Keywords

1 Introduction

Patient experience is increasingly recognized as one of the three pillars of quality in healthcare alongside clinical performance effectiveness and patient safety [1]. The growing body of research demonstrates meaningful links between clinical safety and focus on the patient experience. A summary of 55 studies indicates positive associations and recommendations for patient experience as a primary focus in safety and quality efforts [2]. The concepts of safety, medical errors, and harm have been of interest but were brought into focus when the Institute of Medicine’s landmark report, To Err is Human: Building a Safer Health System (1999), revealed tens of thousands of patients die every year from medical errors [3]. This interest launched an increasing focus on understanding how the patient experience and safety are inextricably linked and have been elevated as the base for performance improvement efforts in healthcare. To be successful in this regard, healthcare facilities must have an integrative model with system designs and a culture that put the patient at the center of all decisions. It will require teams that perform at the highest possible level where performance improvement is continuous. Nursing plays a primary role in the success of patient experience, team functioning, and performance improvement.

2 Importance of Patient Experience and Alignment with Safety Culture and Performance Improvement

A healthcare system should affirm that patients are at the center of all decisions, teamwork focus, and improvement strategies. When patient experience efforts are in isolation from safety and performance improvement initiatives, the opportunities for teams to fully evaluate problems and solutions from a systems perspective is lost. For example, most diagnostic decisions come from the history-taking component of the patient experience with nursing and providers. This interaction requires comfortable and thorough communication between patient and healthcare staff, typically considered a patient experience tactic. If that interaction is poor because a healthcare worker is not perceived as caring or is not thorough, that information gathering, physical examination, lab evaluation, and final diagnosis may be compromised [4]. Careful listening is often considered a soft-skills domain of the patient experience but is as much about safety and clinical effectiveness as it is about positive interactions with our patients. Studies show that patients are often interrupted and not provided the opportunity or time to tell their story leading to incomplete data upon which decision are made [5]. Research shows that enhanced patient experience is associated with better patient engagement and therefore greater adherence to treatment plans and follow-up [6, 7]. Additionally, patients with better care experiences have better health outcomes [8]. For example, studies of patients hospitalized for heart attack revealed that patients with more positive reports about their experiences with care had better health outcomes a year after discharge [9]. These are just a few examples of the importance of effective communication and relationships on the patient experience. Patient experience is also associated with patient loyalty, reduced likelihood of malpractice claims, and even healthcare staff personal resilience. Patient experience is more than soft-skills or kindness but includes all aspects of the patient experience and alignment with all patient quality and safety outcomes is critical. In summary, when patient experience efforts are in the forefront on strategy and integrated with safety and performance initiatives, patients have better outcomes.

2.1 Definitions and Key Drivers of Patient Experience

In order to direct efforts to the needs of our patients, developing patient experience definitions that best encompass those needs is a critical first step. To start, patient experience and patient satisfaction are often used interchangeably but they are not the same thing. The term patient satisfaction might be limited to soft-skills communication and pleasantries to make patients happy or satisfied with a healthcare event. The term patient satisfaction implies that the patient was satisfied with their care but potentially represents a mediocre standard. It does not embrace the many moments a patient may experience and is limited to a single emotion of “satisfaction.” Patient experience encompasses the range of interactions that patients have with the healthcare system, including their care from health plans, and from doctors, nurses, and staff in hospitals, physician practices, and other healthcare facilities [10]. This broad concept should consider all of the moments a patient might experience to include ease of access, first encounters, feelings, safety, adherence to care, diagnosis, long-term health, communication, medical outcomes, and overall well-being. Definitions of patient experience and the components that drive patient experience have spanned a wide range of models with emerging themes. The Beryl Institute defines the patient experience as “We define the patient experience as the sum of all interactions, shaped by an organizations culture that influence patient perceptions across the continuum of care” [11]. The Mayo Clinic offers this definition: “An unparalleled patient experience is the result of inspired and dedicated employees demonstrating excellence, compassion and respect by partnering with patients, family and colleagues to continuously improve the healthcare service experience” [12]. From their definition of the patient experience, the Mayo Clinic provides these patient experience components of focus: first impressions, respect and diversity, rights and responsibilities, hospitality, professionalism and healthcare literacy [12]. In a review of studies, Mohammed and colleagues presented the top three key drivers of patient experience: communication, access, and shared decision-making [12]. Recent studies have found that the strongest overall key driver on patient experience is the care provider interaction with the patient [13]. In the case of radiation nursing, patients seek a close relationship with the clinical staff who often spend the most time with the patient and the patient would perceive the nursing staff to be a most important care provider. Identifying strategies for how to develop a relationship with patients will be important. Research shows that empathy leads to better exchange of information, partnership, increased perception of expertise, increased interpersonal trust, and a positive correlation with patient care [14]. A synthesis of the research on patient experience produced key determinants for positive patient experience: healthcare workers who are empathetic, respectful, timely, collaborative, compassionate, informed, active listeners, curious, and understanding [15]. Patients’ reports of doctor communication are the strongest predictors of overall doctor ratings for both primary care physicians and specialists [16, 17]. Other important facets of the patient experience consistent in research include coordination of care, communication between referring and specialist practices, giving patients handouts that they are able to read and understand, close follow-up care instructions, quick access to care, pre-appointment communication if long waits are anticipated, and managing patient expectations before, during, and after the visit [18]. Recommendations for improving the patient experience in specialty encounters listed similar components and provided definitions of each as follows:

  • Expectations: Providing an opportunity for the patient to tell their story.

  • Communication: Patient satisfaction increased when members of the healthcare team took the problem seriously, explained information clearly, and tried to understand the patient’s experience, and provided viable options.

  • Control: Patient experience is improved when patients are encouraged to express their ideas, concerns, and expectations.

  • Decision-making: Patient satisfaction increased when the importance of their social and mental functioning as much as their physical functioning was acknowledged.

  • Time spent: Patient satisfaction rates improved as the length of the healthcare visit increases.

  • Clinical team: Although it is clear that the patient first concern is their clinician, they also value the team for which the clinician works.

  • Referrals: Patient satisfaction increases when they receive continuing care from the same healthcare provider(s).

  • Dignity: As expected, patients who are treated with respect and who are invited to partner in their healthcare decisions report greater satisfaction [19].

Given the daunting number of communication interventions, researchers have suggested that a key strategy is focusing efforts on aspects of communication that are most important to patients in each specialty area [20]. For instance, Halkett and O’Connor offer this helpful quote regarding the specialty of radiation oncology: “In our previous research we also found that patients placed high importance on radiation clinical staff communicating effectively and were pleased when they were able to form a relationship with the radiation clinical staff who treated them regularly throughout their treatment. Much of our time is focused on patients; however, involvement of family members is also likely to improve the experience of patients and their loved ones” [21]. The point taken from this article is that understanding the specific needs of patients based on specialty areas is important to have in mind, and in the case of radiation nursing, the focus on the relationship will be most important.

