Pennsylvania Hospital’s Bedside Bundle Improves Relationship-Based Care

Added on Jan 19, 2017

Pennsylvania Hospital’s Bedside Bundle Improves Relationship-Based Care
By Erin Graham
Industry Edge January 2017

Chief Nursing Officer Mary Del Guidice and her team at Pennsylvania Hospital knew a significant culture change needed to happen for the organization to achieve the high standard of patient care excellence to which it aspired.

In 2012, the nursing team at the facility, a teaching hospital within the University of Pennsylvania Health System, was struggling with its patient experience scores, particularly around nurse communication.

“Although relationship-based care is our Nursing Professional Practice Model, our patient experience measures were below the national mean,” Del Guidice said. “The problem with patient experience wasn’t about the level of care our team felt we delivered to our patients, it was how we showed our patients that we cared.”

Relationship-based care is a patient-centered care model designed to ensure that patients’ interests and needs always come first.

Results of the hospital’s nursing satisfaction surveys indicated that the nurses perceived they were providing individualized, inclusive and patient-centered care. “So the nurses were shocked to learn that the housewide scores for nurse communication were consistently below the 50th percentile, as this was incongruent with their perceptions of care,” Del Guidice said. “I knew how much nurses loved their patients, but they weren’t delivering care to them in the way that patients needed.”

Further, the nurse communication scores were incredibly inconsistent, bouncing up and down from below the 10th percentile to slightly above the 40th percentile in the three years prior to the intervention. “In our minds, this was a signal that we were not pulling in the same direction and needed a more focused approach,” Del Guidice said.

Armed with nurse engagement and patient experience metrics, Del Guidice set out to find an innovative way to bridge the gap and give nurses the tools they needed to embody relationship-based care in their daily practice. She was confident that the nursing staff was ready to receive this work and that they would rise to the challenge of developing a cohesive vision and implementation plan for improvement. Nursing leadership set a lofty goal: Define a structure that would support relationship-based care in nursing practice and improve patient experience and nurse-sensitive indicators.

To create this structure Del Guidice harnessed the creative energy of nurses from around the hospital, purposefully avoiding a top-down approach, knowing that the solutions would more likely take hold if they were organic. “Nurses wanted our scores to match how they felt about patients, so it was about lifting them up so that they could take ownership and be proud of the care they provide,” she said.

At an all-nurse retreat in early 2013, nurses developed the acronym HEART to define their nursing practice: Holistic, Evidence-based practice and research, Advocates, Resourcefulness and Teamwork. From that point on, HEART became the foundation of the journey in redesigning the care delivery system.

In 2014, under Del Guidice’s guidance, a new care delivery team set about reimagining the care delivery system, starting with researching which interventions strongly affect patient experience.

Utilizing resources and literature on bedside reporting best practices, the care delivery team developed a change-of-shift bundle to be used consistently across all practice areas that involved nursing, which meant that nurses in every part of the hospital would be pulling in the same direction to help move the needle. Called the HEART bundle, it includes a safety huddle led by the charge nurse, standardized bedside report, and patient mutual goal setting.

Implemented via a Plan-Do-Study-Act (PDSA) cycle that involved continuous improvements to the process based on clinical nurse feedback, the bundle was initially employed in the medical-surgical and critical care units, followed by the specialty units, including the emergency department, women’s health division, behavioral health and perioperative services.

The use of bundles in improvement initiatives has gained traction as a powerful tool to connect several established best practices. The Institute for Healthcare Improvement developed the method as a structured way of improving care processes and patient outcomes. Traditionally, a bundle brings together three to five simple sets of interventions that, when performed together consistently, are proven to improve patient outcomes.

While the care delivery team placed equal importance on each element of the bundle, the new bedside reporting and patient-concern processes have had the most profound effect in fostering immediate nurse-patient bonds. Nurses now conduct the bedside report in patients’ rooms and involve the patient in the conversation. Each day, nurses invite their patients to share their concern of the day, which is then written on the whiteboard in the room. More often than not, this concern is unrelated to getting better.

“It serves as a cue for any staff person who enters the room to say, for example, ‘I see you’re most worried your dog is home alone; is that taken care of?’” Del Guidice said. “Patients’ concerns are usually personal, so sharing them serves as a way to naturally connect.”

For example, one patient told her nurse that her biggest worry was not being able to get a present for her granddaughter’s birthday. The nurse picked up the present for her so that she had it when her grandchild came to visit, Del Guidice said.

In another instance, a long-term patient told his nurse his concern was not being able to see the snow fall from his bed. Rather than wheel him to the window, Del Guidice explained, his nurse got permission from his doctor to take him outside so that he could feel the snow. “You would have thought he won the lottery, he was so thrilled!” she said.

Implementing the HEART bundle was methodical and time-consuming. “We had to take our time in order to really make this stick and for it to become part of the fabric of who we are,” Del Guidice explained, noting that it took 14 months to tailor the approach to each unit’s patient population—a process that carefully integrated clinical nurses’ feedback into its development.

Training on the bundled approach was done in small groups of no more than 15. More than skill building, the training was designed to help nurses acclimate to a major culture change, moving from giving reports to a colleague alone at a desk to having a discussion in a patient’s room and involving the family in it.

“It wasn’t just one more box to check or yet another initiative. It was fundamental to the way we practice, and how we take care of our patients,” Del Guidice said.

The bundled change-of-shift nursing protocol has enhanced the patient experience of care through improved nurse engagement and nurse communication. There was a notable improvement across patient experience scores, especially in the area of Communication with Nurses, according to Del Guidice. “In the three years prior [to the HEART bundle implementation], we had four quarters below the 20th percentile, three between the 20th and 30th and just three above the 30th for this item,” she said. “Since this work, not only has our performance improved [to slightly above the 80th percentile rank on that item], our improvement has been consistent and sustained, reflecting the shift in culture.”

Also, the hospital recently got results from its nursing satisfaction survey, and it scored above the benchmark in every domain compared to the national database. “We’ve always had wonderful nurses with tremendous heart,” Del Guidice said. “This is a vehicle for them to show it.”

Perhaps the most telling testament to the value of the bundled approach can be seen in the comments shared by patients and nurses themselves in the patient experience and nurse satisfaction surveys. Patients frequently comment that they were comforted by their nurses’ interest in their circumstances and appreciated being made to feel involved in their care plan, according to Del Guidice.

For the nurses’ part, they believe that collaborating during transitions of care improved patient safety, as it provided an opportunity to catch potential errors. They also feel that connecting with patients about their concerns allows an important opportunity for them to advocate for their patients more meaningfully, Del Guidice said. The following comment was especially rewarding, she said, as it validated the effectiveness of the improvement effort: “As a new nurse, bedside report and the HEART bundle is just the way we do things. It is the culture.”