Patient and Family Advisor Rounding Contributes to Reduction in Falls and to Better Performance on Key Patient Experience Metrics
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Funding Sources
Health Central Hospital
Developers
Health Central Hospital
Snapshot
Summary
Volunteer patient and family advisors at Health Central Hospital regularly observe key touchpoints between clinical staff and patients/family members and independently conduct rounds on patients in the hospital and emergency department. They look for ways to improve staff/clinician interactions with patients, elicit honest feedback from the patient about the care experience, and make visual observations to identify potential opportunities for improvement. The goal is to identify and address the immediate needs of current patients and collect information to guide long-term policy and service delivery changes that will help future patients. The program has directly or indirectly led to improvements in performance on various safety and patient experience metrics, including falls, staff concern for privacy, keeping patients well informed, and communication related to discharge planning.
Date First Implemented
2014
Patient and family advisors began observing and reporting on high-priority touchpoints in 2014; they began conducting independent rounds in 2015.
Problem Addressed
Traditional patient rounds conducted by hospital-based staff and clinicians may not identify information that can be useful in improving the care experience for current and future patients. Patients often feel uncomfortable disclosing information (particularly complaints) to those affiliated with the hospital, and time-pressed clinicians and staff may find it difficult to understand or relate to the patient experience.
- Lack of comfort disclosing information to staff: Patients and families are often uncomfortable disclosing information and voicing concerns to clinical staff, particularly physicians. Some patients may feel it is inappropriate to complain and may even fear that doing so will negatively affect how they are treated during the rest of their inpatient stay. For their part, time-pressed physicians and staff may send out nonverbal cues that they are too busy to listen or pay attention to patient and family member concerns
- Inability to see patient perspective: Hospital-based staff and physicians may not always understand or relate to the experience of a patient or family member and might not be able to identify opportunities to improve that experience.
- Unrealized potential of patient and family advisors (PFAs): As former patients (or family members of former patients), PFAs understand how to listen and relate to current patients and hence can be effective in identifying and addressing patient-specific and systemic issues where the hospital may be underperforming.
Description of the Innovative Activity
Volunteer PFAs regularly observe key touchpoints between clinical staff and patients/family members and independently conduct rounds on patients in the hospital and emergency department (ED). During these activities, PFAs look for ways to improve staff/clinician interactions with patients, elicit honest feedback about the care experience, and make visual observations to identify potential opportunities for improvement. The goal is to identify and address the immediate needs of current patients and collect information to guide long-term policy and service delivery changes to help future patients. Key program components are detailed below:
- Scheduling: Each week, volunteer PFAs who serve on the hospital’s Patient and Family Advisory Council (PFAC) inform the program coordinator (a patient advocate employed by the hospital) of their availability to conduct observational and independent rounds. While schedules vary, each PFA typically comes to the hospital at least several times a week, although some of this work involves other PFAC activities (e.g., committee or task force meetings). Some PFAs also come in during evening hours. During the most recent complete fiscal year (October 2014 through September 2015), PFAs in aggregate spent 667 hours conducting rounds on 4,177 patients.
- Logistics: The program coordinator tells the relevant unit directors which PFAs will be observing or conducting rounds that day and when they will be there. After arriving, PFAs usually meet briefly with the unit supervisor to find out if they should seek out or avoid any particular patients because of specific issues. PFAs do not wear any special clothing but have a badge that informs people of their role on the unit.
- Two types of rounds: PFAs conduct two distinct types of rounds—observational rounds for high-priority touchpoints between staff and patient/family members and independent rounds to elicit honest feedback from patients and family members. Each type of round is discussed in more detail below:
- Observations of key inpatient touchpoints: PFAs regularly observe the degree to which hospital-based staff and clinicians adhere to established standard processes during bedside change-of-shift reports (between the outgoing and incoming nurse) and purposeful hourly rounds conducted by nurses and technicians to maintain a safe environment and address immediate issues, such as pain, need to use the bathroom, and need to be repositioned. The PFAs also periodically observe staff communications with patients related to discharge planning. As part of these observations, PFAs also visually scan the environment to identify opportunities for improvement, such as lack of clarity or completeness of information on the patient white board and potential hazards that could lead to a fall.
- Independent rounds to elicit honest feedback: PFAs regularly conduct rounds on their own, talking to patients and family members on inpatient units and in the ED as independent, objective outsiders who understand the patient/family perspective due to their own experience as former patients or family members of former patients. During these rounds, the PFAs emphasize their independence from the hospital and ask for honest feedback, assuring patients and family members that such feedback will not have negative repercussions on the rest of their stay. PFAs ask about perceptions of the care the patients are receiving, with a particular emphasis on the quality of communication with hospital-based staff and clinicians. In the ED, questions focus on perceptions of the registration process, waiting times, staff friendliness, quality of communications, and other issues. As with the observational rounds, PFAs also visually observe the environment to identify potential opportunities for improvement. In the inpatient areas, patients often receive multiple visits from PFAs (often the same PFA) during the course of their stay. In the ED, patients generally receive only one visit.
