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Strategic Leadership And Future Delivery Models
Strategic Leadership and Future Delivery Models
Caroline M Waweru
Western Governors University
Improving HCAHPS scores in healthcare.
A. Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) survey in healthcare facility reveals with evidence that there is a need to improve communication between nurses and patients. There exist limited nurse to nurse communication and patients in plan care discussions. Healthcare future growth and viability depends on patients and nurse safety and satisfaction. To improve patients and nurses satisfaction, there is a need for organizations to make concentrated efforts to change the environment and assure patients and nurses satisfaction. One of the evidence-based strategies to improve nursing communication and involve patients in plan discussion is bedside handoff. Bedside handoff strategy is introduced using Havelock’s change theory and focuses on the implementation of more beds and staffs to improve patient satisfaction on nursing communication. The purpose of this project is to analyze bedside handoff and determine its effectiveness in improving patients and nurses satisfaction for nurses’ communication as evidenced by the HCAHPS scores. HCAHPS is a patient satisfaction survey that helps us hear the voice of our patients and families. A core set of questions are established to determine the HCAHPS score of Stanford Healthcare, which determines that patient satisfaction with the medical staff and their services is 82 percent which is below average.
B.Stanford Healthcare is an Acute Care Hospital located in California. Based on the survey conducted by HCAHPS, the hospital rated four stars out of five. The HCAHPS scores related to nursing communication as evidenced by the study was 82% below the average goal of 85%. This means that the nurses involved patients in the plan care discussion but not to their satisfaction. The average national HCAHPS score of nursing communication in the United States is 80 percent. However, the nursing communication score of Stanford Health Care is 76 percent. This lower percentage indicates that communication between healthcare practitioners and patients and their families is unsatisfactory. There is an immense need for strategies to promote effective communication among patients and healthcare practitioners in order to enhance the efficiency of healthcare services. Other hospitals such as the Kaiser Foundation hospital based in the same state recorded an HCAPHS score of 78%, and Alvarado Hospital Medical Center scored 73% score related to nursing communication. The scores were based on the survey response rates of 24% in Stanford Healthcare, 25% in the Kaiser Foundation and 19% for the Alvarado Medical center (Hospital Compare: medicare.gov). These figures indicate that Stanford Health Care is doing better than Alvarado Hospital Medical Center, but is underperforming as compared to Kaiser Foundation hospital. It is notable to mention that the performance of these three medical centers is less than the average performance of the majority of healthcare centers in the US.
Stanford Hospital is based at 300 Pasteur Drive, Stanford, CA. It is ranked as the best hospital in terms of quality and delivery of health care services in the United States by the US news. It operates locally and internationally in the provision of medical care and Acute Care services for patients. It delivers clinical innovation across its physician offices, virtual care offerings, health plan programs, inpatient services, and specialty health centers. The facility is internationally known for clinical specialties such as organ transplantation, cardiovascular treatment and surgery, neurosciences and cancer diagnosis and treatment. Besides, the hospital is Level I trauma home between San Jose and San Francisco, and it provides coordinated, compassionate care, and personalizes for every patient's basic needs. With almost 2,000 faculty physicians, nearly 1500 registered nurses, 49 operating rooms, 1200 residents and fellows and 613 licensed beds, Stanford hospital commits to delivering quality care to patients (Stanford Health Care).
Environmental and community factors influence on HCAHPS scores
Improving HCAHPS scores is a priority within a healthcare system. However, environmental and community factors such as the cultural, educational and socioeconomic dynamics may hinder the efforts to improve patients and nurse satisfaction towards communication in nursing.
Cultural dynamics: Cultural characteristics such as language preference, race and ethnicity influence HCAHPS scores. The patient population is diversified; hence cultural competence becomes critical in improving HCAHPS scores. For instance, cultural diversity may be characterized with language barriers especially in a hospital where the patient lacks knowledge of the common language. The inability to communicate effectively with the care provider deprives the patients’ participation in the healthcare plan. Thus, comprehension of patient cultural competencies could improve satisfaction scores.
Educational dynamics also influence HCAHPS scores. Technology advancements and improving healthcare prolongs patients' life and increases the burden of chronic illnesses. Poorly educated patients may not understand the technology applied in their care plan. Learning disabilities in patients, motivation, and readiness to learn affects satisfaction scores especially when the patients do not understand the service delivery methods used by nurses and is unwilling to learn. Thus, poor education hinders patients from understanding their care plan, hence patient dissatisfaction.