2.2 The Patient Experience and Communication

Given that the key drivers for patient experience involves the relationship the patient perceives to have with the healthcare staff and the effectiveness of communication, this section will focus on best practices in these areas. It is important to note that any efforts to improve the patient experience will require that nursing works in close partnership with providers and physicians and those improvement efforts should be clearly defined and based on patient feedback and needs [22]. The teamwork section of this chapter will further discuss coordination among staff for the patient experience but with regard to communication, when clinical staff and providers coordinate their strategies around patient needs, service area priorities, low scoring patient experience components, or deficits in communication skills, everyone benefits. For instance, providers and clinical staff might discuss a difficult patient scenario or a special patient need and coordinate their language, timing, and messages to successfully support a patient. Perhaps the system workflow might be changed to allow for more personal interactions with clinical staff or if metrics reveal that patients need clear instructions (and are not perceiving to receive them), staff can coordinate to use words, handoffs, language, repetition in a coordinated and consistent way. Another key strategy relies on the personal improvement goals and skills of each nursing staff. Nursing staff are encouraged to identify personalized phrases, greetings, and responses that are not scripted but thought-out and natural. These personal formulas might be used for difficult situations or for improved ways of connecting with patients. In this way, staff can feel at ease and capable of managing a variety of interactions in a personal, natural, and effective manner. Often, clinical staff might even develop a list of difficult interactions with personalized phrases for reference. It is not necessary to develop exact or memorized phrases but it can be helpful to have a sense of how to manage situations that reoccur. While there are many communication techniques and scripting phrases to consider, there are best practices for communication with patients based on a synthesis of the research on communication. Communication priorities for patient experience improvement will include building rapport, listening, showing empathy and respect, and giving clear instructions. Healthcare workers can ensure patients feel attended to in a personal way by relaxing the appearance of any time urgency with a calm, caring demeanor particularly at the greeting. The greeting and opening moments and time together are critical in establishing psychological safety and comfort for the patient and in building rapport for a strong ongoing relationship. From the beginning, narrating care and the sharing of next steps reassures patients, provides a sense of structure to the conversation and offers them a sense of control when they are otherwise feeling uneasy. Techniques for reassurance include sharing confidence in the physician and facility by discussing credentials or offering personal phrases and styles of putting the patient at ease [23]. It is helpful to watch the facial expressions and body language of a patient to determine what kind of connection will make a patient comfortable. Patients feel more confident when the healthcare organization or caregivers have been praised with high regard. An example might be, “Dr J is an excellent doctor and he/she and I have worked together for many years. We are going to take great care of you.” Patients are made more comfortable when they feel heard, listened to and understood, so we have to give clear evidence of both [24]. In order for patients to feel more comfortable, another important skill to develop is that of redirecting a patient without seeming dismissive. An example of supportive communication particularly if redirecting might be, “Thank you so much for sharing that. It is helpful that you are organized. I have another question I would like to ask you that is so important to your care.” A helpful mnemonic for improved listening skills is the Invite, Listen, and Summarize sequence that can be applied to understanding a patient’s reports of their ideas, feelings, and values and to ensure a display of understanding and empathy [25]. Empathy skills involve the acknowledgment and recognition of the journey or feelings a patient communicates directly or indirectly and then the communication of that recognition. A helpful mnemonic for acknowledgment of feelings is NURS; Name the feeling, Understand and legitimize it, Respect the patient’s attempts to cope, and offer Support and partnership in the future. Clinicians are encouraged to invite the patient to offer corrections and incorporate them into the summary. Another consistent driver of patient experience is the show of respect by the healthcare worker. Based on research from the Learning Lab of the Studer Group, certain tactics have been identified as being most impactful on improving a patient’s perception of respect [22]. Those are greeting with professionalism, demonstrating empathy, using direct phrases that indicate caring “I care about you and your health…,” and effective service recovery responses with an acknowledgement of feelings and then an apology. Research shows that patients forget 40–80% of the medical information patients receive by the time they leave the provider’s office [26, 27] and nearly half of the information that patients retain is incorrect [28]. Providing clear instructions is a patient need listed in the literature that can occur with verbal explanations supplemented with written information [22]. There are three tactics to consider. The first is to notify patients in advance of the session that written information will be provided. A second method is the Teach Back Method which is as simple as asking the patient to repeat back what they understood about next steps and follow-up care. It also further engages patients in discussion and interest in their own care. The authors of The CG CAHPS Handbook [22] offer these helpful sentences to share with patients as part of the Teach Back Method: “Mrs. A, we are covering a lot of information today for this visit. I care that you walk away from this informed. You must have some questions for me. I am happy to answer.” “I want to do a good job of explaining everything we are covering today during your visit, so please tell me when something I said isn’t clear or if you have any questions.” “To help me know if I did a good job of explaining…”. In summary, it is important to identify the special needs of patients per service area and to recognize the needs of each patient. Then, learning skills for particular areas of communication using techniques or developing personalized phrases are ways to build a reassuring, empathetic relationship that supports patients many emotional and physical needs.

2.3 Domains of Patient Experience Models for Improvement

In order to improve patient care, pursuing a patient care-system design that gives full attention to the medical, emotional, and informational needs of patients and their families will have to involve focus areas that will reach of the growth and culture requirements of the healthcare entity. The Mayo Clinic provides the following common domains found in successful models: service recovery training, metrics with clear measures of success, staff accountability, consultation services, education and training, monitoring and recognition and reward [12]. Additional domains could include physician and clinical staff coaching, sustainment plans, patient advocacy for patient complaints and grievances, and learning resources for improving the patient experience.

2.4 Measurement of the Patient Experience

Healthcare organizations typically have access to or can easily gather various types of administrative data to determine which performance issues should be targeted. Examples of sources of administrative data include the CAHPS family of surveys. The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is an Agency for Healthcare Research and Quality (AHRQ) program that began in 1995 [29]. Its purpose is to advance our scientific understanding of patient experience with healthcare. The acronym “CAHPS” is a registered trademark of AHRQ.CAHPS surveys cover topics that are important to healthcare consumers and focus on aspects of quality that are best qualified to assess, such as the communication skills of providers and ease of access to healthcare services. All CAHPS surveys (and tools) and related documentation are free to anyone who wants to use these surveys to assess patients’ experiences with care. Users of CAHPS survey results include patients and consumers, healthcare providers, public and private purchasers of healthcare, healthcare accreditation organizations, health plans, and regional improvement collaboratives. These individuals and organizations use the survey results to evaluate healthcare providers and to improve the quality of healthcare services [10].The following are key steps for improving the patient experience offered by AHRQ:

  • Compare your scores to benchmarks.

  • Compare your current scores to past performance.

  • Assess which aspects of performance are most relevant to your members or patients.

  • Review complaints and compliments, patients’ comments, and administrative data [30].