- Real-time PFA interventions to educate patients and address immediate needs: As appropriate, the PFA will take action during rounds to educate patients and family members and to address immediate needs. For example, the PFA might talk to the patient or a family member about the importance of writing down any questions they may have for the doctors, nurses, or discharge-planning staff. In some cases, the PFAs will strongly encourage the patient to follow up with his or her nurse prior to discharge and on the day of discharge to make sure the patient receives additional education and materials. PFAs are trained to identify issues that can cause potential falls and inform the nurse and other clinical staff immediately about them. The PFA might also inform care-team members about other easily fixed issues, such as asking a physician or nurse to revisit a patient who has a question or alerting the care team to a family member’s concern about communicating appropriately with a hard-of-hearing patient or the need to update information on the patient white board. In the ED, PFAs often offer “concierge-like” services to help improve the experience during long waits, such as talking to patients/family members, bringing in snacks or blankets, or getting updates for patients about what will be happening next or when an inpatient bed will be ready for those waiting to be admitted.
- PFA feedback: At the end of each shift, the PFAs complete a written report that is given to the unit secretary. The reports highlight key trends identified during the day’s observational and independent rounds, including any patient-specific improvement opportunities that the PFA could not address (so that staff can do so). The program coordinator routinely reviews these daily reports and each month produces a summary that highlights key trends and issues identified by the PFAs. As part of this work, the coordinator compares these key trends to common themes that emerge from the comments section of the Press-Ganey patient satisfaction survey used by the hospital. The hospital president, board members, chief medical officer, chief nursing officer, and other leaders routinely use the monthly report to identify and prioritize key improvement opportunities. The PFAC as a group and individual PFAs often participate in these efforts and in some cases play leading roles in planning and executing new initiatives.
Context of the Innovation
Part of Orlando Health (a not-for-profit health system in central Florida), Health Central is a 171-bed community hospital located in Ocoee, FL, that offers comprehensive inpatient services. Health Central employs approximately 1,500 staff, and more than 500 doctors with admitting privileges regularly work in the hospital.
The impetus for the PFA rounding program came from Health Central’s PFAC, which has been in place for many years. The PFAC works on an ongoing basis with hospital leadership to improve the patient experience. Several years ago, these leaders were not satisfied with the pace of such improvement. At the time, the hospital had a robust rounding process in place for the leadership team, with charge nurses, supervisors, and directors regularly conducting rounds with patients and family members. Yet these activities seldom brought to light any significant issues, with the vast majority of rounding reports suggesting that virtually every patient was happy and highly satisfied. Skeptical that the current rounding system was uncovering the full story, PFAC and hospital leaders began exploring the idea of adding PFAs to the rounding process, believing that having someone independent of the hospital who understands the patient experience could be quite effective in getting patients to open up about issues they are facing and in identifying issues that clinicians and staff may miss.
Results
The program has directly or indirectly led to improvements in performance on various safety and patient experience metrics identified by the PFAs as systemic issues, including falls, staff concern for patient privacy, keeping patients well informed, and communication related to discharge planning. The program also led to a change in ED policy to allow bereaved family members to be with loved ones who are dying.
- Fewer falls: PFA feedback from their observations has helped to remove obvious fall hazards and to “hardwire” staff behaviors related to falls during hourly rounding, encouraging them to focus on any risks that patients may face. In addition, PFAs who regularly conduct rounds actively participate on a falls reduction task force that has come up with creative ways to reduce risk factors that lead to falls. These activities have contributed to a 40-percent reduction in patient falls between fiscal year 2014 and 2016. [These figures compare fiscal year-to-date (YTD) falls between October and March of each year.]
- Greater staff concern for privacy: During rounds, PFAs often heard from patients in semiprivate rooms who were concerned about staff respect for their privacy. In response, PFAs assisted in developing an etiquette flyer that lays out certain expectations for staff and patients. As a result of these efforts, the percentage of patients giving “top-box” scores related to staff concern for privacy increased markedly, from 87.4 in calendar year 2014 to 88.7 YTD in 2016.
- Keeping patients better informed: During rounds, PFAs consistently heard from patients on the medical-surgical unit that they did not feel adequately informed about their care plan. For example, patients frequently voiced concerns about not knowing when a test or procedure was scheduled to occur and what time they needed to stop eating solid foods. PFAs highlighted these concerns to staff, and unit leaders worked with the PFAC and others to put in place structured processes and protocols related to keeping patients informed and engaged. Since this time, top-box scores on survey questions related to nurses keeping patients informed have risen significantly, from 86.2 in calendar year 2014 to 88.6 YTD in 2016.