Socioeconomic dynamics: Social, economic status affects patient’s satisfaction towards nursing communication. Low socioeconomic status patients tend to have a low life expectancy, suffer from chronic illnesses and poor self-reported health compared to high social status patients. Also, their access to healthcare is limited due to coverage and costs and diagnostics tests conducted on them are few. Furthermore, nurses perceive low-class patients as rational, independent, responsible, intelligent and unlikely to comply with the treatment plan. Low-class patients are mostly neglected than high-status patients due to the assumptions of low reimbursement rates and uncooperative with hinders HCAHPS scores improvement in nursing communication since the financially challenged patients are often dissatisfied with nursing services and inability to attend efficiently to them.
The short and long-term financial impact on quality care outcome
Hospital financing impacts the quality and quantity of treatment and care delivered to patients. Specifically, financial incentives to nurses affect the quality of care they provide to patients. Based on recent studies conducted for healthcare facilities in California, fair pricing law contributes to the low quality of patient care. Overall, it can be concluded that the quality of healthcare changes in response to financial incentives. The healthcare organization alters the quality of care depending on economic incentives. When faced with short-term financing, the organization shortens inpatient stays by 9%, reduces the intensity of care, and treats a certain number and group of patients in outpatient instead of the inpatient settings, and often transfer patients to other facilities. The reason is that healthcare lacks the financial strength to hire long-term and professional services and equipment to deliver excellent care.
On the other hand, long-term financial strength influences compliance with changing health regulations, frequent recruitment and retaining of top healthcare providers and facilitates quality care delivery and excellent patient experience. Long-term financing rewards quality and allows patients in the assessment of care provided to them. Thus, funding long-term raises HCAHPS scores related to nursing communication and patients and nurses satisfaction. A long-term financial incentive enhances recruitment and development of healthcare providers with potential and capability to provide quality care and improve patient satisfaction.
C: The potential cause of HCAHPS scores
The nursing communication and discussions to patients and other nurses at Stanford is traditional and rarely involve patients and families in the care plan prescribed. The tradition handoff is consequently conducted at the nursing station in the absence of the patients which excludes their participation and decision regarding the care plan process. The strategy was characterized by poor communication between the patients and nurses and often involved only one party (Wakefield et al., 2012). The poor communication results to the below average satisfaction scores which incur extra health care costs. Thus, the primary cause behind below average HCAHPS scores is that nurse to nurse communication occurs at the reporting desk which limits a patient’s ability to understand their illness and treatment plan prescribed by the healthcare providers. Traditional handoff process contributed significantly to patient’s dissatisfaction.
D. Organizational strategy plan to improve nursing communication HCAHPS scores
Patient satisfaction is a critical element and part of a value based purchase program at Stanford Hospital and other healthcare in California. Improving patient’s satisfaction in regards to nursing communication contributes to nearly 30% of the organization reimbursement. Based on previous studies, nursing reporting in the presence of a patient, or bedside handoff, increases patients participation in the treatment plan, enhance effective communication with nurses, patients and their families, and promote patient’s satisfaction which is a significant element in improving nursing communication HCAHPS scores for the organization (Stanowski, Simpson & White, 2015). Therefore, bedside handoff, especially in shift change is a strategic plan in improving satisfaction in patients related to nursing communication.
A strategic plan enables an organization to look into the future in a systematic and orderly manner to ensure patient satisfaction and community needs. Stanford health care must analyze its internal and external environment to evaluate the effectiveness of its current state. As seen through statistics, the current condition of Stanford is satisfactory for patients and their families, so it should need to improve its communication with patients to provide satisfactory health care. The strategic plan of Stanford Health Care is comprised of three main pillars – to be value-focused, digitally driven and uniquely Stanford. It is notable to mention that by focusing on value, Stanford health care can deliver high-quality care to its patients at a competitive cost. Digital advancements are necessary for a health center to promote effective care. The digital transformation of health care is a proficient way of satisfying patients with quality care.
