A Culture of Ownership Boosts ED Experience and Engagement at Midland Memorial

Added on Sep 22, 2016

A Culture of Ownership Boosts ED Experience and Engagement at Midland Memorial Hospital
By Audrey Doyle
From Industry Edge September 2016

A cultural transformation in the emergency department of Midland Memorial Hospital provided the improvement catalyst to deliver significant gains in patient experience and nurse engagement scores.

When the new Scharbauer Patient Tower at the Texas-based hospital opened in late 2012, the hospital’s leadership team was confident that the nine-story, $176 million building, complete with a state of- the-art emergency department (ED), would boost ED patient experience and nurse engagement scores, both of which had been extremely low for months.

“Instead, it was the total opposite,” said Kit Bredimus, RN, director of emergency services. With the new building came a substantial increase in patients’ expectations and patient volume that the ED staff had difficulty accommodating, which caused patient experience scores to plummet. This caused nurse engagement to decrease, resulting in serious morale and confidence issues that further affected patients’ experience of care.

“Our patient experience scores ended up tanking to the point where we were in the 1st percentile among our peer group for most of 2014, and our nurse engagement scores on the 2014 NDNQI [National Database of Nursing Quality Indicators] survey were below the mean in four of seven domains,” Bredimus said.

When it became clear that the new structure wasn’t going to solve ongoing problems with patient experience and nurse engagement, ED leaders implemented a program designed to promote a strong culture of ownership by combining staff members’ core values with organizational values and workplace attitude.

The result? Patient experience scores skyrocketed to the 90th percentile in just a few months, and nurse engagement scores on the subsequent NDNQI survey not only were above the mean, but reached the 90th percentile in many domains. What’s more, the ED has sustained these improvements to this day. “By transforming our staff’s culture, we’ve transformed our patients’ experience of care,” said Bredimus.

A Growing Problem

Midland Memorial Hospital (MMH) is a nonprofit, 474-bed facility in Midland County, Texas. In addition to housing labor and delivery, nursery, critical care, medical, surgical, oncology, orthopedic and neurology units, the hospital’s Scharbauer Patient Tower boasts an impressive, full-service ED equipped to handle everything from minor injuries to life-threatening conditions.

Although ED patients and staff appreciated the new facility and all that it had to offer, a number of underlying factors were causing patient experience and nurse engagement scores to falter.

For instance, while hospital leaders had been receiving monthly reports indicating that patient experience scores in the ED were low, they hadn’t effectively addressed the issue with the nursing staff. “We were rarely made aware of the reports, and when we were, all we saw were the negative patient comments and all we heard was that our scores were bad and we needed to turn them around,” said Bredimus, who was an ED nurse at the time. “The scores weren’t plotted out for us, and we didn’t see the raw numbers or our percentile rankings, so we didn’t really know what ‘bad’ meant or whether we ever improved.”

Furthermore, the ED experienced an almost 50% turnover in its nursing staff during that time, and recruiting new nurses from local schools resulted in a very young crew of new staff with little training on patient communication and the importance of the patient experience.

Compounding this issue was the fact that the relationship between the ED physicians and nurses was poor. In addition to the large turnover in nursing staff, the ED was experiencing instability in physician staffing and was filling vacant positions with locum tenens providers. “We had new doctors working with new nurses, and negativity among some of our existing staff was tainting the morale of these new hires,” said Bredimus.

This negativity was causing friction on the floor, and patients were noticing. For instance, “The nurses had bad attitudes and were rude to me,” “My nurse made me feel like I was a burden,” “Nobody seemed to know what was going on,” and “The nurses and doctors didn’t communicate with each other” were common complaints on the 2014 NDNQI survey. In fact, Nurse-Physician Relationship was the lowest-scoring of the four domains in which the ED failed to meet the mean in 2014, the other three being Nursing Foundations for Quality of Care, Staffing Resource and Adequacy, and Mean PES (Practice Environment Scale) Scores.

Realizing that negativity in the ED was having a toxic effect on patients and staff, the leadership team tried several strategies throughout 2014 to rectify the situation. However, significant changes in management at the time resulted in improvement efforts that, although well-intentioned, were disjointed and misguided.

For instance, to improve the patient experience the leaders hired a person to greet patients and family members when they arrived in the ED, but an inability to consistently staff the position led to its elimination. To increase engagement they held discussions with the staff on the importance of communication and teamwork, but lack of a thorough framework or guide that outlined expectations made the discussions ineffective. Efforts to raise morale and improve performance by offering financial incentives in the form of extra work shifts were also attempted, but again, the staff wasn’t receptive.

“We’d try to turn things around, but nothing seemed to stick,” said Bredimus, who by this time had transitioned into his current role of director of emergency services. One of the reasons the strategies weren’t working, Bredimus said, was that morale was at an all-time low: “We were in such a deep hole that the staff didn’t know whether they could improve.”

Another reason was that, in discussions with the staff, leaders—including Bredimus—continued to focus on poor performance. “Even though I was still pretty new in my current role, it’s still tough for me to admit that instead of telling them what they were doing well, I was only telling them about the bad scores and negative comments and how awful we were,” Bredimus said. “People were hearing only negative things about themselves over and over, and their morale and confidence were dropping more and more. Needless to say, it wasn’t a good time for us. We just couldn’t get it together.”

