Cultivating The Healing Environment: Changing The Cultural .

Cultivating the Healing Environment:Changing the Cultural Perception ofQuietness in the HospitalDIGNITY HEALTH SYSTEMST. JOHN’S REGIONAL MEDICAL CENTERbyLaurie Harting, CEOCathy Frontczak, RN, BSN, MBA, HCM, CNO VP Patient ServicesGrace Ibe, RN, MSN, Senior Director, Service Excellence & Culture DevelopmentKriselle Lim Walton, MPH, CSSB, Director, Performance ExcellenceSt. John’s Regional Medical CenterOxnard, CA

Cultivating the Healing Environment:Changing the Cultural Perception of Quietness inthe Hospitalcommunities across 17 states. Founded in 1986THE CHALLENGE OF PATIENT EXPERIENCEand headquartered in San Francisco, CA, DignityPutting patients first requires more than simplyHealth is the fifth largest hospital provider in theproviding top-quality health care. It is no longernation and the largest hospital system in California.enough to just treat a patient’s health issue: OneThere exist within Dignity Health thousands ofmust treat the patient’s perceptions of their hospitaltouch points between staff and patients, andexperience. These perceptions can be a challenge,countless opportunities to impact patientas a patient does not require literacy in medicine toexperiences. Dignity Health’s St. John’s Regional“know” whether they received good treatment orMedical Center (Oxnard, CA) recognized thatnot. Patients need only the ability to know if thedelivering high quality care as effectively andservice provider “cared” and showed concern.1efficiently as possible is required in order to achieveoperational and financial success in the future. ToThe seemingly elusive positive patient experiencerealize this success, the hospital leaders knew theygoal remains the proverbial pebble in the shoe forneeded to transform their hospital culture. Theymany hospitals. As one CNO states, “There is nochose the “Healing Hospital” concept as theirneutrality in the patient experience: It is eitherplatform for organizational change, promotingpositive or negative.” Multiple touch pointscaregivers as healers with a duty to providethroughout a patient’s hospital stay provideDignity Healthcountless opportunities for both positive andnegative experiences, and what may have been a Over 40 hospitals across California, Arizona,and Nevada Fifth largest hospital provider in the U.S. andlargest hospital system in California Care Centers providing: Urgent Care,Ambulatory Surgery, Home Health, Hospice,Imaging, Laboratory, and Specialty Services Dignity Health foundations raise funds tocontinually improve and expand upon ways tohealpositive experience to begin with can quicklychange with a single negatively-perceived incident.Inconsistency is the prime killer of patientexperience, yet it takes years to hardwire practiceconsistency into every moment.Dignity Health encompasses more than 60,000caregivers and staff delivering care to diverse2

thoughtful, compassionate care to patients andexperience scores.2 Even voluntary online ratingsfamilies during their vulnerability, treating patients’on websites such as Yelp should be acknowledged,needs holistically, which in turn would impact theas their posted results carry the distinct possibilityoverall patient care experience.of influencing consumer choice behavior.3Therefore, the ability to recognize patterns andFar from simply sending patients home well orimprove practice designs of patient experience is awhole, what makes a “Healing Hospital” aretimely pursuit for health care organizations.2building blocks such as human interactions,empowering patients through education andIn January 2011, St. John’s Regional Medicalinformation, healing arts, human touch andCenter began a quest to improve the patientcomplementary therapies. While curing focuses onexperience through the innovation of transformingthe disease, illness, or injury, healing isthe hospital culture. This journey toward culturalmultifaceted, involving the structural (physicaltransformation included precise changes such asenvironment), process (interactions withdeveloping a roadmap for introducing principlescaregivers), and outcomes (interactions of processthat lead up to a “Healing Hospital,” whichand interpersonal encounters).increased opportunities for leadership and frontlineemployees to collaborate together, and in turnA focus on healing can turn the caregiver’sincreased trust; formation of a Service Excellenceattention from the clinical to the personal,Steering Committee, which increased employeeinfluencing how they perform treatments andengagement to share the importance of the patientinteract with patients, providing high-quality careexperience; and Sacred Work Retreats for allthat is “patient centered” and responsive toleadership and frontline staff that teach thepatients’ preferences, needs, and values.1 In otherprinciples of building a “Healing Hospital,” which inwords, a focus on patient experience.turn also speaks about the patient experience.The defined purpose created by the ServiceExcellence Steering Committee drove the initiativeTRANSFORMING CULTURE: WHY IT MUSTtoward the culture of healing:CHANGEThe Service Excellence Steering Committeeacts as the organized change agent in creating aculture where we continuously demonstrate ourhealing mission, vision, and values.Trent Haywood, MD, JD, writes that patterns ofpatient experience in the hospital setting revealThe objective of the Steering Committee is todevelop a world class environment throughestablishing deliberate strategies, organizationalcharacteristics, and defined practices to ensureevery encounter and experience is valued as a“sacred encounter” and aligned with the corevalues of the organization.opportunities and risks involving both communityreputation and financial rewards for healthcareorganizations. Community reputation may beenhanced through the public reporting of patient3

