Authors' Affiliations: Administrative Director of Service Excellence (Ms Setia), Hackensack University Medical Center, New Jersey; and Research Director (Dr Meade), Analytic Research Associates, Charlottesville, Virginia.
Corresponding author: Ms Setia, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ 07601 (email@example.com).
Discharge telephone calls made by hospital staff provide invaluable opportunities to prevent adverse events, improve quality of care, and increase patient satisfaction. Similarly, the effect of rounding on patients can improve clinical quality and improve both patient and staff satisfaction. The author discusses how the combination of implementing both nurse leader rounding and discharge telephone calls simultaneously produced powerful positive outcomes in satisfaction and patient quality of care.
The literature has repeatedly shown that postdischarge telephone calls made by hospital staff provide an invaluable opportunity to prevent adverse events, improve patient quality of care, evaluate hospitals' patient education efforts, identify trends that may require improvements in practice, determine patients' compliance with discharge instructions, and assess overall impressions of hospital performance. They also support efforts to "close the loop" on patient contact.1-10 Similarly, the effect of rounding on patients has been documented to improve patient quality of care, reduce falls, and improve both patient and nursing staff satisfaction.11,12 However, we found no literature that measured the effect of the combination of both nurse leader rounding and discharge telephone calls on patients' experiences and satisfaction.
Measuring These Tactics
A large university-affiliated medical center in New Jersey was experiencing increased occupancy and volume along with a decreased length of stay. According to the patient satisfaction data, this caused patients to perceive their discharge experiences as less than ideal. In addition, one of the patients' biggest fears was that they would not remember/know what to do when they got home. Healthcare research indicates that "not understanding discharge instructions" is one of the top 8 "dissatisfiers" to patients. How the patients manage their recovery after discharge is vital to maximizing clinical outcomes; therefore, senior leadership gave a directive to all leaders in late 2005 to implement discharge telephone calls as the "best practice" to improve patient satisfaction and safety. Senior leadership knew that this additional demand for documentation would be another task for the staff to complete. In light of this concern for the demand on staffs' time, the medical center needed a way to measure the impact of postvisit calls on their patients to keep the focus on the outcomes that the calls were producing. The administrative director of service excellence added a demographic question to both the inpatient and emergency department (ED) patient satisfaction surveys (measured through the Press Ganey tool) to determine if the patient had received a follow-up call after discharge. The practice began with the ED survey at a time when only 10% of the patients were being called (April 2006). Endorsed by the leaders of the ED, this held them accountable to ensure that the calls were made. In early 2007, the same question was added to the inpatient satisfaction survey tool.
In evaluating the impact of the calls, the organization looked at the key question that directly evaluated the intended purpose of the calls, "Instructions/information given about how to care for yourself at home." Figure 1 depicts the difference in the patient's perception of the questions, with the only difference being receipt of a postvisit call.
In addition, if patients feel comfortable when they get home about how to manage their care, they are more likely to perceive their overall care as better. This is clearly demonstrated in Figure 2.
Sharing the Results From Staffs' Efforts
The department of service excellence regularly prepares special reports and shares them with the patient care leaders, demonstrating the value of the practice through the patients' eyes. This increases their level of engagement with the process and thus increases the number of calls being made. For example, 36% of inpatients discharged in the fourth quarter of 2006 indicated on the survey that they received a discharge telephone call. Two quarters later (ie, second quarter of 2007), 49% of the patients discharged indicated that they received a telephone call. Continuing to monitor outcomes and sharing these findings allow the organization "to use results to get results" and achieve staff buy-in as it reinforces the "what's in it for me" (Figures 3 and 4).
One nurse manager commented,
Nurses react very favorably to the responses harvested from patients during the discharge phone call process. Knowing that the patient is home and safe, that the discharge instructions she provided allowed the patient to care for themselves in their home environment, and that the patient was satisfied with the care delivered to them during their hospital stay provides a sense of accomplishment and reaffirms the purpose for the phone calls to the RN.
The Impact of Nurse Rounding
Nurse rounding on patients has dramatic effects on satisfaction and quality.11,12 Nurse managers regularly "round" on their patients. But with the number of people in and out of a patient's room during one stay, it is difficult to assess how patients perceive the nurse manager's rounding and interaction with them. With the increasing time demands put on nurse managers for staffing issues and hospital meetings, the medical center wanted to know how often the nurse managers are able to round. Consequently, another question was added to the demographic section of the patient satisfaction survey in April 2007, "Did a nurse manager visit you during your stay? Yes or No."
Rounding for public relations, that is, simply saying hello and not asking in-depth questions, and rounding for outcomes can and will produce very different results. The belief was that nurse leader rounding on patients can identify many outcomes including identification of service recovery opportunities, setting expectations about the care that the patient will receive, and building confidence in the team of nurses who will care for the patient. In evaluating if this practice was effective and was achieving the intended outcomes, the organization looked at the key patient satisfaction indicators that measured service recovery ("response to concerns and complaints") and the care provided from the nurses ('nurses section') as well as the overall measure of "likelihood of recommending" (Figure 5).
The most interesting insight indicated by the data is that when a nurse leader rounds on the patients, the patients feel better about the nurses taking care of them. Through a simple process, the nurse leaders are giving back to their staff. Since then, both the questions measuring whether the patient received a discharge telephone call and nurse leader rounding have been added to surveys in a variety of patient settings. The outcomes across all survey tools are similar.
The Impact of Bundling Data From Discharge Calls and Rounding
To understand if the nurse rounding and discharge telephone calls had cumulative effects on patients, data were aggregated using Press Ganey's online analysis program (eCompass). Aggregation is often called "bundling," and in many cases, the bundle concept is applied to patient care settings to improve the quality of care given. Bundling was done for the data from 2 questions: "Did you receive a discharge telephone call?" and "Did a nurse manager visit you during your stay?" As can be seen in Figure 6, patients receiving both a discharge telephone call and a rounding visit from the nurse manager were significantly more satisfied on the 6 questions measured for the analysis than were patients who did not receive a call or rounding visit from the manager.
The implementation and outcomes associated with introducing 2 tactics that are well documented in the literature to increase patient satisfaction and quality of care-discharge calls and nurse leader rounding-had dramatic results. Most importantly, these tactics produced improved patient perceptions of their overall care. In addition, the effect of the combination of these 2 tactics is more powerful than the effect of either one individually. In fact, according to the Press Ganey patient satisfaction survey data (third quarter of 2007), approximately 50% of patients are answering yes to both questions ("Did you receive a follow up telephone call after discharge?" and "Did a nurse manager visit you during your stay?"). The level of satisfaction for those patients is greater than the current 99th percentile score in the Press Ganey national database for several indicators. It is clear that these 2 tactics alone can make the difference of being in the top or bottom of the Press Ganey national database (Figure 7).
Although staff can sometimes be resistant to the additional tasks associated with these tactics, once they begin to see and experience the results, they understand the effects that their efforts have on patients. This is probably the most powerful influence on their continuing behavior to make discharge telephone calls and continue nurse rounding.
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