Use protocols to improve communication with patients
When Louisville, KY-based Hardin Memorial Hospital’s ED sought to improve its patient satisfaction scores, a communication protocol was created. "Including this in protocols ensures that the patient is getting a higher level of service. Teaching these concepts is one thing, but you also have to formalize it with the protocol," says Jackie Gerard, the ED’s CQI coach.
The protocol includes specific instructions for patient communication. "It’s a flow chart of what communication needs to happen from the time a patient comes into the ED until he or she is discharged," Gerard explains. "Also, we have a column for family member communication. This explains exactly what the patient and their family members need to know at what point. It also addresses which staff member gives information to the family member."
At Emory University’s ED, some staff members were uncomfortable making comfort measures part of ED protocols, notes Doug Lowery, MD, FACEP, medical director of the ED. "There was an initial resistance to providing non-medical therapy, because it was viewed as something you do at a hotel. So we had to change that part of the culture," he says. "We had to get staff to realize these are basic support functions."
Using protocols to increase comfort is a way to improve satisfaction without additional resources, notes Lowery. "It doesn’t require an attending physician level interaction. This can be generated at triage and have a tangible effect on patients satisfaction," says Lowery.
Since the communication protocol has been implemented, patient satisfaction scores have increased significantly, notes Gerard. "Our last monthly score for Press Gainey was in the 93rd percentile, and when we started out we were in the lower quarter," she reports.
The following practices are included in the ED patient satisfaction protocols:
Informing patients about the status of their pain management. When staff at Emory’s ED sought to improve pain management, communication issues were also addressed. "We knew our patients weren’t happy with the attention given to their pain," says Lowery. "When we were developing the protocol, we realized there were many other ways to impact a patient’s perception of pain, other than a pill or shot. So our pain pathway evolved into a comfort pathway."
Just talking about a patient’s pain can help relieve it, notes Lowery. "If a patient has abdominal pain and we don’t give them relief, the patient is afraid they will never get out of discomfort. Now we talk about how much pain they are having, and when they can expect relief," he says. "It just sets patients at ease knowing that they will be treated as soon as it’s safe. Instead of magnifying the pain with unnecessary worry, we are taking away that anxiety."
Previously, patients did not understand why they couldn’t instantly receive pain medication, which added to their discomfort. "Now if we can’t immediately give pain medication because we’re watching their abdominal pain, we explain when they can get it," says Lowery. "We don’t leave them in limbo. The goal is to make sure they realize as soon as it’s safe, we will give them something."
Patients are more satisfied with pain management now, reports Lowery. "They feel more strongly now that we’re doing everything we can to control their pain," says Lowery. "One of the questions on our patient survey cards says, did the staff do everything they could to control pain?’ Scores have been gradually rising since we implemented this."
Helping patients to quantify pain. Part of the protocol involves teaching patients how to quantify their pain. "We quantify the amount of pain the patient has at the moment they come in. Some people are very open and others very stoic, so we’ve worked with staff to teach patients to tell patients how to quantify pain," says Lowery.
Providing general comfort measures. "Patients are offered warm blankets, food and beverages, and staff make sure they’re not too warm or cold. Also staff reposition patients who have a hard time moving themselves," says Lowery. "Also, a phone line was put at every bedside." On the nurse’s initial assessment form, a checklist includes asking patients about food and drink, making phone calls, and to address pain medication with physicians.
Escorting patients to registration. Harden Memorials’ protocol states that after the triage nurse introduces him or herself, he or she brings the patient over to registration. "It’s very different from just saying, go over there and someone will take care of you.’ This is a way of elevating the expectation of the quality of care we deliver," says Gerard.
Using a brochure to explain the stages of an ED visit. The protocol includes the use of a patient brochure with a detailed map of care, to facilitate communication. "This helps prepare the patient for expectation of delays, and ensures they understand the process they’re going through," says Gerard. (See the ED brochure inserted in this issue.)
The protocol instructs the triage nurse, ED nurse, physician, patient care assistant, and registration clerk to sign their names on the brochure. "The brochure is taken through the system by the patient, and each caregiver signs his name and explains what the next step is," says Gerard.
The practice helps patients to feel connected with the health care team, says Gerard. "Using our names makes a commitment to the patient in a personal way. We also say, if there is anything else I can do, please contact me.’ It functions almost like a business card," she explains. "Also, because we are signing our names it makes the staff members personally accountable.’
Use of patient’s name at every exchange. The protocol instructs the triage nurse, patient care representative, nurse, and physician to introduce themselves, and then use the patient’s name in the first or second exchange.
Explaining delays. The protocol lists the stages of the patient’s visit, and instructs caregivers to explain delays at each stage. "The registrant gives the patient delay time expectation," says Gerard. If the patient’s wait exceeds 10 minutes over the estimated time, the registrant locates the patient in the waiting room and gives updated information.
If there is a wait longer than an hour, caregivers offer specific services instead of general comments. "For example, they may tell the patient, I brought you these magazines,’" says Gerard.
Explaining procedures. The protocol stipulates that every stage of the patient’s visit must be clearly explained. "For example, the physicians will explain that the patient needs more tests to make a diagnosis, and also explains why the test is needed," says Gerard. "The physicians also communicate with the patient about discharge, and let them know that the nurse will be in shortly to give them final instructions."
Introducing the patient to other caregivers. "When the patient is brought to the back, he or she is introduced to other caregivers by name," says Gerard. "It sounds so simple, but it just doesn’t happen in most EDs."
Being treated by several people can be confusing to patients, says Gerard. "We tried to build bridges between caregivers, because, from the patient’s point of view, people were sort of popping in and out of the room," she explains. "If the lab test will be going to lab for analysis, when doctor orders the test, he or she explains that the nurse will be in a few minutes. This way, unfamiliar faces aren’t just jumping in and out."
That soothes the patient’s anxiety, says Gerard. "Although so much teamwork is going on outside, the patient is not aware of that. They just see people are coming in and out who may seem unconnected to their care," she adds. "Now the patient can understand the coordination of care."
Electing a family communicator. "We ask the family to elect a communicator, which is part of the protocol," says Gerard. "At times, there may be 12 people waiting for a patient. This way, the family chooses a spokesperson and it’s up to that person to convey information to others."
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