Incredibly Easy blog

The Incredibly Easy blog will expand on selected topics presented in the print journal.

Monday, December 9, 2013

Building a culture of excellence from a nursing perspective

With today’s economy, an increasing number of medical institutions realize that satisfied patients are the most productive fruit. Patient satisfaction affects pay-for-performance ratings on quality of care received, which is publically reportable. Since 1999, every federally-sponsored healthcare center is required to evaluate patient satisfaction.


The Centers for Medicare and Medicaid Services partnered with the Agency for Healthcare Research and Quality to develop the Healthcare Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The goal of the HCAHPS survey is to provide patients’ perceptions of care received through voluntary collection. Patients are able to rate their care as always, usually, sometimes, and never response scores. Patients are also asked to rate the facility from 1 to 10 and then are asked to endorse the hospital as definitely no, probably no, probably yes, or definitely yes scaled questions. The results provide a methodology and reporting vehicle that enhances accountability. Organizations must aim to provide excellent care, an exceptional environment, and outstanding employees.


The impact of excellence on patients is initiated upon the entrance door of your institution. The moment the patient enters, his or her hospital experience starts. If the floors are shining and employees (with their ID at the shoulder) are smiling and projecting a welcoming persona, a positive experience begins to evolve. Every department, floor, wing, and employee is responsible for providing a positive patient experience and excellent care. This message must be stressed by every administrator, supervisor, and staff member regardless of the department or rank. Every employee can be a leader who can make positive change in an institution and deliver excellence to patients’ care. 


Nurses are the critical link to outcomes. When we care for our patients, we are able to gauge their perceptions of the care received and can positively impact their experience by correcting negative practice or improving care delivery. The HCAHPS survey connects care to patient experience and provides a comparison between hospitals from a patient perspective. The impact of nursing care on patient satisfaction and outcomes has long been established but hadn’t been linked to financial incentives—until now.


So what can you do to build a culture of excellence at your facility? Education, awareness, accountability, and persistence are keys to providing excellent care and sustaining a culture of excellence.



Increasing the knowledge base of employees can both resolve knowledge deficits and result in higher patient satisfaction scores. Education includes defined indicators, such as customer service, on time appointments in clinics, on time surgery starts, minimal wait to be seen in the ED, welcoming security officers, answering the phone by the second ring, providing pain medication within minutes of the patient’s request, or providing hot food for breakfast, lunch, and dinner. All of these points are critical indicators for any patient experience. The HCAHPS survey measures patients’ experiences as we provide care.


Education should always be presented in verbal, written, and electronic formats to staff members because each person may learn new concepts differently. There must be a path developed to educate all employees. To be able to complete the education for individuals who were sick, on vacation, or attending a conference on that day, staff meetings must have an agenda and minutes taken. Attendance sheets must be 100% complete. So if a staff member was unable to attend on the day that the education in-service was held, the employer can open the in-service book, read the agenda and minutes, and sign-in on the educational session held. The goal is to reach all staff members with knowledge sharing and the message communicated 100% of the time.



Every employee, regardless of department area or rank, must be aware of the indicators or goals that pertain to his or her area and the institution as a whole. So, if we strive for excellent customer service standards, then this must be posted in visual areas of the department, which can serve as a reminder for staff members that there’s a focus of care we’re striving for or a minimal achievement standard we’re measuring. Focused visual posting creates awareness of pride for the department and serves as a common goal. Place bullet point information on lockers and in staff-physician lounges, and discuss it at staff and department head meetings. If everyone is aware that the customer service standards need to be improved, then this becomes a common goal. For example, if the focus is on environmental cleanliness, then identify key points and expectations and create measuring tools and parameters. Employees need to know what their job roles and expectations are.



All members of the healthcare team are responsible for positive HCAHPS scores. Start thinking about shared governance and interdisciplinary team building, with common shared goals and expectations. Nurses are the most frequent healthcare providers with whom patients interact, and communication is a key indicator of positive patient satisfaction. Holding each other accountable can be rewarding, and it isn’t impossible for any organization. When communication is effective, clear, and concise, there’s an opportunity to develop the healthcare partnership and produce compassion, human-based connection, and respect.


Accountability is based on the W system:

Who: Who needs to say?

When: When do they need to say?

Why: Why do the need to say?

Where: Where do they need to say?

What: What do they need to say?


Create a tool that outlines this system. For example: Who cleans? What’s cleaned (closets, floors, stretchers, vents, corridors)? When are they cleaned? Why are they cleaned? Where are they cleaned? Each checkpoint must have a lead person who has been educated on this system of accountability.



Persistence deals with finding the ways to impact change. A path to excellence may have many twists and turns, but the destination must always be seen. It should involve not many departments, but ALL departments. Not some staff, but ALL staff. Being persistent in achieving goals is the actual road to excellence.


Sour apples

Let’s briefly talk about “sour apples” or those staff members who are negative. This is the staff member who never has anything positive to say. The idea to get these employees involved is an important accomplishment. Every negative comment is required to be followed by a solution. Ask your colleagues for their recommendations. Tell them you want their feedback for a possible answer to the problem. Every problem or complaint needs a potential improvement and solution plan. After you institute this rule, complaints will come with potential solutions and staff involvement will develop.


The road to excellence is an interdisciplinary process, involving all departments of patient care and every discipline. Building a culture of excellence isn’t an impossible task; rather, it’s a rewarding achievement that every nurse, department, and organization can attain. The stronger our understanding of excellence, the higher the awareness, and the more robust the persistence, the greater the achievement.



Agency for Healthcare Research and Quality. HCAHPS fact sheet.


Agency for Healthcare Research and Quality. Theory and reality of value-based purchasing: lessons from the pioneer.


American Sentinel University. Effective nurse communication key to patient satisfaction in health care system.


Bombard CF, Jordan CE. HCAHPS is all about patient satisfaction.


Kutney-Lee A, McHugh MD, Sloane DM, et al. Nursing: a key to patient satisfaction. Health Aff (Millwood). 2009;28(4):669-677.


By Eleonora Shapiro, DNP

Vice President of Perioperative Services

Mount Sinai Hospital

New York, NY