3 Teamwork as a Part of Safety, Quality, and the Patient Experience

It has widely been established that organizational culture is related to performance [31]. There is also broad acceptance within the healthcare literature of the importance of culture on patient outcomes to include patient experience, safety, and medical outcomes [32]. Many organizations such as the Joint Commission (TJC), Institute for Healthcare improvement (IHI), the National Quality Forum (NQF), and the Accreditation Council for Graduate Medical Education(ACGME) have sited of the importance of teamwork and patient safety [33]. The saying by Peter Drucker, “Culture Eats Strategy for Lunch” [34], suggests and reminds us that no operational effort can succeed without a culture of employees that support it. In order for a patient experience effort to be successful, the coordination of the staff around that effort will be required. This is more likely to happen in a supportive environment that fosters psychological safety and has clearly defined communication protocols and meeting structures as well as team coping skills for stress management and conflict resolution. For instance, we cannot implement a process improvement strategy if the employees are not ready for change, are overworked, or if relationships are poor. When a culture is defined by stress, conflict, or poor communication, it is not possible for improvement efforts to move forward. On the other hand, it is possible to have a culture where employees are not stressed and have good communication and coping skills but who have no interest or structure by which to improve processes. In that case, the mission needs to be redefined and new team norms need to be established. In the wake of reports documenting the sources of medical errors, there is a belief and re-invigorated focus on the notion of culture change to include team coordination as a key element of health system redesign [3]. A healthcare system must fully embrace an integrative model that builds systems, processes, and a culture that puts patient experience and patient safety at the heart of all decisions and does so by engaging staff and fostering an environment where collaboration is a natural part of daily work. Nursing plays a primary role in the overall functioning of a healthcare system and its success in these areas. The following section will explore the importance and methods of teamwork, a program called TeamSTEPPS for building teams, culture, and strategies that lead to successful patient outcomes.

3.1 The Models and Domains for Building a Teamwork Culture in Organizations

A synthesis of research reveals themes of what comprises the healthy culture of an environment. Those would include leadership alignment among the leaders and with the mission values and goals, effective teamwork, mutual accountability, behavioral norms, support, performance management, reward systems, conflict management systems, role clarity monitoring, clear processes and procedures, and employee engagement. Davies (2002) offered practical steps and interventions for each of these areas [35, 36]. The next section will provide information about the most prominent healthcare teamwork program today, which is TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety).

3.2 TeamSTEPPS®

Given the necessity for cooperation among healthcare workers who are dependent on one another, it is critical that they are successful as a team. Teamwork requires an organization that is committed to sustaining a patient-centered culture as well as competencies and beliefs that become permanent mental models for how a healthcare facility functions as it relates to interactions beyond the process improvement domains previously discussed. The best and most widely known teamwork program is the Team Step Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) [37]. TeamSTEPPS is a systematic approach developed by the United States Department of Defense and Patient Safety Program and the Department of Health and Human Services Agency for Healthcare Research and quality (AHRQ). It works to improve the quality, safety, and the efficiency of healthcare [33]. The program was built on research conducted in healthcare that first determined the core mechanisms of teamwork that became the foundation for the TeamSTEPPS program. Those core mechanisms are communication, leadership, situation monitoring, and mutual support.

The AHRQ then designed tools to help healthcare staff members build skills around the core competencies. For communication, the commonly used acronym, SBAR stands for: situation, background, assessment, and recommendation. This tool organizes communication to be brief, timely, and clear in verbal conversation or as a written template in the variety of electronic communications. A nurse could use the format to organize personal conversation or as an electronic template with prompts added to ensure critical information is collected or provided. For handoffs between staff members during patient care, mental and verbal checklists can ensure all patient care information has been transmitted. An appropriate handoff also requires that the staff members receiving information ask the right questions for clarification to ensure a final handoff. AHRQ used the term “Call-out” for healthcare workers to point out a potential or real error. It is suggested that assertive communication should be clear, direct, and respectful. Healthcare workers are encouraged to practice phrases they are comfortable with when pointing out potential errors. Teams are encouraged to discuss communication patterns openly in staff meetings in order to establish ground rules for how best to phrase needs and recover from poor interactions. The management of meetings is another area addressed in the communication section of the AHRQ TeamSTEPPS [37] program. The Brief is a meeting that occurs between nursing staff and providers they support in preparation for a variety of events such as a difficult patient, a procedure, and early in the day organize patient flow. These meetings are most effective when they follow a standard checklist so that healthcare workers are prepared to ask questions or respond to predicted questions. It can be very effective for clinical staff and providers to brief to begin the day with a shared understanding of patients’ needs as well as clarification of needs for one another. The Huddle is a meeting designed to be impromptu and to respond to changes or urgent situations. Huddles are a semi-structured kind of meeting designed to respond to urgent situations while quickly getting people organized. Finally, the Debrief is a meeting that follows an event such as the end of the day, the end of a week, or after an encounter with a difficult patient scenario. It is designed for staff members to recover, regroup, or to learn from an event and to bring people together. Learning from these meetings can often be tied to performance improvement efforts and tend to generate discussion around events as opposed to pointing out blame.

