Sibley Engages Staff in Transforming the Maternity Care Experience

Added on Feb 21, 2019

Sibley Breaks Down Communication Silos to Engage Staff in Transforming the Maternity Care Experience
By Audrey Doyle

Labor and delivery is just one stage among many in a woman’s childbirth journey. Ensuring safe, high-quality, patient-centered care across the maternity care continuum requires collaboration and coordination across multiple stakeholders. When patient experience scores at Sibley Memorial Hospital’s Women’s and Infants’ Services department (WIS) indicated that was not happening, leadership targeted the workforce communication barriers that were standing in the way, and the results they’ve achieved to date are impressive.

Since leaders began implementing an innovative staff training program consisting of communication and behavioral best practices designed to build relationships, prevent errors, and deliver a seamless continuum of care throughout the service line—from admission to discharge to at-home follow-up—WIS’s ranking on the patient experience survey has increased exponentially in nearly every domain. Most notable are the advancements the department has attained on the Overall Rating and Likelihood to Recommend survey items, which skyrocketed from the 1st and 16th percentiles, respectively, in 2016 to the 96th and 99th percentiles, respectively, in 2018. The department also experienced a statistically significant improvement in employee engagement and patient safety.

Identifying the Cause of Patient Dissatisfaction

A member of Johns Hopkins Medicine, Sibley Memorial Hospital is a 318-bed community hospital located in Washington, D.C. Sibley’s Women’s and Infants’ Services department includes the Labor and Delivery unit, Family Centered Care unit that provides postpartum and newborn care as well as lactation services, and Level II Special Care Nursery for newborns requiring advanced medical attention.

Although unit leaders and staff were delivering exceptional care, the department was nevertheless failing to meet patients’ care expectations. “Our 2015 survey had ranked us in the 3rd percentile for overall care. We thought, there’s no way we’ll drop lower than that. But when the next set of scores came out we were in the 1st percentile,” said Pauline Solomita, Special Care Nursery nurse manager. “We had to figure out what was happening at the unit level that was making patients dissatisfied with their overall experience.” 

According to Patricia Haresign, patient experience nurse specialist, nearly every unit in the hospital has its own Comprehensive Unit-based Safety Program (CUSP) team, composed of nurses, physicians, and other front-line caregivers, whose focus is to assure the safety, quality, and experience of care delivered on the unit. In 2015, each unit in WIS had its own CUSP team as well. However, leaders learned that because the three CUSP teams were meeting and working independent of each other, any effort, change, or best practice being implemented in one unit sometimes wasn’t implemented or was implemented slightly differently in the other units in the service line. 
In addition, ineffective communication between the units’ nursing teams was producing inconsistent messaging to patients, and any needs or concerns that patients relayed to their nurses in one unit weren’t always passed on to nurses in the other units. As a result, patients perceived the stages of their childbirth journey as being more disjointed than connected.

The insufficient standardization and coordination of care was causing patients stress and anxiety, reducing their trust in their caregivers, and leading to negative perceptions of their overall experience. And because, at an average of 800 survey responses per quarter WIS has the biggest n or sample size in the hospital, those negative perceptions were affecting Sibley’s overall patient experience ranking, which was potentially influencing prospective patients’ opinions of the quality of care provided there.

“It became clear that, while the units were delivering great care, they were working in silos,” Solomita said. “It was like they were competing with each other. They were caring for the same patients, but each unit was working on its own and there was no cross-communication.” The WIS leaders determined that to transform patients’ perceptions of their experience, they had to break down the silos that were preventing the staff from communicating, collaborating, and providing integrated care across the continuum of services, from labor and delivery, to postpartum/newborn care, to specialized neonatal care.

Breaking Down Silos with Five Star Behaviors

The leaders began by combining the three unit-based CUSP teams into one large WIS CUSP team that includes leaders and nurse champions from each unit, an executive champion, a physician, an anesthesiologist, a lactation consultant, and a patient and family advisor. They met regularly, and using staff input regarding potential areas of improvement, they developed “Five Star Behaviors,” a framework of behaviors for staff in all three units to practice to build closer relationships with patients while integrating them into the care process.

WIS’s nearly 250 employees began training in the Five Star Behaviors in the summer of 2015. Each behavior—courtesy, respect, caring, healing, and teamwork—is accompanied by tactics intended to create the foundation for a better care experience.