- Better information about discharge: During rounds, PFAs frequently heard that patients felt inundated with paperwork related to the discharge process and that no one sat down with them to explain the information. In addition, they frequently observed issues with nurse–patient communication related to discharge planning and provided feedback on the issues. PFAs also played a key role in writing new text and designing new materials intended to make discharge-related information more clear, including a checklist of things patients need to take home. As a result of these efforts, top-box scores related to satisfaction with discharge information increased significantly, from 76.9 in calendar year 2013 to 80.5 YTD in 2016.
- New ED bereavement policy: A PFA who regularly conducted rounds in the ED shared the story of family members who complained about not being able to be with their loved one as ED clinicians removed life-sustaining equipment. As a result of this feedback, the ED director worked with others to change the policy to allow bereaved family members to be with their loved ones during this time.
Planning and Development Process
Key steps included the following:
- Introducing program to staff and physicians: Hospital and program leaders met with unit-based leaders and staff to educate them about the role and value of the PFAC in general and about the PFA rounding program. During these sessions, the leaders answered any questions that staff had and elicited their reactions to the rounding program. Many staff members expressed skepticism and concern about being “spied on” by the PFAs.
- Developing support materials for PFAs: Program leaders developed lists of specific questions and issues that PFAs should focus on during their rounding activities, along with guidance on what to look for when observing the key touchpoints described earlier. They also developed brochures to explain the program and the role of the PFAs to both staff and patients.
- Training PFAs: Each PFA went through approximately 8 hours of hands-on training, including education on Health Insurance Portability and Accountability Act (HIPAA) requirements and how to address key issues that might arise, such as poor communication by physicians and nurses with patients and with each other. Before going out independently, each PFA spent several hours shadowing the program coordinator, first watching as she conducted rounds and then conducting rounds under her supervision. After this shadowing period, the program coordinator provided constructive feedback to the PFAs.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as existing staff and volunteer PFAs participate as part of their regular responsibilities. The hospital currently has 18 PFAs who serve on the PFAC; 13 of these individuals regularly participate in rounding activities. Many of these PFAs have substantial experience as past Health Central patients or as family members of past patients. Many also are very active, accomplished members of the local community.
- Costs: The program does not require a meaningful financial outlay.
Funding Sources
Any minor expenses associated with the program are funded out of the hospital’s internal operating budget.
Getting Started with This Innovation
- Secure leadership buy-in: Organizational leaders must support the idea of having PFAs actively provide input to the organization. To secure such buy-in, it is important to share information on the value of the PFAC (assuming one exists) and to explain how PFAs can offer a unique perspective that may be missing. It is also useful to contrast the value of PFAs versus other, traditional ways of eliciting community input, such as general surveys or focus groups.
- Involve staff in planning: Planners should bring PFAC members together with unit leaders and frontline staff to develop goals for the program, discuss how it should work operationally, and plan any needed education and training for PFAs and care teams during the rollout phase.
- Expect pushback from staff: Unit leaders and frontline staff are likely to voice skepticism about the program and perhaps publicly oppose it at first. While every effort should be made to assure them that PFA observations will be used only to promote continuous improvement (not punish staff), some initial resistance and pushback is inevitable. Over time, staff should come to support the program once they see its value in enhancing the patient experience.
- Recruit experienced, effective PFAs: As noted, Health Central’s PFAs not only have experience with the hospital, they also are established, respected members of the local community and have the intelligence and insight to contribute effectively.
- Invest in training: PFAs should receive substantial training and support before conducting rounds on their own, including shadowing others and receiving hands-on feedback from an experienced observer.
Sustaining This Innovation
- Share success stories with leaders and frontline staff: Program leaders should regularly share examples of improvements that have occurred as a direct result of the program, including operational or policy changes and trends in scores on various performance metrics.
- Elicit feedback to facilitate ongoing improvement: Leaders should periodically get input from the PFAs, unit leaders, and frontline staff and clinicians about the program, including problems that need to be addressed or other opportunities to improve its effectiveness.
Contact the Innovator
Bibi Alley
Patient Advocate
Health Central Hospital
10000 W. Colonial Dr.
Ocoee, FL 34761
(407) 296-1817
E-mail: bibi.alley@healthcentral.org
Christina McGuirk
Chief Nursing Officer
Health Central Hospital
10000 W. Colonial Dr.
Ocoee, FL 34761
(407) 296-1813
Innovator Disclosures
Ms. Alley and Ms. McGuirk reported having no financial relationships or business/professional affiliations related to the work described in this profile.
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