Hartford uses report cards to teach nurses to teach

Having patients see nurses as caring proves tough

(Editor’s Note: This is the last of a three-part series examining how effective definition of provider roles can enhance patient and staff satisfaction. In the first article, we reported on some recent research on job role complexity. Last month, experts shared their thoughts on why proper role definition is important and signs that you don’t have the mix right. This month, Patient-Focused Care and Satisfaction looks at how one hospital found problems in this area and solved them.)

In its most recent survey of its hospital clients, consulting firm EC Murphy of Amherst, NY, found that the less satisfied staff members were in their jobs, the more likely they were to be sick.

"That’s quite a twist," says the firm’s president and CEO Emmet Murphy, PhD. The preliminary results of the study, which is due out later this winter, reinforces the importance of making sure your staff are doing the right jobs. "If their positions aren’t well-defined, you’ll have a problem with job satisfaction," explains Murphy. "And we have found that if you have dissatisfied nurses, your patient satisfaction scores will suffer, too. You have to redesign the jobs so that it works. If 40% of what a nurse does is inappropriate to his or her training, then you are spending big dollars to make your staff unhappy. Health care professionals have to get truly serious about redesign."

That’s precisely what Hartford (CT) Hospital did when it implemented a quality report card program in 1997. (See Patient-Focused Care and Satisfaction, December 1999, p. 133.) The goal was to find out what nurses were doing right, where processes and procedures needed changing, and then develop programs that addressed the problems the report cards identified.

The report cards look at clinical, financial, functional, and satisfaction indicators, explains Laura Caramanica, RN, PhD, co-director of the women’s health and cancer programs at the hospital. "This was the first time we developed a data set of important indicators and shared that information with staff so that they could do something about it."

Among the problems identified were lapses in patient teaching, patient satisfaction with pain control, and patient ratings of nurses as "caring." The first two areas have responded well to the programs Hartford Hospital has put in place to address them. (For more on how Hartford Hospital fixed its patient education problems, see p. 3.) Subsequent quality report cards have shown tangible improvements in those areas.

Pain control satisfaction is something Caramanica might not have considered looking at if not for the report card program. "We didn’t collect data on that before," she says. The hospital put together an interdisciplinary team of pharmacists, nurses, and physicians to develop improvements. In the six months between March and September 1998, the satisfaction with pain control measures improved from 75.3% to 78.9%.

How patients view nurses has been a tougher nut to crack, though. "We are adamant that we don’t just produce reports, but use them," says Caramanica. Not having at least 95% of patients seeing nurses as caring was hard to take, so the hospital decided to take action. "We did two different treatments with two different teams," Caramanica says. The first was a research round table in which faculty and nurses reviewed the literature on what were caring behaviors.

The behaviors that were decided upon are currently being tried out on a surgical unit. Two tools are used — one for the nurses to complete, and one for the patients. But Caramanica says it is too soon to see if the program is working. "We are doing a study to see if it makes a difference. The results should be out in March."

In obstetrics, a different approach was taken. All staff — from physicians and nurses to housekeepers — went through a two-day training program. The program included team-building exercises that increased everyone’s awareness of their communication behaviors and learning to understand and respond to the needs of the customer so as to meet or exceed in meeting their needs, Caramanica explains.

Training to be caring

It took nearly two years to get 80% of the staff through the training. Patient satisfaction scores from the pre-training days of 1996 and 1997 were compared to 1998 and 1999 scores. That was over 2,000 surveys, says Caramanica. "What came out was that nurses are caring and are viewed as more caring after the training. And also that there was a decrease in the response time for the call bell." (For more on the results of the training, see chart, p. 4.) The latter is probably due to the fact that staff members now have beepers due to the size of Hartford Hospital’s new facility — four times the size of the pre-training building. Caramanica says she expects those scores to increase in the next surveys.

Patient Satisfaction Scores Before and After Training

Satisfaction Question

Before Training Percent Answering "Always"

After Training Percent Answering "Always"

Treated me with respect and courtesy



Staff introduced themselves and explained role



Staff responded to my questions in a professional manner



Call button answered promptly



Help received in reasonable time



If I had a concern or complaint, someone listened and responded



The doctors were caring



The nurses were caring



Caramanica thinks there are a couple of reasons patient satisfaction scores aren’t as high as she would like them to be. First, Hartford Hospital uses a scale that only includes the word "always" for its most positive response. There is no "most of the time" or "often" option. That means that scores might be lower than they would be if the facility were using another scale.

"If you do often’ and always,’ you might get 95+ scores. But our goal is to delight the customer, not just satisfy."

Another reason could be related to what EC Murphy found: workers are less satisfied than they might be, and that probably comes across to patients. "I would guess that when we look at our 1999 report card and include employee, physician, and nurse satisfaction ratings, they will be lower than they used to be," Caramanica says.

The numbers bear out her feelings. While most nurses feel they are doing something worthwhile, a large minority feel their positions don’t give them enough opportunities for professional development and growth. A significant number also feel they have adequate input into their work activities.

"This is a tough time for nurses," says Caramanica. "And we have been putting a lot of pressure on them to improve quality of care; we have put them in a unit four times the size of the old one with the same staffing ratios. We have instituted mandatory call- and cross-orientation. Those things have impacted staff satisfaction."

Despite that, Caramanica has reason to be proud: patient satisfaction is rising. And in the future, she thinks that worker satisfaction will also go up. "We are putting in a shared governance structure, we are sharing meaningful data with them. And we will look at the correlation between units where the supervisors and administrators were rated highly and those where staff and patient satisfaction were high to see if there is a relationship."

Managing the kinds of data that Hartford’s quality report card generates is tough, but worth it, she says. "You can really use this information to improve patient care, as long as you get the support to make interventions work. Getting our staff to the classes, having faculty work with staff to identify caring behaviors, you need that additional support because staff can’t do it by themselves."