Uncover the root of patient dissatisfaction
Causes identified, including poor patient education
After making a commitment to improve patient satisfaction, Bay Area Medical Center in Marinette, WI, contracted with Press, Ganey Associates, a health care satisfaction measurement firm in South Bend, IN, in 1996. Data soon revealed that IV starts and venipunctures were hurting the medical center's scores. A performance improvement (PI) team was assembled to investigate the problem.
"We worked together as a group, going through the FOCUS-PDCA process we use at the hospital. The process provides enough background to ensure success once the team reaches the PDCA cycle, which is the plan, do, check, and act part," says Sue Larson, BSN, RNC, director of OB-GYN and team coach. (See improvement process flowchart, inserted in this issue.)
The group, following a step-by-step process, uncovered many issues that contributed to patient dissatisfaction with IV starts and venipunctures, including poor staff and patient education.
Creating a foundation for success
To clarify the issue and start the PI process, the team developed a blueprint for change following a format created at the medical center. The format for the blueprint has a list of questions to help the team become organized. For example, questions on the blueprint help the team determine if the right members are participating and if all departments affected by the issue are represented.
The blueprint also prompts the team to look at the resources available for a solution to the problem. If the team recommends that the medical center purchase equipment that costs $10,000, they need to determine if there are funds available to cover the costs, explains Larson. (See sample of blueprint used by Venipuncture Team and newly created form for PI teams, called Team Sanction and Charter, both inserted in this issue.)
Following are the steps in the FOCUS process that the Bay Area Medical Center venipuncture team took to improve patient satisfaction for IV starts and venipunctures:
· Find a process to improve.
A team organized to review Press, Ganey scores uncovered a patient satisfaction problem with IV starts and venipunctures.
· Organize a team that knows the process.
The venipuncture team was created to investigate the reasons for the low patient satisfaction scores. It had five members who were selected because of their departments' involvement in IV starts and venipuncture. The members were a lab technician, an RN from the emergency department, an RN from medical surgery and oncology, an RN from medical surgery and pediatrics, and Larson, who represented obstetrics.
· Clarify current knowledge of the process.
The team created a flowchart of the processes involved in venipuncture, from the time a lab test or IV was ordered until it was done. (See example of flowchart, inserted in this issue.) Team members also reviewed department policies regarding the procedure, looked at patient comments in the satisfaction survey, and interviewed staff.
· Understand underlying problems.
The team uncovered several problems, including inadequate staff training and patient education. For example, laboratory had a checklist that indicated how many phlebotomies, heel sticks, or fingersticks new technicians had to complete under supervision before doing these tasks on their own, but no one was tracking their performance.
No one told patients bruising is normal
Furthermore, patients did not have a clear understanding of what to expect. For example, if a patient's arm bruised, the patient often thought staff members were incompetent because no one told them bruising is often a normal result of venipuncture.
· Select the process improvement.
The team made several recommendations for process improvement. These included:
- The lab department should implement a preceptor program for training of all new personnel so training would be consistent.
- The nursing staff should determine how many successful IV starts a newly hired nurse should complete during orientation, because IV starts were on the checklist but a specific number was not listed.
- Floor units should identify experts that staff can turn to following two unsuccessful IV starts or lab draws.
- The hospital should develop a patient education pamphlet answering patient concerns.
- Because nurses complained that equipment was changed so often they did not have time to become skilled at using it, management should standardize venipuncture equipment so different or new products don't jeopardize performance.
- The hospital should add a teaching section to the admission assessment form for discussion of IV starts and lab draws.
- Nurses should educate parents of pediatric patients about IV starts and lab draws so they understand the procedure and how to help restrain their child. The pediatric department took the recommendation a step further and developed a separate room for the procedures so the children would not associate an IV start with their bed, says Larson.
Courtesy, skill now monitored
The recommendations were implemented by the appropriate departments and the team watched the Press, Ganey scores to see if patient satisfaction had improved. Now the team monitors scoring on the courtesy and skill of the IV starter and courtesy and skill of the lab technician.
After recommendations from the team were implemented, positive patient satisfaction scores jumped significantly. The rating of the courtesy of the technician went from 64% to 92%, and skill in drawing blood went from 87% to 98%. The skill of the IV starter went from 87% to 99%, and the courtesy of the IV starter went from 71% to 99%.
The recommendations were created with substantial feedback from individual departments. That's why most of them worked, says Larson. "We didn't come up with the recommendations in a vacuum. We talked to staff ahead of time and involved them in what we were doing so they accepted the recommendations because they knew they were realistic," she explains.
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