The evidence-based practice and shared governance lead to higher quality of care and helps in reducing the expenses. The selection of a suitable framework is first to step to integrate evidence-based practice in an institution. Evidence-based practices include the formation of PICOT to identify clinical problems. In PICOT, ‘P’ stands for population or patients based on their sex, and ethnicity. ‘I’ stands for interventions, ‘C' stands for comparison in treatments, ‘O' stands for the desired outcome, and ‘T' stands for timing. An example of PICOT question includes problem: the presence of family, intervention: multidisciplinary ICU rounds, comparison: not being present, outcome: enhance the satisfaction of patient (Wakefield et al., 2012). Shared governance is designed to integrate core values and beliefs. Shared governance can be increased by using different strategies such as allowing teleconferencing, emphasizing accountability, and promoting multidisciplinary involvement.
Shared accountability involves every person in improving care such as healthcare organizations, patients and health plan members, physicians, payers, and the community. There are three strategies that can be implemented in Stanford healthcare in order to improve quality care. These strategies include redesigning care, engaging patients, and aligning financial incentives. Stanford health care needs to redesign care by developing and implementing standards of care based on treatments as it is an effective method to improve health care among patients. Effective communication is essential to engage patients in health care choices to build trust in order to enhance the performance of medical staff. Aligning financial incentive is an effective strategy to reward physicians and medical staff for providing the right care, which will help in improving health care service.
There is an immense need for advanced technology in the Stanford health care to improve nursing practice and patient outcomes. It is beneficial for the higher management of Stanford health care to use a chip or code embedded in certain medical equipment to track them down without wasting much time. Moreover, management should need to invest in the wireless patient monitoring to help nurses in getting an idea about the changes in patient's status. Incorporating new technology needs investment, so stakeholders and investors must invest in integrating new technology in Stanford health care in order to improve health care.
The health care system is enhancing their capabilities to innovation in health care delivery due to urged new payment models and new incentives. The Stanford health care needs to use mobile clinics to go to the patients to provide clinical services in underserved areas. It should need to team up with Independent Transportation Network (ITN) to provide transport to patients who are unable to visit the hospital on their own. These methods will help in enhancing the healthcare services to patients but can place the burden of extra cost.
Stanford should need to focus on certain methods to improve their revenue. Stanford should need to reconsider the number of hired physicians and acquired physician practices in order to reduce out of network revenue leakage. It must need to utilize web-based applications such as Enterprise HIT vendor applications as they are effective for advanced clinical documentation and are inexpensive. Stanford health care also needs to reduce denials and underpayments to save their revenue. Moreover, it is also effective to optimize revenue from physicians’ referrals and orders that can save the revenue of Stanford health care.
E. Implementation plan.
The stakeholders involved were the hospital executive team, nursing staff, nurse managers among others. They were briefed on the likely change and advised identify challenges and develop potential solutions to the issues. Frequent reporting of any identified problem such as ineffective communication, patient handoff timing would keep the stakeholders accountable and involved in the improvement quality plan. It is crucial for all the stakeholders that they have proper realization of all their roles and responsibilities. Board members are established as prominent shareholder in the entire scenario. There is need of proper exploration of the features of quality of healthcare and safety for all the patients. Offering quality healthcare services should be core agenda when it comes to proper attainment of primary responsibilities relevant to the idea of healthcare services.
Nonetheless, it is vital to develop an educational program to train nurse staff and guide them on bedside handoff implementation; observe nurses practice BSR during the change of shifts. Secondly, a communication training program is also critical in teaching learners on the efficient methods to communicate with the high number of diverse patients and include them on the treatment plan. The implementation plan would be based on introduction, situation, background, assessment, recommendation, and question. Introduction part involves introducing an oncoming nurse by the off going nurse (Lehman, 2008). Situation includes patient's details, background; patients' history, medications or testing, Assessment; pending tests, safety check or medication, Recommendation; follow up tests or care plan and finally the question: patient's inquiry. In every stage, the stakeholders undertake a review and reports on every element such as the communication efficiency on medications, inquiry and with nurses to establish deficiencies.
F. Evaluating strategic plan success
One must need to engage individual stakeholders to improve the credibility or funding/authorization organization. One must need to increase the credibility of the evaluation in order to implement the interventions in the health care department to increase care services. Stakeholders needed to be involved in the decision-making process to increase their trust in the medical center and advocate the changes to institutionalize.
The results of the stakeholder evaluation include utility, feasibility, propriety, and accuracy. One must tell who will use these results, and how much efforts are being devoted by the stakeholders in a process. It will also include how accurate the engagement of stakeholders went in the given program.
