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A Framework for Improving Parent Satisfaction with the Inpatient Pediatric Admission Process
What was the opportunity, issue or challenge you were trying to address and in what setting?
Recently, there has been a considerable shift towards prioritizing patient experience during admission process as it is critical to improving clinical outcomes as well as patient satisfaction with health care services. Literature reporting parent experience regarding perceived quality of care in low middle income countries is limited. In August 2017, a baseline survey was conducted to assess factors related to parental stress on parents of 221 admitted patients at the Children’s Hospital, AKUH. Nearly 40% of them stated to be “extremely stressed” as they felt that they had not received adequate explanation regarding their child’s condition from the nurse or doctor. It appeared that although the current messages are part of standardized protocols at the hospital, lack of data monitoring and accountability of the staff regarding these led to the parent being stressed and unhappy with the admission process.
In light of this feedback, the purpose of this initiative was to implement a communication and accountability strategy to engage all relevant hospital staff with whom the family interacts during the child’s admission process, hence improving their satisfaction with the service quality and improving patient experience.
What process did you use to develop a solution?
The Theory of Change (TOC) model was developed by a team of Children’s Hospital employees (including 2 faculty, 1 resident, 2 nurse and 2 support staff) who volunteered to help improve patient experience. This team of 7 individuals met weekly for a period of 4-6 weeks (Dec 2017 – Jan 2018) to develop the TOC. This TOC included the assumptions behind developing this model (poor communication from staff and lack of monitoring of these messages), the goals, desired outcomes and a detailed implementation plan. Live dashboard for data monitoring and timely feedback was developed for accountability and continual improvement. This plan was presented to the service line leadership and finalized for execution.
What outcomes were you looking to achieve?
The objectives for this initiative were as follows:
- To reduce parental anxiety related to hospital admission by informing parents regarding their child’s management plan within the 1st hour of arrival at the Children’s Hospital inpatient unit
- Informing the parents regarding basic amenities available for the child and the parent at the Children’s Hospital
What specific steps did you take to address the problem?
The lead team which included representatives from each cadre (i.e support staff, nurses, residents and faculty), finalized the messages that needed to be focused upon by each cadre during this initiative. The messages which were based on our prior experience, focused on the child’s current medical condition as well as the inpatient ward environment. All messages were to be delivered within the first hour of admission to the inpatient unit so as to address the anxiety of the family. The messages were pilot tested for 2 weeks in Feb 2018 on 20 beds in the general pediatric ward at the Children’s Hospital using the survey form.
Once the messages were finalized, detailed trainings of 250 administrative, nursing and medical staff involved with pediatric inpatient admissions at our hospital were conducted. These trainings were organized on a weekly basis for 30-60 minutes for each cadre and were conducted by the lead team. Several learning mediums such as role plays and short videos depicting the delivery of these messages were created for each cadre. These trainings focused on the messages along with a strong emphasis on the communication style during these interactions. Three of the six International Patient Safety Goals namely correct patient identification, effective communication and fall prevention were specifically addressed in these messages.
To ensure delivery of these messages, a detailed monitoring and evaluation plan was designed with a live dashboard to track the indicators and weekly reports sent to the team leaders of each cadre for targeted intervention on the information that lagged behind. A supervisory checklist was also created to help the team leaders objectively monitor the staff and mentor them for skills improvement.
The figure below describes the intervention package that was developed to train the staff who interacts with families during the admission process along with its accountability plan.
What resources, if any, did you engage – either internally or externally – to address the problem?
These were conducted by the lead team. Role plays and smartphone based videos were developed by the team demonstrating the communication style for the messages to be delivered. Verbal and structured written feedback obtained from the trainings was used to improvise subsequent sessions. These were conducted between Feb – May 2018.
Execution and Accountability
A dedicated staff was hired to collect the data on a smart phone based application which synced to a service management dashboard. Baseline data was collected between March-May 2018 while post-intervention data was collected from June 2018. The application and dashboard was developed and managed by an internal data team.
What measures did you establish to determine the success of this effort?
To ensure fidelity of the implementation, a detailed monitoring and evaluation plan was also laid down. Daily surveys were conducted with all parents of children who were admitted to the Children’s Hospital inpatient unit in the past 24 hours. The app-based survey asked questions related to the informational messages provided by each cadre and were finalized after the pilot testing in February 2018. These were related to communication with the team physician regarding child’s current condition and further management plan, key indicators regarding admission process, visitors policy, basic amenities such as child and attendant meals, and patient safety and comfort messages (use of call bell and side rails). The parent was asked by the data collector regarding provision of the information in their first 24 hours of admission.
The information was asked in the local language and answer choices included “yes, no, maybe, don’t know or not applicable”. A response of “yes” scored 4 while “no” scored a 0. Once completed and synced, an overall satisfaction score was generated. If the total score on this survey was less than 50%, the concerned bed was highlighted in red color on the dashboard for quick feedback to the service management to intervene immediately.
Children's Hospital Admission Dashboard
Parents were asked to rate their anxiety level on a scale of 1 to 5 at admission and 24 hours post admission. Although this crude way of measuring stress has its limitations, yet it is useful and most feasible to obtain in settings such as ours.
Besides the daily feedback, a weekly cumulative data sheet for these messages was circulated to the relevant supervisors to reinforce compliance to the intervention.
What was the ultimate outcome of your effort?
Baseline data was collected on 202 parents while post intervention data has been collected on 877 parents whose child was admitted to the Children’s Hospital at AKUH. The details of each indicator are shown in table 1 below. Most of the indicators showed a significant improvement in the information provided by
Comparison of Admission Indicators at Baseline and 6 Months Post Intervention
The overall satisfaction with the admission process also showed a significant improvement (from 60 to 84%) over the 6 months of intervention. Further, a reduction in patient anxiety score within 24 hours of admission (from 4.6 to 1.5 points) was also observed during this period. Parents reported that they felt at ease after 24 hours of admission as compared to the stay in the emergency room.
What lessons did you learn you would share with others as they consider addressing a similar issue?
This initiative highlighted that reengineering the current system using existing resources to improve communication between staff and parents regarding their child’s medical condition and the surroundings with an adequate accountability and governance strategy can help reduce parental anxiety, thus improving satisfaction with the health care system and overall patient experience.
About The Aga Khan University Hospital
The Aga Khan University Hospital (AKUH) is a private, not for profit, university hospital, focusing on the delivery of the highest quality health care in Pakistan since 1985. It is the only Joint Commission International (JCIA) accredited academic medical center in Pakistan, serving as the teaching hospital for highly skilled doctors, nurses, and midwives in the country.
The AKUH operates on the core principles of Quality of care that has Relevance to the community for the maximum Impact and Access to all. One of its many missions is to strive for excellence in healthcare through the provision of the highest quality, expert, compassionate and ethical care to all patients irrespective of their background. The 13 service lines operating at AKUH work towards this mission by offering multi-disciplinary care to its patients.
The Children’s Hospital at AKUH is the largest service line. With 120 beds, it strives to cater to the most complex pediatric patients < 18 years age, requiring multiple specialties. The spectrum of care spans managing 26 weeks premature babies to adults with congenital heart disease.
Case Study Authored by: Dr. Zahra Hoodbhoy, Senior Instructor, Research, Department of Paediatrics and Child Health