Capstone Project

Indirect Clinical Project: Quality Improvement

Abstract

Healthcare has become a consumer driven industry with patient satisfaction equating to good customer service. Effective communication has been shown to be a key factor in both patient outcomes and satisfaction. Additionally, patient satisfaction has become a tool used by insurers to evaluate medical facilities and may impact reimbursement to hospitals for patient care. In this paper, I will discuss the issue of ineffective communication in the waiting area of the surgical services department at Mount Carmel East Hospital.

The impact of ineffective communication effects patients and members of the perioperative team. Results of patient surveys consistently showed a decrease in overall patient satisfaction with areas of communication scoring the lowest across the continuum. Substandard scores necessitated a further look at the process of communication and a root cause analysis was used to evaluate the scope of the issue. The current communication process was then observed and compared to best practice models. A summary of this data, included in this report, was used to develop possible solutions to improve communication as part of a continuing quality improvement process.

The impact of quality improvement is instrumental in overall patient satisfaction and customer service.

Indirect Clinical Project: Quality Improvement
The purpose of the Indirect Clinical Project (ICP) is to provide an opportunity for students working toward a Bachelors of Science in Nursing (BSN) to use critical thinking and problem solving skills to explore an issue related to their professional interest. BSN students were asked to work with Masters of Science in Nursing (MSN) preceptor in a professional role for this project.

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My ICP is designed to address the issue of ineffective communication in the waiting are of the surgical services department at Mount Carmel East Hospital. I choose this particular problem as it related to my current area of practice in the post anesthesia care unit. The problem of ineffective communication in the surgery waiting room has been a longstanding issue. This is evidenced by substandard patient survey scores in areas related to communication and overall satisfaction with the surgical waiting area. In this paper, I will establish the framework for the problem of ineffective communication and how this translates into the quality improvement process. For this project a root cause analysis was done and the results were then used to develop a process improvement plan. A comparison was made between current practice and best practice related to perioperative communication. As the problem was analyzed and areas in need of improvement recognized, the process improvement plan was developed. The benefits and drawbacks of the possible solutions will be present along with rationales. PROBLEM

Mount Carmel East (MCE) has had numerous complaints regarding ineffective communication within the surgical services waiting area. Complaints typically are related to patients and families not being informed of delays and/or updates. Currently a small number of volunteers are functioning as the surgical liaison for patients and families throughout the surgical care process. The liaison is responsible for facilitating communication to patients, families, nursing staff and surgeons. The task of being a liaison for patients in the perioperative setting can be daunting with many demands that present a variety of challenges. While these volunteers do not provide medical information, they are expected to understand the surgical schedule and perioperative process. No formal training for these duties is provided and volunteers are expected to convey appropriate information in a timely manner. Despite the placement of volunteer liaisons, complaints from patients and families not being informed of delays and updates continue to be received.

Inconsistencies in the number and abilities of the volunteers have a direct impact on the communication process. The schedule of the volunteers is the responsibility of the volunteer coordinator and while requests have been made to have the same volunteers this is not always possible. Some days there may be a single volunteer to manage the numerous responsibilities without any assistance and on occasion, particularly in the evening, there is no volunteer and the waiting room is left unattended. The waiting room is
the first impression customers, patient and family, see when they arrive for surgery. Leaving the waiting room unattended is a poor reflection on the department and can be perceived as unwelcoming. “The perioperative environment is often seen as impersonal and unfriendly” (Stephens-Woods, 2008, p. 7). Without someone to receive patients and answer the phone, communication becomes fragmented and impersonal.

