Care continuity boosts patient satisfaction

Where patients are concerned, less may be more

It became clear to quality managers at Melrose-Wakefield Home Health Care in Saugus, MA, that patients were not satisfied with the agency’s nursing continuity of care. Patients indicated too many nurses were visiting them, and didn’t like the frequent changes.

The agency’s patient satisfaction surveys shows the overall satisfaction was about 85%; but the question about continuity of care resulted in only a 68% satisfaction rating, says Patricia L. Finocchiaro, RN, MS, clinical director of the agency, which is part of the Hallmark Health System, a four-hospital system in Malden, MA. The agency has about 115,000 visits a year.

The agency formed a team using the quality improvement process called FOCUS-PDCA, devised by Health Corporation of America in Nashville, TN. FOCUS-PDCA stands for the following:

Find a process to improve.
Organize a team.
Clarify current knowledge of the process.
Understand the causes of process variation.
Select the process improvement.
Plan to implement improvement.
Data collection and analysis.
Check data for process improvement.
Act to hold, gain, and continue improvement.

Improve patient satisfaction

The results have been encouraging, Finocchiaro says. Nursing care continuity rose from a baseline of 60%, to as high as 85% after major changes were implemented. Some of the initial changes were revised, and the latest continuity of care rate hovered in the 78% range.

Using FOCUS-PDCA as a framework, Finocchiaro describes how the agency improved its patient satisfaction levels:

1. Find a process to improve: The agency selected nursing continuity because of its direct relationship to improved patient satisfaction and because continuity is addressed in the home care accreditation standards of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

Department managers were also concerned that variations and inconsistencies in nursing practice could harm patient outcomes, Finocchiaro says.

2. Organize a team: The team consisted of Finocchiaro, two clinical nursing supervisors, an education coordinator, a clinical information system coordinator, and the director of quality improvement, who also served as the team’s advisor. "We chose those members because they were familiar with the operations and the current system of scheduling that we used," Finocchiaro says.

The team was supposed to be temporary, created solely to work on this particular problem and disband when the process was completed. "We would, however, meet periodically to review the process improvement cycle," she says.

3. Clarify current knowledge of the process: The team gathered information to develop a best practice standard for continuity.

First, they had to collect data to establish the agency’s current rate of nursing continuity. They used a tool that asked nurses why they did not see their primary patient on a particular day.

The nurse-driven variables included vacation time, personal time, and sick time.

Supervisors conducted one-on-one interviews with five nurses, following them over a one-month period, and keeping track of each time they missed seeing one of their patients, Finocchiaro says.

The team tallied the results, looking for trends in the top reasons selected.

They found:

• a nurse-driven variable of nurses scheduling their own days off;

• a patient-driven variable of patients needing a visit at a certain time of the day, and the nurse couldn’t make the visit at that time.

The results surprised team members. Nurses were able to plan their own schedules, and might arrange days off to have less impact on patients, Finocchiaro says.

Formula for success

The team also determined the agency’s current rate of continuity by using a simple formula: Continuity = Number of primary patients seen by primary nurse (in one quarter) divided by the total number of patients on the primary nurses’ caseload (in one quarter).

The overall rate of continuity for nurses in the agency was calculated to be 60% based on that formula. The team looked for guidelines or benchmark data about continuity of care.

"We felt instinctively that we could improve the process of continuity, and thus the associated rate," Finocchiaro says.

They found a study conducted in 1996 by the Home and Health Care Association of Massachusetts, the industry’s statewide education and lobbying group. The study examined continuity of care in 17 Massachusetts home health agencies. It reveals that the average rate of continuity was 77%.

"We chose to use 77% as the standard with which we would compare our own performance," Finocchiaro says.

4. Understand the causes of process variation: Team members brainstormed factors that could impact continuity. They listed their ideas on a flip chart, and organized them into three categories on a cause and effect diagram:

Nurse-driven: Vacation, sick time, and personal time.

Administrative-driven: Staff meetings, caseload assignment, other mandatory team participation, and other meetings.

Patient-driven: Patient scheduling needs (if a patient requires an early morning visit for insulin administration, for example); patient condition change requiring an unscheduled visit; fluctuation in patient census leading to too many patients for one nurse to see, or too few patients requiring nurses to take patients from other nurses to meet productivity expectations.

5. Select the process improvement: The team decided to target only continuous improvement activities related to patient satisfaction and nursing continuity. They chose not to evaluate the effect of poor continuity on clinical health outcomes because that would change the focus of their improvement efforts, Finocchiaro says.

