I recently had the opportunity to hear Maureen Bisognano, CEO of Institute for Healthcare Improvement, speak at the Society of Hospital Medicine 2015 Annual Conference. In her keynote address, she challenged us to focus less on asking what's the matter with our patients and more on asking what matters to our patients. One way to do this, she noted, is to start asking our patients what a good day looks like to them. Why is this so important? As providers, we have a specific agenda we want to accomplish while in the room with the patient. As we've gotten busier, the time we spend just talking has decreased. Given the rush, we often don't stop to ask our patients what their actual preferences are. Taking a moment to ask our patients, What's a good day look like for you?, puts the focus back on our patients and their wishes. It's not complicated, and it only takes a minute, but the answers could be transformative.
Imagine a patient with pneumonia. As the physician, a good day in my opinion would be one in which my patient takes the antibiotics and doesn't spike a fever. However, in my patient's mind, a good day may be one in which he or she sits outside in the hospital's healing garden for a few minutes. You can see that my good day and my patient's good day are completely different. In fact, I may never suggest the healing garden on my own. By taking the time to ask the patient what a good day looks like, I now know one small thing I can assist with to make a huge difference for my patient. The nice thing about this question is it applies to both the inpatient and outpatient setting.
Maureen Bisognano challenged all of us at SHM to start asking our patients what a good day looks like for them, so now I challenge you to do the same.
To be honest, rounding with nurses is something I did in residency as part of team rounds, but I had gotten away from it since moving beyond an academic setting. Thus, when hospital leadership asked the hospitalist team to consider nurse rounding, I was a bit skeptical. I always thought it sounded good in theory, but I didn't think it would work in reality. As it turns out, I've really enjoyed it, so I wanted to share it with you so you can consider it as a way to improve your patient experience.
The exact logistics will vary based on your hospital's size, but for me, when I arrive on the unit, I find the nurse's portable phone number and call him or her. I let the nurse know where I'm headed, and he or she makes it a priority to join me. I spend a lot of time with my patients, so I try to respect the nurse's time by stating the plan while the nurse is present. That way, if he or she needs to move to another room, the plan has been discussed. I also make sure to ask the nurse his or her input and address any questions or concerns he or she has.
It's been working great, and one of the things I like most about it is that everyone can benefit - the patient, the nurse, and the physician. One of the challenges when introducing new initiatives for staff and providers is to show how it benefits them. Nurse rounding is a patient experience initiative where everyone benefits.
Everyone benefits * Patients benefit by having the nurse and doctor working together at the same time to discuss the patient's care. Rounding is done at the bedside with the patient so the patient is really able to participate and feel included. If the patient or family has a concern, they can express it at that time to the two members of the care team who are best able to advocate for them. It's also an opportunity to show the patient and family that you work together as a team. Patients want to know their entire care team is on the same page and focused on their care, and physician/nurse rounding is one way to accomplish this goal.
* Nurses benefit because they hear the plan directly from the physician, as it is conveyed to the patient. Oftentimes, nurses have information that would alter the treatment plan, so being in the room with the physician as the plan is being expressed helps both the physician and the patient.
For example, if I'm discussing discharge planning and my nurse tells me the patient is unsteady on their feet and requires 2 nurses to get out of bed, I'm going to think about rehab placement as opposed to sending the patient home to live alone.
Physician/Nurse rounding allows nurses to be more knowledgable of the plan, so they can reiterate important information to the patient and family about that plan throughout the day.
For example, if the nurse hears me tell the patient they will be going home on insulin, he or she can begin educating the patient on insulin and how to administer it.
Physician/nurse rounding also encourages nurses to raise questions and concerns during rounds as opposed to trying to locate the physician at a later point in time. This helps nurses to feel like valued members of the care team, which improves nurse satisfaction and retention.
Finally, physician/nurse rounding helps nurses to better learn their physicians' styles and preferences to better assist the physician in taking care of the patient.
*Physicians benefit because the nurse is more knowledgable about the plan, and can more easily answer patient and family questions. Pages to the physician are reduced. No more pages from nurses asking questions that have already been addressed in rounds, and fewer pages from nurses asking doctors to update families. It doesn't completely eliminate the need for physician/family updates, but having the nurse give a basic update eases family anxiety and often alleviates the need to speak directly with the doctor about every concern. As doctors are increasingly pressed for time, anything to improve efficiency helps. Physicians also benefit because nurses have a unique perspective, and this perspective can help the physician as they create the treatment plan. Common things nurses bring up are issues related to wounds, debility, nutrition, and discharge planning. However, as the physicians and nurses become more comfortable with each other, the relationship evolves and the nurse truly becomes a valued ally to help the physician with his or her work.
