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Case Studies provide real stories of current efforts, including programs being initiated, practices being implemented, and outcomes being targeted and/or achieved. Case studies are presented as both an opportunity for learning from others as well as a spark for further ideas on how we work to improve the patient experience. If you have a case study to share please contact us
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Improving Patient Experience by Focusing on “Always” and “Never” Behavior and Language
What was the opportunity, issue or challenge you were trying to address and in what setting?
Long Island Jewish Valley Stream (LIJVS) is one of 23 hospitals within Northwell Health, the largest integrated health system in New York State. In 2015, Northwell began a cultural transformation by instituting the Culture of C.A.R.E. framework. Our promise to patients and customers, the Culture of C.A.R.E. is grounded in core tenants of Connectedness, Awareness, Respect and Empathy. Despite widespread Culture of C.A.R.E. education, the dedicated healthcare professionals at LIJVS delivered exceptional quality but struggled with achieving patient experience excellence, consistently ranking within the bottom quartile.
What process did you use to develop a solution?
With an increased focus on transparency, patients and families are armed with a wealth of information to help guide their provider-of-choice decision making process. Although delivering world-class service was a steadfast priority, the team realized the importance of delivering compassionate and humanistic care. Listening to the patient’s “voice" revealed opportunities regarding patient-centered communication, addressing concerns and expressing empathy. Baseline observations and a gap analysis confirmed deep-rooted deficits in staff professionalism and knowledge regarding patient experience basics. With patients and families as our “North Star,” we focused on developing a foundational program to address the familial communication style of our staff with patients, families, and each other.
What outcomes were you looking to achieve?
An overarching goal was to build professional awareness and enhance teamwork. By engaging leaders and teams, the program was intended to enhance publically reported Star Ratings by improving outcomes within patient experience communication domains.
What specific steps did you take to address the problem?
In 2017, LIJVS had a change in senior leadership beginning with a new Executive Director (CEO). He thereafter brought on a Director of Patient and Family Experience, known as the Culture Leader. To obtain a baseline cultural analysis, the Culture Leader systematically performed a series of observational assessments over a period of three months across all shifts. One significant observation included a staff member telling a patient that “we were understaffed” as an apology for the delay in call bell responsiveness. Another staff member politely stated she “was on break” when a family member asked for way finding assistance. These observations revealed a vital need to build awareness on how team members choose the words and sentiments they routinely use and how they are expressed verbally and nonverbally.
At the core, we realized the need to educate and develop patient-centered communication skills through promoting a culture of professionalism.
From gap analysis observations, a comprehensive list of “Never” words, phrases, and behaviors was generated – those that needed to be removed from our organization’s vocabulary and cultural norms. This list was introduced to frontline staff members and physicians at staff meetings and huddles. Through candid conversation, it became clear that the “Never” list was relatable with many commenting, “I’ve said that,” or “I do that sometimes.” During this early stage in the development of the program, the interdisciplinary teams inquired what they should say and do in place of the “Never” phrases and behaviors. This prompted them to develop an “Always” list and educational sessions began shortly thereafter.
Every session was presented by the Culture Leader beginning with the hospital’s Executive Director, followed by all Senior Leadership, Directors, Managers, and Supervisors. Leadership drives patient experience and thus engaging the leadership team was a critical first step in our change management process. Once leadership was onboard, the “Never / Always” sessions were delivered to physicians and clinical teams on the patient care units during huddles and staff meetings, and ultimately customized for each non-clinical, support services departments. As an example, the Respiratory Department requested a peer to peer “Never/Always” statement to be included, such as, “Why didn’t you do the ABG?” were rephrased to state, “I see this ABG wasn’t completed. Was there a delay for some reason?” Consistent feedback was provided and the “Never / Always” lists were continuously updated based on staff requests, such as the “Never” phrase, “I didn’t know you were coming,” in response to a patient arrival on a patient care unit.