Working toward a Culture of Ownership

By the end of 2014, with the ED’s negative reputation well-known and the community’s faith in the department fading fast, the leadership team tried a different approach—one that focuses on values and culture and that emphasizes the importance of improving the patient experience from both an objective and an emotional viewpoint.

The primary goal of this aptly named Values and Culture initiative, which was also being rolled out elsewhere in the hospital, was to advance the patient experience through self-improvement rather than organizational mandates. The first step toward achieving that goal was for the ED staff to learn details regarding their survey scores.

“We met as a group and used a graph to show our ranking compared to those of our peers. When the staff saw the trend line and there we were, hovering down at the bottom, that was a powerful image,” said Bredimus. “But if you hang up a graph and you don’t describe what it means, it’s just wallpaper, so we explained that our scores were among the worst in the country, what that meant for the ED and our patients and why improvement was necessary.”

Subsequent staff meetings focused on the negative culture in the ED—the lack of respect for co-workers, the excessive amount of time being spent complaining and gossiping—and how this negativity was affecting staff engagement and the patients’ perception of the care they were receiving. “We made it clear that we knew the staff was providing safe care with good outcomes, and that it was the bad attitudes and negative culture that were leading to poor patient perceptions,” said Bredimus.

Once the staff understood the effect that negativity was having in the ED, the focus shifted to identifying core values and working toward a culture of ownership. “A person’s core values define who that person is, and what that person stands for and won’t stand for,” explained Bredimus. To learn how to “identify and own their core values,” in early 2015 the staff attended a two-day class during which they learned the essential characteristics of a culture of ownership—Commitment, Engagement,Passion, Initiative, Stewardship, Belonging, Fellowship and Pride—and how these characteristics can contribute toward a more positive and productive work environment when they’re combined with the core action values of Authenticity, Integrity, Awareness, Courage, Perseverance, Faith, Purpose, Vision, Focus, Enthusiasm, Service and Leadership.

Led by staff members who were recruited to become certified values trainers, the class focused on the importance of living one’s values, the idea being that if employees can identify what they can do to better achieve their more authentic selves, they can improve their lives as well as the lives of those around them. “This is not about becoming a better employee; it’s about becoming a better person,” emphasized Bredimus, who himself is a certified values trainer. “A lot of that has to do with not focusing on the negative and what you can’t do, and instead focusing on the positive and what you can do.”

In addition to the culture of ownership and core action values class, several other strategies were employed to further cultivate an atmosphere of positivity in the ED. For example, training sessions were held in which staff members learned how to communicate better with patients and with one another, and how this can result in exponential improvements in the patient experience.

Also, staff members began a ritual of reciting at each shift change a Self-Empowerment Pledge that features a different promise for each day of the week. Tuesday’s promise, for example, is Accountability: “I will not allow low self-esteem, selflimiting beliefs or the negativity of others to prevent me from achieving my authentic goals and from becoming the person I am meant to be.” Hospital leadership also recite the day’s promise every morning when they gather in the main lobby for their leadership huddle.

The leadership team also began posting on a regular basis unedited patient feedback in the break room and patient experience scores on a bulletin board in the ED. In addition, they began sharing the scores and patient comments in an ED-only Facebook group so that the staff could see the positive effects of change and monitor their progress.

“Shifting the mindset from punishing failures to celebrating successes, and using that as an opportunity to improve even further, has changed people’s attitudes,” Bredimus said. “People especially enjoy celebrating successes on Facebook because they’re being celebrated in front of their peers. It’s one thing to receive a positive comment from a patient, but it’s another thing for your peers to read the comment, like it and share it.”

Sowing the Seeds of Empowerment

Instilling a culture of ownership among MMH’s ED staff continues to have a positive impact on patient experience and nurse engagement scores. “For July 2016 we were at the 94th percentile for patient experience, and on our 2016 NDNQI survey we scored above the mean in every category, reaching the 75th to 90th percentile in most domains,” said Bredimus.

Meanwhile, the staff’s perception of negativity in the workplace has decreased. In an internal survey conducted recently, 64% of respondents reported that their co-workers were more positive and more fully engaged than before the Values and Culture initiative was implemented and 87% reported that they themselves were more positive and engaged. “Communication also improved, with 93% of staff surveyed citing an improvement in overall communication,” said Bredimus.

In addition to improving their work lives, the Values and Culture initiative has also enriched the personal lives of numerous staff members. For instance, some employees went back to school and earned master’s or doctorate degrees. Others pulled themselves out of debt. A few employees shed a significant amount of weight. And one RN entered rehab and overcame a narcotics addiction.

“The whole idea is to strive to be the best version of you that you can be—to identify that version of you and overcome whatever it is that’s holding you back from being that person,” said Bredimus, whose own journey down the path of self improvement resulted in achieving a long-standing goal of learning to play cello.

Moving forward, Bredimus says the objective is to continue focusing on the positive and on nurturing a culture that encourages staff to take ownership of their actions. “My favorite saying is ‘Proceed until apprehended,’ which to me is about being empowered to take the initiative and get things done,” said Bredimus. “When you shift your mindset from fear of retribution to ownership of your actions, you’re more aware of how your values and your behavior affect your patients’ experience of their care. And you’re more likely to do the right thing as a result.”