Regardless of how you implement physician/nurse rounding, I definitely encourage you to give it a try. It really is a win/win for all - patients, nurses, and physicians.
by Dr. Trina E. Dorrah
I’ll admit it. I like reality TV. In fact, one of my favorite reality TV shows is Dallas Cowboys Cheerleaders: Making the Team. It shows what it takes to become a Dallas Cowboys Cheerleader. Why am I talking about cheerleading in a health care blog? Because the Dallas Cowboys Cheerleaders put more effort into hiring cheerleaders than most health care organizations do in hiring doctors. If you’ve read any of my previous blog posts, you know I spend a lot of my time training doctors on specific things they can do to improve the patient experience. Physician training is a common tactic in health care, but when those efforts fail, health systems spend a lot of resources trying to help their habitually low performing doctors. Lately, I’ve been thinking we should try a different approach. Why not focus more attention on hiring for the patient experience from the start?
How does this relate to the Dallas Cowboys Cheerleaders? In health care, we aspire to hire the best. The Dallas Cowboys Cheerleaders are one of the country’s best professional cheerleading teams, but they didn’t gain this distinction by solely focusing on dance skills. Instead, they have created an audition process that ensures they select cheerleaders who embody the mission and values of the organization. I think health care should follow their lead.
3 hiring tips … taken straight from the Dallas Cowboys Cheerleaders
1. Redesign your hiring process to produce the results you want.
· DCC: To become a Dallas Cowboys Cheerleader, you must be able to do more than just dance. The interview process puts applicants through a variety of situations, all designed to ensure candidates have what it takes to uphold the values and vision of the Dallas Cowboys Cheerleaders.
· Health care: In health care, we are often understaffed, so we fall into the trap of hiring the first competent physician who applies for the job. The problem with this approach is we really don’t know how well they communicate with patients, if they are empathetic, or if they connect well with others. Health care needs doctors who are excellent clinicians and patient experience advocates. Unfortunately, we’re really good at assessing technical competence, but we’re lousy at assessing the more subtle qualities that make or break a patient’s experience.
2. Focus on your core values.
· DCC: In order to become a Dallas Cowboys Cheerleader, you have to repeatedly show the judges that you posses the values and characteristics they desire. Because the interview process spans several weeks, it’s easy to know who is genuine and who is simply faking it.
· Health care: We all have a code of conduct we want our doctors to adhere to and we all have a set of core values we expect them to possess. However, few health care systems have a reliable way to gauge during the interview process if a doctor can or will live up to these standards. Even when we ask, we take the doctor’s word for it without ever verifying if his or her prior actions demonstrate hostility towards improving the patient experience.
3. Assess communication skills.
· DCC: To become a Dallas Cowboys Cheerleader, you must demonstrate that you are a good communicator by performing well in a Q&A interview session. If an applicant fails to communicate effectively, she gets cut.
· Health care: In health care, our interview process does assess general communication skills. However, communicating to an interviewer is entirely different than the communication that is required for effective patient care. Being able to communicate things in a way patients understand is critical for providing a good patient experience, and health care currently does little to evaluate this skill when hiring.
Now that I’ve mentioned some of what’s missing from health care’s current hiring process, let me explain what I think we should do to change it. Yet again, the Dallas Cowboys Cheerleaders have already figured out the solution.
“Assess applicants’ skills before offering the job.”
What does it take to be a Dallas Cowboys Cheerleaders? Their website outlines the following steps: 1) Complete the application, 2) Preliminary Audition, 3) Semi-Final Audition, 4) Personal Interview, 5) Written Test, 6) Final Talent Auditions, and 7) Complete training camp. Notice how many steps I listed - seven! The last step alone takes several weeks. In health care, most interviews last 1-2 days max, and although applicants speak with several interviewers, they are rarely asked to demonstrate one of the most important things – their commitment to the patient experience.
3 ways to assess patient experience skills before offering the job
1. Review prior patient experience survey results – virtually every health care organization measures the patient experience. Review your applicant’s prior results. If you’re planning to hire a physician who consistently scored at the bottom of his or her peer group, or who consistently had more patient complaints, consider hiring someone else.
2. Focus on the patient experience throughout the hiring process – this should begin as soon as a physician submits an application. For example, put a video on your website explaining your organizations’ commitment to the patient experience, and require applicants to review it before they can submit an application. Likewise, the patient experience should be discussed throughout the interview process.
3. Interact with patients – before you make an offer to a new doctor, observe his or her interactions with patients. You can work with your legal department to use real patients under the direct supervision of a staff physician. You can use volunteers, members from a patient advisory council, or paid secret shoppers. The point isn’t to judge the doctor’s diagnostic or technical skills, but to observe their body language, emotional intelligence, and communication skills.
In the end, not every physician will be a good fit for your organization. By learning to hire better, you can hire physicians who embrace your organization’s commitment to the patient experience. This is much easier than trying to correct behavior after the fact. What do you think?
Dr. Trina E. Dorrah (@drtrinadorrah) is an internal medicine physician/hospitalist and the author of Physician’s Guide to Surviving CGCAHPS & HCAHPS. She can be reached through www.drtrinadorrah.com.