While the contributions from the volunteers are greatly appreciated, abilities and level of commitment vary greatly. As a result, the families experience dissatisfaction when trying to obtain information, the surgeons experience frustration trying to find patients families, and the clinical staff find it difficult to update the volunteers when they need to communicate information. Currently, the volunteers are not held to any performance standards and while they may be in attendance, they may not be fully present. All employees of MCE are expected to work together and adhere to the guiding behaviors set by Mount Carmel which include being fully present and accountable (MCE, 2012). STAKEHOLDERS

The issue of ineffective communication affects first the patients, our customers, who are the center of focus. Family members waiting for their loved ones are also affected. Lack of communication to patients waiting for surgery, particularly when there is a delay, can contributed to a heightened level of stress and anxiety. “Ineffective communication can be linked to higher levels of stress and anxiety which can negatively affect patient outcomes” (Stephens-Woods, 2008, p. 7). Additionally, health care workers and volunteers are impacted. Other key stakeholders include the perioperative staff, anesthesia team and surgeons. This domino effect extends to administration and ultimately the facility.

AVAILABLE DATA
Data from outpatient satisfaction surveys was compiled and reviewed for this project. Results were reviewed for each quarter of 2012. Data from questions relating to communication was obtained from questions contained on the survey. The questions and results are as follows: when asked if instructions were received upon arrival to the outpatient area patients responded “yes”
an average of 84% of the time; being informed of delays averaged 77% of the time; overall waiting area satisfaction averaged 77%; and the likelihood of recommending MCE outpatient surgical services was an average of 83% (Mount Carmel, 2012). The data supported a need for communication that occurred within the waiting area with scores below department goals which have been established to be 90% or better. STRATEGIES/RESOURCES

In order for any quality improvement project to be success a variety of resources must be utilized to analyze the problem. For this project, a root cause analysis was done and the results were then used to develop a quality improvement plan. This method of analysis was helpful in determining who was involved; where communication breaks down; what factors contribute to the issue and possible solutions to improve communication. Additional data from the results of the patient satisfaction surveys was also used. With the problem clearly analyzed and areas in need of improvement recognized, the process improvement plan was developed. The plan to incorporate a surgical services patient liaison was formulated as one possible solution. This plan was developed using best practice models in comparison to current practice routines. Strengths include available data and research from best practice models. Another consideration to improving communication is the impact it will have on patient satisfaction scores. With improved communication comes improved patient satisfaction (Otani et al., 2012, p. 257). The director of surgical services has worked alongside those involved with the project in order to develop a conceivable plan. Additional input from the clinical staff has been positive and supportive. The biggest obstacle, of course, is budget. The role of the patient liaison, with all of the responsibilities is encompasses, would be a paid position. The addition of an employee is not without financial burden upon the department. However, unsatisfactory results will impact reimbursement. Medicare will examine these scores when reimbursing hospitals and better-performing hospitals will benefit from the incentive (Lang, 2012). Improving patient satisfaction is paramount due to the potential loss of revenue. SOLUTIONS/IMPLEMENTATION

The current practice model of volunteers being used as the surgical service patient liaison does not follow best practice guidelines. My proposal is to create a surgical services liaison as a navigator in the surgery waiting area. Current best practice models use nurse navigators and nurse liaisons as point persons to improve the communication process and overall patient and family satisfaction (Stephens-Woods, 2008, p. 7). However, there is limited research in relationship to outpatient surgical settings. My proposal would incorporate a liaison; however, this role would be filled in an administrative capacity rather than clinical thus alleviating some of the financial burden to the department. My second solution is to first address staffing levels. Currently there is no guarantee for consistent staffing. Continuity with those volunteers who do function as staff in the waiting room is somewhat limited.

Requests have been made for the same volunteers to be used in the waiting room, but this is not always possible. Periods of time volunteers are requested for the waiting room are vacant. This issue was once again presented to the volunteer coordinator. Requests were made to make the surgical services waiting room a priority for volunteer staffing. While these requests have been made, there remains no guarantee that staffing levels will be met. The use of volunteers to fill a staffing need will continue to be problematic and this will continued to be reflected in overall patient satisfaction. The importance of satisfying the needs of families as our customers is just as important as providing care for our patients. This can best be accomplished by having trained staff members to meet these needs which in turn will improve patient and family satisfaction. Patient satisfaction is now considered as a critical part of the quality outcomes of health care (Otani et al., 2012, p. 257).

