Nursing and Ancillary Services Partner to Improve Care at Community Hospitals

Added on Apr 18, 2019

Nursing and Ancillary Services Working in Partnership Improve Care at Community Hospitals
By Andrea Fitzgerald

Meaningful collaboration between nursing and ancillary services is critical to the delivery of high-quality, efficient care. Recognizing this, an increasing number of community hospitals are nurturing partnerships among these providers to advance their journeys to patient-centered excellence.

Inova Fair Oaks Hospital (IFOH) in Virginia and WellStar Cobb Hospital in Georgia are among the facilities empowering nurses and ancillary staff to work together to drive sustainable improvement efforts. According to Deborah Fulbrook, IFOH’s chief nursing executive; Tammy Razmic, IFOH’s chief operating and financial officer; and Yona Roberts, Cobb Hospital’s clinical pharmacy manager, nurses working in partnership with pharmacy, environmental services, food services, and other ancillary services can deliver exceptional care experiences that reduce patient suffering.

This may seem intuitive. Ancillary providers influence patients’ perceptions of room cleanliness, care coordination, overall service quality, and more. However, because these providers are considered to be indirectly related to patient care, much of their potential to positively influence the patient experience has been unrealized.

Recognizing that every provider plays a role in the delivery of integrated care, both IFOH and Cobb Hospital include front-line nurses and support staff in the development and execution of performance improvement programs. By using a team-based approach to standardize workflows at and beyond the bedside, both organizations have raised their top-box scores for Likelihood to Recommend and Communication about Medication (CAM), among other HCAHPS domains.

Clinical and Nonclinical Providers Reduce Patient Suffering

In 2015 and 2016, respectively, nursing and ancillary services leaders at IFOH and Cobb Hospital formed interdisciplinary teams to better meet their needs as well as the needs of their patients. The goal at IFOH was to identify and remove barriers to providing a safe, clean, and patient-centered environment, whereas Cobb Hospital aimed to standardize a process for consistently and effectively communicating with patients about new medications and possible side effects.

Both organizations sought to support and inspire nursing and ancillary services to carry out their shared mission of improving the health and well-being of the patients they serve. Doing so required that nurses and ancillary services employees understand and appreciate their own role and the role of others in advancing their organizations’ missions. “Nurses can’t reduce patient suffering without ancillary partners any more than ancillary partners can without nurses,” said Fulbrook.

To demonstrate the importance of this partnership, IFOH redefined nursing as the internal customer of support services, and support services renamed themselves ancillary partners. “It was important to demonstrate that the work of ancillary partners directly impacts nurses’ ability to care for patients. We know that if a nurse has to search for a Foley catheter that is missing from its shelf, it is the patient that suffers most,” said Razmic, who leads the Support Services division at IFOH.

Fulbrook and Razmic began holding monthly combined operational meetings to identify and address ongoing issues and monitor the progress of improvement initiatives. This organizational restructuring has helped align ancillary operations to the needs and values of both patients and nurses, according to Razmic. For example, when housekeeping-related issues were identified as a barrier to consistent, purposeful rounding on the medical unit, environmental services partnered with nursing to create process improvement steps. Using a high-level process map to demonstrate the far-reaching implications of a clean and well-stocked room, the pair showed that ensuring every patient is supplied with pillows, sheets, and toilet paper is about more than providing the basics of a positive patient experience. It is about removing distractions from nurses’ focus on clinical care functions to enable them to complete their hourly rounding.

To engage and empower providers on the front line, IFOH implemented a visual management system. Across the hospital, boards display lagging and leading indicators (monthly HCAHPS scores and daily key performance indicators, respectively) to align performance with the organization’s strategic imperatives and highlight the synergy among each unit’s goals. “These displays reinforce that a win for the inpatient unit is also a win for environmental services, pharmacy, dietary, and others,” said Fulbrook.

In 2016, Cobb Hospital also turned its focus to cultural alignment. With disparate processes and team members in place to explain medication plans to patients, the hospital was struggling to move the needle in the HCAHPS CAM domain. “As a pharmacist, I was committed to providing better education to our patients. I knew we could do it, but not by ourselves,” said Roberts.

Partnering with the CNO and Lucy Leclerc, executive director of Nursing Professional Practice, Roberts convened front-line nurses, clinical nurse leaders, unit-based pharmacists, patient experience leaders, and clinical informatics specialists to design a standardized medication education process. Their goal was to make it easier for nurses to effectively communicate with their patients, not simply to add another item to their workload, according to Roberts. Together the team designed and developed CAM cards, which use emojis to represent a medication’s most common side effects. Collateral to support this educational tool was also developed, including an EMR alert to inform nurses when their patients are prescribed a new medication.

By offering a visual tool to patients, nurses create a memory marker to help patients understand and adhere to their medication plans after they leave the hospital and to resolve some challenges associated with language, literacy, and sensory deficits that can hamper education efforts, according to Leclerc.

At both organizations, these visual education pieces are incorporated into the rounding process to reinforce accountability and provide a real-time feedback loop. At IFOH, visual management boards are a site of real-time coaching during leader rounds and daily huddles. At Cobb Hospital, nurse managers audit patients’ discharge folders when rounding to verify that CAM cards have been reviewed and placed in the folder and to check whether the patient or family has any additional questions. According to Fulbrook and Roberts, rounding is an unparalleled opportunity to provide additional coaching to individuals, gather real-time feedback, and nurture relationships within and across departments.

“All of our efforts—from rounding to restructuring—have been focused on bridging the gaps between nursing and ancillary services to ensure that our patients receive the best care at every stage of their journey,” added Fulbrook. 

Advancing the Pursuit of Performance Excellence

Working together, IFOH’s nurses and ancillary partners have standardized workflows across the continuum to reduce material and medication stock-outs and late food trays. As a result, IFOH’s ranking has increased dramatically in nearly every domain. In 2014, only the HCAHPS domains of Care Transitions and Likelihood to Recommend ranked above the 75th percentile. In 2017, six additional domains—Nurse Communication, Physician Communication, Staff Responsiveness, Communication about Medication, Communication about Pain, and Overall Rating—rose above that benchmark. These gains were sustained in 2018.

Performance on the Communication about Medication item has also improved substantially at Cobb Hospital, including two units that rose from the 1st percentile to the 78th and 89th, respectively.

Though these efforts have led to dramatic improvements in their HCAHPS scores, each hospital is driven not by metrics, but by a shared vision of patient centricity. “Realigning the organizational structure strengthened our ability to deliver exceptional care across the continuum. Everyone from greeters to registration to preoperative staff feels empowered to improve the patient experience,” said Fulbrook. Razmic also emphasized the professional growth of ancillary partners that has been prompted by IFOH’s dyad model.

“Considering any member of the workforce to be ‘behind the scenes’ is limiting their ability to drive improvements in patient experience, safety, and quality,” added Roberts. “That is why we encourage our nurses and pharmacists to help reduce the costs, ED visits, hospitalizations, and deaths associated with medication nonadherence and errors from the front line of care.”