from a team of volunteers on the Dartmouth-Hitchcock Patient and Family Voices team, who meet informally with patients and their families to gather information about successes and opportunities for improvement from the stories people share during a confidential interview in person or by phone.

Majewski said she and her team use all the feedback they gather as catalysts for creating more tools, such as the videos and conversational prompts, to empower employees as they decide together what the solutions to their specific situations should be.

In discussing Dartmouth-Hitchcock’s culture, one word Majewski does not use often is change. “That’s because culture is not something you just decide to change. Culture evolves,” she said. “When I speak at orientation I remind new employees and clinicians that they are the culture. To evolve, it takes every one of us. Who we choose to be is in each of our hands.” Words Majewski does use include connection, conversation and, most of all, communication, which she says are key to the Culture of Caring she and her team are dedicated to creating.

Statistical data collection on the program, now in its third year, is ongoing. However, Majewski noted that there is a noticeable buzz around improved communication, both with patients and co-workers. “They say hi to me in the halls and know who I am by name and what I do,” Majewski said of employees in general. She also points to the health system’s second annual Patient Experience Week as a sign of change: “This year I had more leaders sign up to greet patients at the door. The schedule was filled, mostly with mid-level managers.”

Majewski believes the uptick in enthusiasm is due to a dawning realization across the system that the program, while intended for patients, also benefits employees by helping to reconnect them with their personal values and what it was that drew them to health care in the first place.

“When we burn out in this profession we often say we have lost our way. But really, we lose our ‘why’,” Majewski said. “When you lose that sense of connection and caring you become complacent. If we can help remove barriers that come between employees and patients, and help our staff remember the ‘why’ of their profession, they will figure out the ‘how’ to care.”