Employee empowerment leads to better solutions
Satisfaction scores up on cardiac surgery unit
For a man who winces at catch phrases such as "employee empowerment" and is uncomfortable referring to patients as "customers," Hal Augsburger, RN, CCRN, director of patient care services for cardiac surgery at The Cleveland Clinic Foundation, has come a long way. Such a long way that the cardiothoracic telemetry unit he leads saw a rise in patient satisfaction scores from 61 in November 1994 to 82 in August 1995. A mean score of 75 or higher indicates that most patients classify service as very good or excellent.
What led to success?
To what does Augsburger, who doesn’t see himself as "progressive," attribute this success?
• Again and again staff informed about a situation have been able to solve problems better by themselves than by having a solution dictated from the top down, he says. "When people are part of the process and they understand what the goals are and are given the authority and freedom to make changes, they can accomplish a lot," he says. Sounds suspiciously like employee empowerment, doesn’t it?
• "We explained the changes in health care and how it is more of a business," he says. "We need to come at it from the point of supplying the needs of a customer." This is a concept he refers to as retail medicine. "Typically, in the past, people in health care said, We know what’s best for you, so we’ll align our services that way,’" Augsburger says. "When you go into a store, you want information, and you want people to be friendly to you. You want a good experience. Well, they want the same thing from us." Just like "customers," wouldn’t you say?
Changing staff attitude
To change staff attitude, Augsburger put staff in patients’ shoes and shared patient satisfaction data to let them know his bid to improve patient satisfaction was not an administrative whim.
In a role-playing exercise that was uncomfortable at first, Augsburger and other managers demonstrated what a family or patient encounters during a visit to the hospital. "My assistant and I went through a scenario where a patient or family would come up to the floor, and people were sitting at the desk and no one is paying attention to them," Augsburger says. "We addressed how something has to happen sooner." After seeing the role-playing once, staff put themselves in the position of a patient or family member facing unfamiliar situations in a hospital.
While effective, Augsburger does not recommend going overboard with role-playing sessions. "It doesn’t take long for you to feel how it is to be in someone else’s shoes," he says.
Augsburger backed up the need to address patient satisfaction issues with more formal patient satisfaction data gathered by a quality consulting firm. This was supplemented by feedback from quality monitors who randomly select patients for interviews, patients’ letters, informal feedback from patients on the unit, and The Cleveland Clinic’s Ombudsman Department, a patient information service.
Operational processes also influence satisfaction levels, he says. For example, managers at The Cleveland Clinic struggled to improve patient transfers from the intensive care unit (ICU) to the cardiothoracic telemetry unit. This was no small task for a unit that handles 3,200 cases annually.
With the idea that the people on the front lines have a better understanding of such situations and likely have a clearer insight to possible solutions, Augsburger sought help from the charge nurses. The problem was in balancing the higher acuity patients throughout the unit. When a patient was scheduled to be discharged, a new patient coming out of ICU would be assigned that bed without regard to condition.
As a solution, the charge nurses suggested doing rounds on the ICU patients scheduled for transfer. Armed with a list of impending discharges, the patient care coordinator now evaluates the ICU patients and places them according to acuity throughout the telemetry unit. Then they fax the information to the admitting department. This has helped alleviate situations in which one side of the unit is bogged down with more complex patients while the other side has a relatively light load.
Dramatic staff redesign
The other key to the telemetry unit’s increase in patient satisfaction was the dramatic staff redesign. The unit went from a 75% to 25% percent ratio of professional staff to technical staff to a 60-to-40 mix, without increasing payroll.
"We traded down the number of professional staff we had, to buy technical people," Augsburger says. The rationale behind this move was to increase the hours of care per patient day, which subsequently rose from 5.5 to 7.4 hours per day. "The goal was to create an environment of high-quality, high-touch care while remaining fiscally solvent."
Using patient satisfaction information, managers determined where on the unit additional staffing would be helpful. The Cleveland Clinic invested thousands of dollars in training to improve the skills of the patient care technicians and patient care services associates. Now nurses can devote more time to issues other than paperwork and bed baths, including high heart rates, high blood pressure, patient education, patient family issues, and discharge planning.
Altering a staff skill mix moves an organization into dangerous water, Augsburger says. Managers can jeopardize the quality of care by cutting the professional staff too far. Also, deep staff resentment can develop if the redesign is done without proper training of the technical staff.
Other operations scrutinized
Augsburger and other administrators carefully investigated operations around the country before going forward. Even after goals are set, they may need readjustment as the redesign is implemented. For example, the telemetry unit’s goal was a 55-to-45 mix of professional to technical staff. "We just couldn’t do that," he says. The unit started out with a one-to-five nurse-to-patient ratio, then increased the nurse-patient ratio gradually until the unit reached one-to-seven. "We never got to one-to-eight because our acuity that year shot tremendously high," Augsburger says. In 1995, the unit started seeing more complex patients and new technologies. Diluting the skill mix any more would hurt quality, he says.
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