Sarasota Memorial Hospital serves one of the oldest populations of any hospital in the country, with patients aged 80 years and older making up about 25% of all hospital admissions in 2017. However, while the hospital always has performed well on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, analysts combing through the data in 2012 found that the scores were not uniform across all age groups.1
In particular, satisfaction seemed to be lagging among patients 80 years of age and older. For example, among patients aged 18-49 years, the hospital was at least meeting national average satisfaction scores in nine out of 10 publicly reported satisfaction measures. However, among those aged 80 years and older, the hospital was achieving average patient satisfaction in only two of 10 measures.
To correct the problem, the hospital focused new energy on improving the patient experience among older patients with the creation of a project dubbed PEACE (patient experience for acute care elders). Developers first piloted the effort on the nursing units that treated the highest concentration of patients aged 80 years and older.
“For us, it was three cardiac units and our orthopedic unit,” explains Shawn Halls, MA, manager of consumer and competitive strategy in the Sarasota Memorial Health Care System, and the person who first discovered the discrepancy in satisfaction scores in the older patient group. “Orthopedics didn’t have the highest percentage, but it had the highest volume of patients aged 80 and older. [The PEACE project] moved to a house-wide initiative after we became a NICHE [Nurses Improving Care for Healthsystem Elders] organization in the summer of 2017.”
The NICHE program, offered through New York University’s Rory Meyers College of Nursing, provides resources and expertise to teams seeking to improve the care of older adults. (Learn more about the program at: https://bit.ly/2QaOaRX.)
From the start of the PEACE initiative, developers focused on securing support from frontline staff members who would be critical to achieving project goals. As part of this effort, each pilot unit identified a geriatric resource nurse (GRN) to serve as the primary contact for the project.
“The GRNs are staff nurses who have volunteered to go through additional training to understand some of the specific needs of older adults,” explains Jackie Garabito, MSN, RN-BC, manager of clinical specialty programs at Sarasota Memorial. “Staff nurses can call on GRNs when treating patients who exhibit conditions that indicate they are at risk of developing additional challenges, using the Fulmer SPICES assessment tool for older adults.”
The SPICES tool prompts clinicians to consider several common syndromes affecting older adults, including sleep disorders, problems with eating, incontinence, confusion, evidence of falls, and skin breakdown. (Learn more at: https://bit.ly/2GJ7vtL.)
In the early days of the PEACE project, the GRNs followed the hospital’s own informal program of training, Garabito explains. However, the NICHE program has formalized training for the GRNs, including tools offered through the program.
In addition, in the ED, nurse leaders are GENE (Geriatric Emergency Nursing Education) certified, explains Lisa Collins-Brown, MSN, RN, the director of emergency care at Sarasota Memorial. “[They] play an integral role in training ED staff in how to communicate with and assess special needs in older adults and coordinate care that will help improve the patient experience and outcomes,” she says. “The majority of our ED patients are elderly, and so many of our processes and protocols are designed with the older adult in mind.”
Both the PEACE and NICHE initiatives have enhanced staff understanding of the challenges in older adults and reinforced their commitment to serving the needs of that population, Collins-Brown adds. “We have designed our nursing stations so that clinicians have a clear line of sight of patients in our ED waiting area and private rooms,” she says. “Our team includes case managers, social workers, and sitters who aid in the care of and communication with patients and ensure they or family members/caregivers understand their plan of care, which ensures a safe discharge.”
To ensure they were on the right track, developers of the PEACE approach note that they received continual feedback and support for the project from a senior advisory council consisting of members from the community and representatives for local organizations that serve seniors. With input from this group, the PEACE project team decided to focus their efforts on improving communications, particularly in three areas: the interface between nursing staff and patients or family members, directions regarding the correct use of medications, and ensuring that both patients and caregivers fully understand discharge instructions.
Staff spent time learning and practicing the “teach back” approach, in which patients or caregivers are asked to repeat back to the clinician important instructions to ensure that they are understood completely. Further, the PEACE project team used empathy training to help healthcare workers understand the challenges that seniors face when they are in the hospital. This included the use of glasses designed to simulate several age-related vision problems and special gloves to simulate the effects of arthritis. Staff members were asked to perform common tasks, such as opening a pill bottle, while wearing restrictive gloves to understand what seniors sometimes face when trying to carry out routine self-care tasks.
With patients older than age 80 years in mind, PEACE project developers decided to add “transport chairs” to the supply of wheelchairs on hand on the hospital’s first floor to help older patients or visitors navigate the hospital. Experts note the transport chairs serve a similar function as wheelchairs but are designed to be less clinical-looking so users do not feel as though they are disabled. A team is on hand to direct patients where they need to go in the facility and to provide assistance when there are mobility constraints.
The efforts to improve patient experience scores among patients aged 80 years and older have occurred at the same time as steep volume increases at Sarasota Memorial. For instance, from 2013 through 2017, inpatient volume increased by 30%, representing 8,000 additional patients.
“We focused our efforts on managing capacity and adding resources to handle such a large increase in such a short period,” Halls explains.
However, despite the added capacity challenges, the PEACE-driven changes have delivered promising results.
“During the same time frame, we saw improved scores in nine of 11 HCAHPS domains for patients aged 80 and older,” Halls notes. “Importantly, we’ve seen a five-point increase in responsiveness of staff, a six-point improvement in communication about medicines, and a four-point improvement in care transitions and overall rating.”
Meanwhile, HCAHPS scores among other age groups have remained robust. “Our biggest opportunity and focus has been in our 80 and older age group,” Halls says. “When we segment our HCAHPS scores by age, our patients under age 65 are largely satisfied, and the younger the patient, the more satisfied they tend to be. Even our patients aged 65 to 79 are overwhelmingly satisfied with their experience.”
For instance, Halls notes that in 2017, in the 65-79 age group, the hospital finished above national averages in eight of 11 HCAHPS domains, although Halls anticipates seeing some upward movement from this age group, too, as a result of the PEACE and NICHE initiatives.
“Because of the complexity of many patients aged 80 and older, we don’t expect their experience to be the same as their younger counterparts, but we’re focused on narrowing the gap between groups,” he says. “As we continue with our NICHE protocols and roll the tactics out to more of our units, we expect to see improvements in our 65- to 79-year-old patients, but we’re not at that point yet.”
After working on the original PEACE project team, Halls has some advice for other hospitals that struggle with their patient experience scores in the ED or elsewhere.
“Each hospital has its own unique challenges. For us, it is that such a high percentage of our patients are over the age of 65. Of those, 25% are aged 80 and older,” he says. “In the PEACE project, we started by segmenting by individual age rather than age group and determined that our experience drop-off point was age 80. [Another] facility’s drop-off age may be younger or older, which is important because it will dictate strategy and tactics for improvement.”
Halls also recommends that leaders of similar initiatives first take the time to review programs or services that are in place already to see what enhancements could be helpful and look for enthusiastic staff to help drive improvement efforts.
David Verinder, MBA, president and CEO of Sarasota Memorial Health Care System, adds that the PEACE/NICHE initiatives are not just about improving satisfaction.
“Older patients face greater challenges today than previous generations, [with] higher incidences of chronic disease, more complicated medical conditions, and increasingly complex technologies, therapies, and treatments,” he says.
“That’s why investing time and resources into these initiatives is so important. They not only enhance communication, but also promote the best health outcomes and experience.”
1. Reynolds K, Halls S, Jones M. The PEACE Project. NEJM Catalyst. Available at: https://bit.ly/2Q89Hul.