Conflict management is a critical component to TeamSTEPPS in that conflict and disagreements are a primary source of nursing turnover and sentinel events [38].TeamSTEPPS provides this acronym for managing difficult conversations: DESC which stands for Describe, Express, Suggest, and Consequences and is used for organizing thoughts before having a difficult conversation. Feedback guidelines for communication suggest it should be timely, respectful, specific, directed, and considerate. Situation monitoring involves a team’s commitment to watching the flow of work as it changes through the day and knowing how and when to assist one another. It is important that team members come to agreement for norms and ground rules around mutual support and task assistance. This may involve some discussion around role clarity, the changing demand of the workflow through the day, and ground rules for how to ask for help and how to gracefully decline. The developers of TeamSTEPPS are clear that embedding this program into a culture cannot be successful simply through training but must be embedded into orientation programs, ongoing training efforts, regular local meetings, customized interventions by clinical area and offered regularly to leaders. TeamSTEPPS is a widely used, evidenced-based program that has successes consistently supported in research.

3.3 Performance Improvement Models

Healthcare cultures, teamwork, and coordination have been associated with success in the implementation of continuous quality improvement practices [38].Patient communication and safety culture initiatives must be integrated with a systematic, structured performance improvement model that continuously focuses on problem solving and provides metrics on the progress of the patient experience. The AHRQ CAHPS Improvement Guide [10] lists these three main models: The Institute for Healthcare Improvement’s Model for Improvement, Lean and Six Sigma. Key principles for operational excellence in healthcare are the development of a culture that sees problem solving as continuous with rapid cycles of experimentation. In this paradigm, engaged employees collaborate with leaders and problems are addressed immediately. If those problems lead to successful outcomes, improvements identified as best practices are then shared across the system. Problem solving follows a scientific process using the PDSACycle (Plan, Do, Study, Act) method and for larger improvement projects the DMAIC model is used (Define, Measure, Assess, Improvement opportunities and Control and sustain) [10].

From the May 2017, AHRQ Ambulatory Care Improvement Guide, steps for improvement are encouraged at the micro level: “To develop and refine such systems, healthcare organizations start by defining the smallest measurable cluster of activities” [10]. Healthcare organizations can take advantage of established principles and approaches to quality improvement, and should involve employees from a bottom-up approach with those closest to the problems, solving the problems. First, metrics are reviewed and clinical areas are identified as priorities for improvement goals, strategies, and interventions. A possible action plan is established with identified goals that should follow the SMART model (specific, measurable, achievable, realistic, and time bound) [10]. The guide offers this list of common features for improvement models:

  • Emphasis on leadership to hold people accountable, communicate the vision and strategy, and eliminate cultural and other barriers to improvement.

  • Clear goals.

  • Use of measurement and analysis to identify issues and guide decisions.

  • Emphasis on stakeholders as participants and audiences for the improvement processes.

  • Use of structured, iterative processes to implement improvement interventions.

  • Use of many of the same tools to support analysis and implementation.

  • Monitoring of front-line clinical activity through observations and the collection and reporting of process data as feedback on the effect of changes or to track the progress of the implementation process.

  • Transparent metrics.

4 Conclusion

Several key points have been made in this chapter. First, it is important to understand that patient experience, teamwork through safety culture, and performance improvement must be integrated into a single paradigm and jointly drive all decisions for patient care. It has also been established that key strategies should be developed based on the needs of patients by specialty area and personalized for each staff member. Many techniques are available for learning positive communication skills and several examples were offered. Improving patient communication is also a strategy for patient safety given that when patient communication is enhanced patient outcomes are improved. Patient experience outcomes cannot be improved without the coordination of the team members who rely on one another. A teamwork section was offered that focused on TeamSTEPPS, a widely used healthcare teamwork program. It is important that teams join together in regular discussion about norms for communication, positive interaction, handoffs, call-outs, meetings, briefs and debriefs, and for managing conflict and stress. Nursing is a critical component and central to the success of a healthcare organization. Nursing insights move beyond medical care of a patient to the medical, emotional, and cognitive needs of the patient. Nursing is also instrumental in the health of the organization as they play a key role in monitoring both patient well-being and the well-being of the culture around them.