Teams then suggested a laminated index card with the “Never/Always” information on it for peer-to-peer accountability - placing the card in a colleague’s pocket or on their workstation as a reminder to maintain professionalism. The Culture Leader presents a “Never / Always” reminder at monthly leadership meetings and continues to attend huddles and staff meetings regularly as part of a robust sustainment plan. The “Never/Always” program signifies how every role, every person and every moment is a moment of truth between patients, families and healthcare professionals and how language and behavior makes meaningful and lasting impressions. Hospital leadership role modeled and supported the program by scheduling team huddles and staff meetings throughout implementation and sustainment phases. Most importantly, physicians, clinical and non-clinical teams who contributed constructive feedback and ensure self and peer accountability.
What resources, if any, did you engage – either internally or externally – to address the problem?
Throughout this process, we relied on internal resources by means of observations and open forum discussions with leaders and teams. Utilizing our existing shared governance model, we were able to gain frontline team member feedback and insight, disseminate education and knowledge and empower teams along the cultural transformation. Creating the collateral required a collaboration with internal Marketing colleagues. Due to our success, in partnership with the system Office of Patient & Customer Experience, this program will be expanded across the Northwell Health organization in 2019.
What measures did you establish to determine the success of this effort?
We chose the following HCAHPS domains and patient experience questions to measure our effort’s success:
- HCAHPS: Communication with Doctors Domain
- HCAHPS: Communication with Nurses Domain
- HCAHPS: Responsiveness of Hospital Staff Domain
- HCAHPS: Discharge Information Domain
- HCAHPS: Care Transitions Domain
- Patient Experience Question: Response to Concerns/Complaints
- Patient Experience Question: Staff Worked Together to Care for You
What was the ultimate outcome of your effort?
Focusing on behavior and language that expresses connectedness, awareness, respect and empathy led to significant outcomes. Comparing 2017 YTD to August 2018 YTD, Communication with Doctors improved by 34 percentile points, Communication with Nurses improved by 17 percentile points, Responsiveness of Hospital Staff improved by 30 percentile points, Care Transitions increased by 24 percentile points and Discharge Instructions increased by 13 percentile points. Additional patient experience survey questions also had improvements: Response to Concerns/Complaints increased 20 percentile points and Staff Worked Together to Care for You increased 14 percentile points within the same timeframe. Our program has been presented at national patient experience conferences as an engagement and experience best practice. Lastly, since much of this work has been grounded in collaboration and grass-roots change management, we intend to measure employee engagement at the end of the year. We believe engagement scores will mirror the patient experience trajectory given both are highly correlated.
What lessons did you learn you would share with others as they consider addressing a similar issue?
By performing an observational assessment, we clearly identified high-impact opportunities for professionalism and patient-centered communication. Engaging the interdisciplinary team in developing the “Never/Always” words and having leaders embrace and role model that change, was critical to the success of our cultural shift. Also, we learned that simple is best by streamlining concepts so that expectations are clear and achievable. Every role, every person, every moment matters.
About Long Island Jewish Valley Stream
Long Island Jewish (LIJ) Valley Stream is a 284 licensed-bed, full-service community hospital caring for patients in Nassau County and southeastern Queens, New York. As part of the Northwell Health system, LIJ Valley Stream is a hospital of choice for comprehensive orthopedic care delivered by highly skilled experts who specialize in all fields of general orthopedic care and surgery. LIJ Valley Stream is also a designated stroke center certified by the American Heart Association and is affiliated with the Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell.
Northwell Health is a dynamic organization of 23 hospitals, and more than 700 physician practice locations spanning geographically from Westchester County to New York City and across Long Island. With 63,500+ employees, Northwell is the largest private employer in New York State, caring for more than 4 million individuals each year. Our mission statement, is “to improve the health and quality of the life for the people and communities we serve by providing world-class service and patient-centered care.”
Case Study Authored by:
Michelle Rossetti, MSN, FNP-BC, RN, CPXP, Director, Patient & Family Experience, Long Island Jewish Valley Stream Hospital
Sven Gierlinger, Chief Experience Officer, Northwell Health
Nicole Giammarinaro, MSN, RN, CPXP, Director, Education & Research, Northwell Health Office of Patient & Customer Experience