Among the courtesy tactics, for example, are knocking and pausing before entering a patient’s room, asking how the patient and family want to be addressed, and making eye contact with patients. “We also instruct staff to narrate the care they’re providing,” said Haresign. “What’s routine for us isn’t routine for our patients, so we explain what we’re doing, and why, to keep patients informed.”

A tactic demonstrating respect is the bedside shift report. Although this was already a best practice prior to the initiative, it wasn’t being done consistently. Including it in the framework hardwires the tactic to ensure compliance, said Haresign.

An example of a caring tactic is the implementation of “Caring Moments”: Every nurse at every shift sits at eye level with their patient and discovers something unique about them or what matters most to them. Nonclinical support staff share Caring Moments with patients as well. “We’ve made incredible connections with patients by getting to know them as individuals,” said Haresign.

According to Solomita, a comment that appeared frequently on surveys concerned patients’ inability to get uninterrupted rest while in the Family Centered Care unit. So, as a tactic for the healing behavior, the team made signs to hang on patients’ doors. One side of the sign says “Welcome to Family Centered Care”; the other side says “Request to Rest” and directs staff and visitors to stop by the nurses’ station before entering the patient’s room and unnecessarily interrupting their sleep.

Finally, an example of a teamwork tactic is a thank-you card that follows the patient along the continuum of services they receive in WIS. The patient’s nurses in each unit write a note on the card, and the patient receives the card at discharge. According to Jen Suess, nurse manager in Labor and Delivery, the thank-you card personalizes the care the patient received. “It also implies consistency in messaging and a seamless flow throughout the service line,” she said.

To ensure that the behaviors and messaging are sustainable and consistent, they’re hardwired into staff’s daily practice through constant communication—between the units, between nurses at patient handoff, and between nurses and patients. “For example, in Labor and Delivery we talk to patients about things they’ll experience when they move up to Family Centered Care, like the lactation services and the Request to Rest sign,” said Suess.

At the final stage of their childbirth journey, patients receive a follow-up call from a dedicated discharge nurse within 48 hours of discharge. The discharge nurse reiterates the messaging the patient received throughout her stay, reinforcing the integration of care across the continuum.

Sustaining Engagement

Although the WIS staff embraced the improvement initiative from the beginning, leaders acknowledge that, mid-journey, behaviors started to backslide. In September 2016, WIS moved to a new, larger, state-of-the-art tower on campus, resulting in exponential growth in patient volume. “With the growth came kinks in the process that we had to work out. The stress that went with that sometimes brought out bad or rude behaviors,” Haresign explained.

To resolve the issue, the team launched Courtesy and Respect training sessions. Managers selected staff to lead the sessions in role-playing scenarios illustrating bad behaviors they’d recently observed. “They discussed how it felt to them, how they thought the patient felt, and what could be done to improve, then conducted the scenarios with the Five Star Behaviors and talked about the improved outcomes,” said Solomita.

The sessions got the staff back on track and improved nurse communication, which has led to better connections with patients, according to Haresign. “We saw a big bump in our scores after that, particularly in the ‘Nurses treated me with courtesy and respect’ question, which went from 74.3 top box in July 2016 to 91.7 top box in September 2018, proving that how we treat each other impacts how we treat our patients and their perception of their care,” she said.

Over the past two years, the WIS team has greatly improved their ability to communicate and connect with patients and families. But there’s one survey question they still struggle with: “During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?”

“We ask patients about help at home, using consistent messaging, so many times during their stay. Nurses ask it; leaders ask it during rounds; the nurse asks it prior to discharge. Yet patients still say we didn’t discuss it with them, which is ranking us in the 13th to 16th percentile for this question,” Haresign said. So the team plans to accompany the verbal message with a nonverbal message that will remain with the patient throughout her stay: a line drawing of a house with space to identify who the patient said would be helping them at home.

“It’s a simple way to remind patients that the issue was discussed at each stage of their childbirth journey,” Haresign said.

“It’s also another way patients will get the sense that they received integrated care when they were with us,” she concluded. “We may be in different units, but we’re all on the same team and we all share the same goal: to make sure every family that chooses to deliver at Sibley has an exceptional experience.”