Another component to the solution using the volunteers is based on documentation. Currently, the volunteers do not document when communication occurs and therefore there is no data to support that communication has occurred. My proposal would be the implementation of a spread sheet used to document communication. This spread sheet would be integrated with the daily surgery schedule with columns provided to document times when key communication has been achieved. Key communications include: time of arrival; time taken to pre-operative area; time surgery started and ended; arrival to recovery room; post surgical physician update; hourly update; etc. . The spreadsheet is currently being reviewed by department leaders.
Changes will be made as necessary based on feedback provided and it will then be submitted for final approval. Volunteers will be instructed on use of the spread sheet and written instructions provided. Clinical staff will continue to document in the electronic medical record. EVALUATION PLAN

The spreadsheet has been presented for approval for interdepartmental use. Pending approval, the spreadsheet will be used for a period of ninety days at which time patient complaints and patient satisfactions scores will be reviewed. Documentation for patient and family notification for clinical staff for the same time period will be reviewed and compared to documentation on the spreadsheet. Results will be evaluated and further recommendations will be based on these findings. ICP EVALUATION

Working with a mentor for this ICP has been challenging and informative. My preceptor was the director of surgical services at MCE. Working with a mentor in this role provided a wide variety of opportunities not only those related to the project. While most of my practice has been focused on the clinical aspect of patient care, this project has given new insight into the significance of data as a value measurement for good patient care. The role of managers and their ability to make positive changes based on research has gained greater significance. With the knowledge gained through this process, I will not hesitate in the future to participate in continuous quality improvement projects. The ability to put into practice what has been learned in theory has been an invaluable experience. CONCLUSION

Effective communication has been show to be a key factor in both patient outcomes and overall patient satisfaction. The value of patient satisfaction is now considered as a critical part of the quality outcomes of health care (Otani et al., 2012, p. 247). Patient satisfactions surveys from MCE surgical services have consistently show a decrease with overall patient satisfaction with areas of communication scoring the lowest across the continuum. Substandard patient satisfaction scores necessitated a further look at the current communication process. Currently, communication is facilitated by volunteers who staff the surgery waiting room. Availability and commitment of the volunteers have contributed to the issue. The use of
volunteers provides no guarantee staffing levels will be fulfilled and on occasion the waiting room is left unattended. In order to address both staffing issues and facilitate timely, effective communication recommendations have been made to hire a regularly scheduled employee in the role of surgical liaison. Limitations to this plan are primarily monetary. Considerations for budget allowances and cost of training are not without financial burden to the department. The overall picture must be evaluated and the cost of an additional employee compared to potential revenue loss considered. Unsatisfactory patient satisfaction can impact reimbursement and lead to potential loss of repeat business.

A second possible solution was developed based on monetary considerations. A spreadsheet designed to correlate with the surgery schedule was created. Simplistic in nature, it was designed to provide a place for volunteers to document times when specified communication occurs. The rationale behind the use of the spreadsheet is twofold. First, providing written documentation that communication has occurred; second, prompt those using the spreadsheet to provide communication in a timely manner. Pending final approval, the volunteers would be shown how to use the spread sheet and written instructions will be provided as a reference. Plausible solutions have been presented in an effort to improve communication with an overall goal of improving patient satisfaction. Effective communication between patients and members of the interdisciplinary health care team is essential (Belizario, 2011, p. 19). Using data as a tool to value patient centered care is an essential component to the quality improvement process; however, implementation, evaluation and continued quality improvement are a continual process. References

Belizario, S. (2011, August). Inspiring change. Boosting patient satisfaction scores-and nurses’ morale. Nursing 2011, 41(8), 18-21. Retrieved from: http://dx.doi.org/doi:http://dx.doi.org.proxy.library.ohiou.edu/10.1097/01.NURSE.0000399591.81228.3e. Hollan, J. (2010). Communication key to patient satisfaction scores. Hospital Case Management, 18(11), 164-166. Retrieved from http://www.library.ohiou.edu.proxy.library.ohiou.edu/cgi-bin/redir_allcampuse