The innovation of this approach resided in beingSt. John’s also established a formal HCAHPS teamable to look at the bigger picture of the patientin 2012 that developed specific innovative tacticsexperience. HCAHPS questions may be defined inrelevant to HCAHPS. This team established seveneach composite, though innovation does not takeinitial main action items (Table 1) involving theplace simply by solving how a hospital can scorehospitals’ HCAHPS scores. Under each actionhigher in each of the questions patients answer.item, they developed specific opportunities andInnovation takes place because thetactics to improve each area by hardwiring themultidisciplinary teams—and the hospital as asupporting strategies. Specificity in not only subjectwhole—begin to understand the importance of thebut also solution only made the efforts to improvingoverall patient experience through storytelling,the patient experience stronger. As a result, scoresinstruction and leadership commitment.trended steadily upward.Table 1: Summary of HCAHPS team’s initial action planCommunications with NursesCommunications with Physicians “Take 5” initiativeChairs in the rooms used during conversationsRevised patient whiteboards to include patient’spreferred nameTeach-back, limiting the use of medicalterminologyHardwired hourly rounding Shadowing Hospitalist/Customer Service Accountability ofeach physician through individual scorecards pulled fromAvatarChairs in the rooms used during conversationsAIDET principlesSacred Work retreat (future) Increasing MD/RNCollaborationCommunications about MedicationsPain Management House-wide education to reinforce patient educationon medication purpose and side effects during eachadministrationRevised patient whiteboards to includemedications and side effectsMedication Reconciliation visual cues every 12hours in Quadramed (EMR) and tab in patientchart Education gap assessment and training developedthrough gapsIntroducing medication alternatives for pain reliefTraining for staff to become pain resource nursesIncreased rounding by nurse pain specialistsReferral to physician pain specialistsPatients with pain levels greater than 6 reminded during dailyhuddlesResponsivenessCleanliness/Quietness AIDET principles“No Pass Zone”Hardwired hourly roundingService Recovery/LEASH principlesCall light re-routed to appropriate staffTurn down serviceHardwired rounding three times dailyInclude EVS contact information in patient whiteboardQuiet ResearchHUSH ProgramEvening Prayers signifies silenceDischarge Information Discharge phone callsDischarge packets with education material on patient’s discharge diagnosisDaily multidisciplinary rounding, including primary and charge nurses, case management, house supervisor, and managersSource: St. John’s HCAHPS teams, January 2012.4

Of particular note were the concepts ofLeadership Development Retreats – ThisCleanliness/Quietness. Trent Haywood, MD, JD,refresher course focused on patientperformed research for Dignity Health on patternsexperience and tying that back to the vision ofof patient experiences and opportunities for newthe “Healing Hospital.”practice design. In one section of his research, Haywood focused on two key aspects: cleanlinessDaily Leadership Rounds – Each clinicaland quietness in the patient environment. Heleadership member was assigned to visitobserved that the perception of cleanliness isspecific patient rooms and report findingsimpacted by the expectations and experiences ofduring a designated time each day using athe patients, and the perception of quietness isstandardized tool. (Figure 1)impacted by patient expectations relative to various factors such as instruments, visitations and time of2Daily Leadership Huddles – During the final 15day. Timing of the sound and the expectationsminutes of the designated leadership roundingassociated with such sound also impacted thetime, all leadership members participated in aperception of quietness.huddle to collaboratively address servicerecovery and additional patient needs, inaddition to recognizing individual staff,leadership or physician members, encouragingLEADERSHIP IN TRANSFORMATIONfurther collaboration and accountability. Driving change in any environment requires greatMeasureventionist (Measure and Intervene) –responsibility and accountability in leadership. AsThis new position measured actions andSt. John’s educated frontline staff that a healinginterventions during medication passes toenvironment included taking care of the people whoimprove communication about medication’stake care of the patients, they acknowledged thatpurpose and side effects. This createdthe best way to demonstrate this concept was inaccountability within leadership at the unitthe collaboration of hospital operational and clinicallevel.leadership and how they were taking care of theirpeople. The innovation was through connecting theSpecifically, Daily Leadership Rounds confirmeddots between frontline staff engagement, structuredthe strategic action points and created an ongoingapproaches, and cultural transformation anddialogue about patient experience. To promotecementing that with the “glue” of the leadership.consistency at the bedside, the LeadershipRounding Tool called out each specific action, notAdministrative leadership increased involvement byonly to guarantee that all points were covered byparticipating in the following activities:every leader, but also to ensure that every patientwas treated the same way. Additionally, this toolprovided the opportunity for real-time feedback5