6. Plan the improvement: "We decided the only way we could impact some of these variables was to look at a different approach to nursing care," Finocchiaro says. "Unless nurses work seven days a week, there’s always going to be some break in continuity."

The team looked at the option of using primary nursing teams, instead of its traditional primary nurse approach in which a primary nurse is responsible for a particular number of patients. In the new approach, two or three team nurses would follow the same patients. That way, the patient would consistently have the same nurses providing care.

Other options the team discussed include having nurses work 10-hour days and every other weekend, or hiring only full time staff nurses.

7. Data collection and analysis: Clinical supervisors reviewed patient caseloads of five nurses over a one month period, and the team analyzed this information.

"The outcome indicators, patient satisfaction, and continuity rate were identified as our key quality characteristics because of their importance to our customers, and we could accurately measure them for improvement," Finocchiaro says.

The team anticipated that patient continuity would increase and patients would be happier if the agency switched to the primary team approach, she adds.

8. Check data for process improvement: "We took two staff nurses who had joined our quality improvement focus team, and asked them to schedule their patients for the next month as a team rather than as individuals," she says. "We asked them to cover each other’s weekdays and weekends off, then we gave them a smaller, manageable caseload of patients."

The two nurses tried this model for one month. Their patient continuity, measured together as a team, was 85%. They were considered to have achieved continuity if either one of them had seen a patient within their joint caseload.

"It brought us up to what we thought was our goal, but it was still not a reality; it was just a predictor model," Finocchiaro says.

9. Act to hold, gain, and continue improvement: The next step was to discuss the model’s results and changing the staff’s structure with the staff. "We had to deal with a lot of staff anxiety about how that would impact their ability to practice independently," she says.

Then managers developed nursing teams, matching nurses to others with complementary skills and expertise. Nurses seemed willing to try the teams, although later nursing buy-in would prove to be a problem.

They gave nurses a month to discuss the changes with patients. "Staff nurses suggested that we include the patients in the education process," Finocchiaro says. "If patients knew from the beginning of their home care experience that they would be followed by a team of nurses, they would have different expectations of what constituted continuity."

Once the entire nursing staff began to use the team model, quality managers measured the continuity rate on a quarterly basis to make sure they held their gains in continuity.

The patient satisfaction survey is only sent out annually, so the process improvement team had to find other ways to measure patient satisfaction in the interim. For example, they conducted telephone surveys on a regular basis. The telephone surveys indicated patients were becoming more satisfied with nursing continuity.

"We monitored the scheduling. We had a scheduler involved, so she knew who the teams were and how to refine schedules," Finocchiaro says. "We also posted the continuity rates monthly in a graph, so staff could see how they were doing."

The agency achieved the desired outcomes, with continuity rates of 84.1%, 81%, and 81% in consecutive months following the change.

"But there was another glitch here," Finocchiaro notes. "The staff didn’t like it, and they were very unhappy with the change." After trying the team process for three months, managers met again with nurses and asked them how they could revise it to meet their needs.

You’ve got voice mail

The nurses said they were unhappy with the phone message system used, for instance. When the teams were enacted, each team of nurses was given one voice mail number. This was supposed to improve communication between team members, but nurses said it was hampering their patient care by making them spend more time taking messages.

The agency again gave each nurse a separate voice mail number.

Some nurses also said they preferred to work independently; they could not adjust to working in teams. "We met with the QI director again and talked about the staff needing time to get through these things," she explains. "We looked at revising the primary team approach, instead using a primary pod approach."

Patients would be assigned to individual nurses instead of two-person teams. Only each nurse would work within a nursing pod, meaning more than two nurses would handle patients’ care. A pod might consist of three nurses and a float nurse. If none of the three nurses could be available to visit a particular patient, then the float nurse would visit. The pod would see the patient weekdays and on weekends.

Nurses appeared to like the change. Finocchiaro believes they even began to make greater efforts to see their own patients more often because the whole process made them aware of continuity issues.

The quality team learned that they could have avoided some of the buy-in problems over the change if they had involved front-line nurses in the beginning of the process. "By engaging the staff at the front end of the total quality management process, the team could have benefited from their input and elicited their support," Finocchiaro says.

The agency continues to monitor the continuity on a monthly basis, and a recent measurement indicates that the continuity rate still is slightly above its 77% initial goal. The 1998 patient satisfaction rates are not yet available.


Patricia L. Finocchiaro, RN, MS, Clinical Director, Melrose-Wakefield Home Health Care, 1715 Broadway, Saugus, MA 01906. Telephone: (781) 979-6301.