Post-honeymoon, does patient-focused care deliver on its promises?

Four years later, one facility is happy with its satisfaction scores

It was perhaps not surprising that in the first year after Sioux Valley Hospital & University Medical Center in Sioux Falls, SD, opened two patient-focused care (PFC) units, there was an increase in patient, physician, and staff satisfaction numbers. Other quality indicators also increased (for specific improvements, see box, p. 74).

None of this came as a shock to Joan T. Reisdorfer, MS, RNC, director of medical, urology, and oncology units at the 500-bed hospital, and a leader in the creation of the two units.

Four years after PFC came, the benefits remain. "Generally, positive results have continued," says Reisdorfer. "Patient satisfaction is consistently high. We get letters from our oncology and long-term medical patients telling us how much they appreciate us. Physician satisfaction is high, although not all docs like this. There will always be those who mourn the way it was." Quality indicators also remain within the hospital parameters, despite a patient census that is consistently above budget.

The positive results were strong enough to encourage the facility to make its oncology floor into a PFC unit, too. And Reisdorfer remains committed to the principles that guide the units at Sioux Valley (for a list of those principles, see box, p. 75). Indeed, they are posted in the units and are a focus of staff orientations.

New floors, new philosophy

The original units were conceived in 1992, when the hospital was putting in new medical and orthopedic floors. "We wanted to look at a different way to work more efficiently," Reisdorfer recalls. "We wanted to find ways to delight the patient." PFC was a new concept then, and it seemed to fit the bill for what Sioux Valley’s administration wanted to accomplish.

"There were so many steps to accomplish some things — 101 for a chest X-ray," she says. "A typical patient would see up to 60 different people during his or her stay. There were issues about reporting relationships, about the workload of some caregivers, and the lack of meaningful work for others."

A steering committee involving management from almost every department in the hospital created the PFC principles and also looked at what issues needed addressing to bring those principles to reality. The group broke into several committees who were charged with creating flowcharts of existing processes and finding ways to improve them.

One of the biggest changes the steering committee made was to take the existing nurse aide role and expand it. "Many of them felt they could do more," says Reisdorfer, "so we created the patient care tech role." Designed to provide a variety of patient support functions, the technician has more training to do the tasks that previously were left to the nurse or an interdisciplinary care team member.

The patient care technicians assist with activities of daily living, check vitals, and provide catheter insertion and oxygen therapy. They must take three computer classes to help with computer order entry skills, and two medical transcription classes. Additional training includes a lab theory class, with clinical practice of phlebotomy and blood sugar testing, and optional courses in team work and leadership. Most of the technicians are nursing students, which creates a turnover problem. On the upside, says Reisdorfer, many of them end up being great nursing candidates.

Other changes made in the PFC units included making housekeeping staff reportable to the nurses. "That eliminates the fighting to get the room cleaned, and allows them to do things for the patient if the patient is in the room asking for assistance."

The PFC program allows clerical staff to handle precertifications for elective procedures, Medicare and Medicaid paperwork, and patient consultations regarding bills. "That eliminated the need for discharged patients to have to stop at the business office before they left," says Reisdorfer.

Some of the more popular changes included putting a pharmacist on each of the PFC floors, which cuts down on medication errors, and giving portable phones to the nurses, which keeps noise levels down and physicians in touch with the nursing staff.

One of the key goals of the new unit was to eliminate the "it’s not my job" attitude, says Reisdorfer. "Our CEO at the time told me he didn’t want any idle time for staff. No one should ever say, This isn’t my job.’"

The committees looked at primary and secondary jobs for all staff, and the changes that were instituted were significant. The secondary job description for everyone includes seeing to patient needs. "Anyone can answer the phones, answer patient lights, and get water or something else for patients, and assist with patient transfers," she says. "Even our pharmacists and social worker went through the training."

Tweaking the program

In the years since the PFC units were established, Reisdorfer says few changes have been made to the program. Initially, medications were dispensed on the unit. "But that wasn’t cost-effective. We decided having a pharmacist on the floor was enough."

Other changes included eliminating training for clerical staff in admissions. With so many patients being directly admitted for tests and procedures, those skills were not being used. Originally, says Reisdorfer, the units were also going to do some lab tests on the floor, believing that time savings would be significant. However, machinery available to do tests was too specific; and after looking at testing volumes, the idea was scrapped.

Physicians had some complaints that since charts were now left outside the patients’ rooms, they were interrupted with questions as they made notes before or after seeing a patient. As a result, the units now have a physician dictation area in every wing where they can avoid such interruptions.

There has been difficulty in ensuring that some of the principles are followed. The third PFC principle — that staff are all responsible, accountable, and professionally challenged — has bumped headlong into a 1.8% unemployment rate in Sioux Falls. "It’s very hard to hire and keep staff, especially non-licensed personnel," Reisdorfer admits.

In addition, it is hard to ensure that the allocation of resources is appropriate — the ninth principle — based on traditional cost per unit of service equations. "We look at the number of full-time employees per admission rather than just at patient days," she says. "A patient might come at 5 p.m. and leave early the next day. That’s only one day, not the two that would be counted. We find it better to look at admissions."

Some physicians remain difficult to please. "They liked the status quo," says Reisdorfer. "They would prefer an all-RN staff, but that’s not realistic." Many complain that since central nurses’ stations were eliminated, they can’t find nurses easily. "But we all have phones, and the lack of stations means that the nurses are with the patients more. It also cuts down on chitchat."

Some nursing staff were also slow to come on board. "They have had to endure change after change, and are disillusioned with it in general," she says.

By keeping staff informed — through unit and hospital newsletters and e-mail, and every unit and committee meeting — and getting them actively involved in the change process, Reisdorfer has been able to limit some of the ill feelings. "Even then, it takes time. I had one nurse wait two years before she admitted she liked the changes," she says.

In the beginning, she adds, it’s important to let people vent their fears. "We had a lot of general sessions where people could question us. We held FYI meetings so that everyone in the hospital knew what was going on."

Reisdorfer says there are three words that will ensure a PFC program’s success: "Involvement, involvement, involvement."

She says letting people know that changes are coming as soon as you know they are imminent can alleviate some of the fear change always brings. Getting all staff involved in the process, she says — from helping to redesign roles, coming up with job descriptions, and developing evaluation parameters — was instrumental in making her project fly.

It’s also important to have savvy administrators who understand that change will occur in everything from reporting relationships to financial accounts. "When you have a PFC unit, you take on some of the housekeeping budget or the phlebotomy budget," Reisdorfer says. "How can you compare that to other hospitals where those budgets are separate? You end up having a lot of notations in your accounts; and there is more than just the unit staff involved. You cross borders. You might have quality checks for housekeeping done by your environmental staff."

The goal should be to delight the patient. "PFC should mean that the staff have many different roles and more responsibilities so that patients feel a closer sense of caring. The unit staff should be there more than other outside staff," she says.

Reisdorfer continues to study the impact the PFC units have. Currently, she is concentrating on educational and retraining needs for staff, and the hospital has forged links with an area technical college to offer a phlebotomy technician program and a health unit coordinator technician program.