Audits: Bedside reporting audit tool was used to ensure staffs compliance to the process, including verification that the reporting was conducted at the bedside; engaging oncoming nurse; scripting introduction, situation, background, assessment, recommendation and question; and care review Reporting time audits, measured from beginning to end of reporting, were completed pre and post implementation. The project manager analyzes the scores for the data collected to identify patients’ satisfaction trend and compare mean report on pre-implementation and post-implementation reporting to establish the role of Bedside handoff on both patients and nurses satisfaction.
Satisfaction surveys: Application of both HCAHPS and Press Ganey questions were used to compare four months before implementation and four months of post-implementation. HCAHPS tool measured the element of communication on the satisfaction of patients and nurses. The question focuses on nurse responsiveness to patient's needs, listening to patients' concerns, respect and courtesy, and timeliness in responding to a patient. Currently, the Center of Medicare reported a satisfaction core on communication at 82% below the benchmark of 85% (CMS, 2016). HCAHPS tool reliability is measured through its ability to measure satisfaction consistently and provide different observer results (AHRQ, 2013). The tool would ask discharged patients two questions on their experience during their stay in the organization; How often did the nurses explain health-related information to your understanding? Did the nurses listen carefully to your needs? Press Ganey, on the other hand, focused on questions based on follow up information, nurses' ability to address emotional needs, courtesy among others. The goal of these measures was achieving at least 90% satisfaction score concerning nursing communication. The stakeholder made use of Havelock's theory to facilitate HCAHPS process. Project manager reviewed weekly data collection to identify satisfaction score.
Analysis
The HCAHPS was computed using the mean average since 2016 to compare patient volume each year. Bedside handoff pre and post-implementation satisfaction scores were monitored; hence the primary domain was on nurses’ ability to engage effectively with one another and with patients. The questions targeted the levels of respect and courtesy provided by care providers, and the frequency of care plan explanation, listening and timely responsiveness. Statistical Package for Social Sciences (SPSS) was used to analyze the results. A t-test analysis was used to differentiate satisfaction scores after implementation of bedside reporting. The analysis compared response through selecting the best response on the scale of Likert which is on a scale of always to never. Patient’s rating on courtesy and respect during treatment plan, listening and efficient communication was the primary elements measured and compared to identify satisfaction score with nursing communication. It is notable to mention that communication of nursing with the patients and their families is not satisfactory in Stanford health care. Therefore, certain implications are necessary such as effective communication and advanced technology to increase the satisfaction and healthcare for patients.
Conclusion
Implementation of bedside reporting in Stanford health care shows a positive response on patient’s perception in how nurses deliver care plan hence improving HCAHPS score with nursing communication. Bedside handoff enhances careful listening and respect during treatment and explaining that allows patients and families to understand and engage in the care plan. The strategy implemented using Havelock’s theory ensures that all parties are involved in defining the problem and generating a solution. Improvement of HCAHPS scores in patient satisfaction in regards to nursing communication calls for health care organization to adopt the bedside handoff strategy throughout care policies and units.
References
Agency for Healthcare Research and Quality (AHRQ). (2013). Strategy 3: Nurse bedside shift report. Retrieved from: https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/guide.html
Centers for Medicare & Medicaid Services (CMS). (2016). HCAHPS Executive Insight Letter. Retrieved from: www.hcahpsonline.org/executive_insight
Hospital Compare: Data sources. (n.d.). Retrieved from https://www.medicare.gov/hospitalcompare/details.html?msrCd=prnt1grp1&ID=050760&stCd=CA&stName=California
Lehman, K. (2008). Change management: Magic or mayhem? Journal for Nurses in Staff Development, 24(4), 176-184. doi: 10.1097/01.NND.0000320661.03050.cb
Stanford Health Care (SHC)? (formerly Stanford Hospital & Clinics). (n.d.). Retrieved from https://stanfordhealthcare.org/?kwcid=adwords&campaignid=194581047&adgroup=18258713007&keyword=%2Bstanford%20%2Bhealthcar
Stanowski, A. C., Simpson, K., & White, A. (2015). Pay for performance: Are hospitals becoming more efficient in improving their patient experience? Journal of Healthcare Management, 60(4), 268-284. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26364350
Wakefield, S.D., Ragan, R., Brandt, J., & Tregnago, M. (2012). Coordination of care making the transition to nursing bedside shift reports. The Joint Commission Journal on Quality and Patient Safety, 38(6), 243-254. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22737775
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