For example, if physicians go on rounds around 2 p.m., and nurses note an order for a medication around 2:30 p.m., while the discharge pharmacy closes at 3 p.m., by the time the order gets to the pharmacy, there may be difficulty filling the prescription, says Kimberly Horton, chief nurse executive at Alameda. This slows the patient's discharge and may delay another patient from getting an inpatient bed.
“We realize that frequently the experience the patient has is dictated by how well the departments work collaboratively,” which is not always good, Horton says. “We're getting rid of those silos.” Alameda also has created a special team with patients and family members who advise the hospital and participate in Lean quality-improvement projects.
There also are direct financial reasons for hospitals to make it easier for patients and their families to be engaged in their care. The federal standards being used to recognize the meaningful use of electronic health records are ramping up the amount of information that needs to be made available to the patients to qualify for the financial incentives in the second stage of the program.
“Stage 2 really had much more emphasis on patient engagement,” says Dr. Jeff Hummel, medical director for clinical informatics at Qualis Health, a Seattle-based not-for-profit healthcare quality-improvement and consulting group. The final rule for Stage 2 mandates that EHR technology must provide patients with an online means to view, download and transmit selected data.
Alameda County Medical Center and others are including more low-tech approaches to boosting patient engagement. Alameda's heart clinic, where much of its patient-engagement work originated, has patient navigators to assist patients in coordinating their care through a self-funded pilot, and the hospital has partnered with community groups to try to perform follow-up care with homeless patients, Horton says.
She says that the fact that their often uninsured patients delay care and may not get a lot of primary-care services means patients tend to be sicker, which complicates patient-engagement efforts that take place early on in the care process. As a result, the medical center promotes its engagement efforts at times when patients are better able to absorb information, after they've been treated.
Public hospitals also face a different set of challenges than do private hospitals in boosting engagement among patients and their families. “A public hospital may face more difficulties,” given they often are struggling financially, their patients may not have the level of social and economic resources as patients at private hospitals have, Bo-Linn says. And the generally greater level of diversity can create social and language barriers to engagement, he adds.
“Nonetheless, even with those challenges there is nothing to suggest … that public hospitals should be less dedicated to patient and family engagement,” and one can argue that they should be more engaged, he says.
San Mateo's Ehrlich echoes that, saying that “public hospitals need to be held to the highest standard” for taking care of their safety net patient population. “We have to be judicious stewards of their care.”
At 469-bed Hennepin County Medical Center in Minneapolis, executives are working to transform the care processes. Caregivers attend hospital-sponsored events in which physicians and staff sit down for a day to hear stories told by patients and family members about the care they've received. The events include three patient panels, one of which is composed of hospital employees who have been patients.
“They tell us the good, the bad and the ugly,” says Kathy Wilde, chief nursing officer. All physicians and staff are required to attend one of the meetings, which in total are estimated to eventually cost $1.7 million to conduct, Hennepin officials say.
Yet Hennepin's progress as measured by improvement in patient-satisfaction scores has not been as good as hoped, Wilde says. Hennepin's status as an academic medical center has made it tougher, she says. The teaching environment makes it more difficult to always put the patient first, but Hennepin is moving in the right direction, she says. For example, the hospital is shifting multidisciplinary rounding so that patients can learn more about their care.
Wilde's colleague, Sheila Moroney, director of patient experience services and patient and family-centered care, says that Hennepin officials expect the move toward more patient-engaged care will pay off to the degree they want, but notes that improving the patient experience can be more difficult at a safety net hospital, given its role and patient population.
“It's not the same as delivering (care) through a suburban … hospital with a waterfall in the lobby,” she says.
Moreover, often overburdened staffers and physicians at public hospitals might not be receptive to changes that at least in the short term will make their job harder. “It's a tougher work environment,” says Dr. M. Bridget Duffy, CEO of ExperiaHealth, a patient-experience consultancy based in San Francisco. “My heart goes out to the people in the trenches at public hospitals,” Duffy says.
UC Davis Medical Center, Sacramento, has turned what was once considered a portent of doom for nurses—the arrival of a patient-relations official on a floor—into an event that now might be welcomed by patients and staffers, says Cheryl Clyburn, manager of patient relations at the 563-bed hospital.
The patient-relations official meets with the patients not to survey them, but to make sure their needs are being met and they have the information they need. At first, nurses did not appreciate the visits but now are more inviting, Clyburn says. Some floor nurses will even encourage a visit for certain patients if they see a need, she says. Key to the success of that effort is finding a person who can relate to patients and the staff members, she says.
Contra Costa's Roth says that getting hospital staff and physicians to go along with its somewhat drastic patient-engagement changes has been a relatively smooth process. “It wasn't as tough a sell as people might think,” she says. “It does help that the CEO is strongly on board.”
And Roth expects the process to continue even if she were to leave the medical center. “This is a key strategy,” she says. “It's not my strategy, it's our strategy.”
TAKEAWAY: Safety net hospitals are getting patients and their families more engaged in the care process and in healthcare design.