Patient Engagement

Using a “Nursing Bundle” to Achieve Consistent Patient Experiences Across a Multi-Hospital System

Case Study · May 14, 2017

Geisinger Health System has evolved and grown in terms of diverse cultures, demography, and size over the past 4 years. We addressed inconsistent patient experience by creating a nursing bundle that helped make patients’ experiences more consistent, and more consistently excellent, improving overall patient satisfaction and Geisinger’s performance on standard assessments of patient satisfaction.

Key Takeaways

  1. Measure what you treasure (data are critical). We are measuring our HCAHPS and nursing bundle scores on a monthly basis.

  2. Give frequent feedback (both recognition and coaching). The Patient Experience team and leadership acknowledges positive feedback via personal notes and recognition and coaches employees and leadership on the specific behaviors and process required for each element of the nursing bundle. For example, if the coach sees team members interacting with a patient without introducing themselves, he or she reinforces that expectation.

  3. Have a well-stocked toolbox for leaders and staff. Our toolbox includes videos of employees performing C.I.CARE well in multiple scenarios across the system.

  4. Be persistent but patient — changing culture takes time. Consistently reward effective communication and bundle compliance and focus on continuous improvement.

The Challenge

Geisinger Health System (GHS) is one of the nation’s largest health service organizations, caring for more than 3 million residents throughout 45 counties in central, south-central, and northeast Pennsylvania and southern New Jersey. This physician-led system has approximately 30,000 employees, including nearly 1,600 employed physicians, 12 hospital campuses, two research centers, and a 551,000-member health plan.

Over the last 4 years, GHS has added seven new hospitals, all with their own cultures, traditions, demographics, and employees. To create a consistent experience for patients, we needed to decide on, and implement, best practices for our nursing staff. This challenge was related to the ProvenExperience initiative, begun in 2015 under our new president and CEO, David T. Feinberg, MD, to offer partial or even full refunds when Geisinger’s care does not live up to patients’ expectations.

The Goal

Our goal was to develop and adopt a consistent “nursing bundle” across all of our sites. A bundle, as defined by the Institute for Healthcare Improvement, is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices — generally three to five — that, when performed collectively, consistently, and reliably, have been proven to improve patient outcomes. This definition allowed us to focus on the most critical elements of the bundle.

The Execution and the Team

We created a team comprising chief nursing officers (CNOs) and key nursing leaders across the system. This team identified evidence-based practices that were proven to provide the best experiential and clinical care outcomes. Each CNO was charged with vetting the best practices and eventual nursing bundle plan with managers and frontline registered nurses. This process assured support, buy-in, and input from all levels within the organization.

Geisinger Health System Proven Nursing Bundle: Final Bundle of Five Practices

  Click To Enlarge.

  • Purposeful Hourly Rounding:  The care team enters every patient’s room each hour, rather than waiting for the patient to call, and addresses pain, toileting, and positioning.
  • I.CARE:  All care team members are expected to connect (knock prior to entering a patient’s room), introduce themselves and their role, communicate what they would like to do (e.g., give medications), ask permission (if it is a good time for the patient), respond to questions, and end with excellence (e.g., “Is there anything that I can do for you before I leave the room?”). The C.I.CARE model was originally developed under Dr. Feinberg’s leadership at UCLA.
  • Whiteboard:  A whiteboard in every patient’s room, visible from the bed, shows the date, the names of the care team for the day, anticipated discharge date, and goals for the day.
  • Bedside Shift Report:  Nurses ending their shift discuss the progress toward achievement of goals with the nurse coming on duty, the patient, and any family present.
  • Nurse Leader Rounding:  The unit nurse leader will round on each patient at least once during the hospitalization and leave a business card with the patient.


We developed a set of customized questions for the patient satisfaction survey we distribute to patients, addressing key components of the nursing bundle. To date, from baseline data approximately 6 months ago, GHS has improved in the above-noted components being consistently (always) performed. These responses came directly from the feedback provided by our patients from the custom questions.

Also, a C.I.CARE competency tool was developed to provide ongoing training as needed, to hold all employees accountable to the process, to coach and mentor, to provide an ongoing competency check, and to use for annual performance evaluations. Senior leadership rounding was kicked off at the system, hospital, and department levels to ensure appropriate setting of expectations and role models. System leaders round together quarterly across the system using videoconferencing and share patient and employee stories that illustrate both successes and opportunities for improvement. All leaders are expected to attend 75% of scheduled rounds. Hospital leaders round monthly using the same process. Department leaders are expected to round in their accountable areas daily. The overall Nursing Bundle compliance is being measured by the HCAHPS Nursing Communication scores. Since our C.I.CARE and bundle implementation, scores for GHS have consistently increased by up to 3 points and 10 to 15% over the 6-month period.

Geisinger Health System Nursing Bundle Compliance Trends

  Click To Enlarge.

Where to Start

Because each of our hospitals was starting at a different place, we needed to establish a baseline against which we would be able to measure improvement. We created the Patient Experience Bundle Gap Assessment Tool to assess initial performance of the elements of the bundle at all campuses.

We also created a nursing competency tool that our facilities could use both for initial training on the bundle components and for ongoing assessments of competence. The program includes an annual competency review for each nurse. In this program, the nurse will be observed demonstrating the elements of the competency tool such as knocking while entering a patient’s room, conducting a patient report at the patient’s bedside with the patient and family, and making sure that the whiteboard is up to date in each patient’s room.

Approximately 25 to 30% of Geisinger’s patient complaints come from communication failures. As a result, communication has become a major focus for the entire health system, not just nursing, and everyone, from the organization’s top leadership on down, has been trained to use the C.I.CARE communication framework, Dr. Feinberg’s first mandatory initiative. The entire organization of 30,000 people received this communication training over 4 months, from March through June 2016.

Lessons Learned

Executive leadership must make patient experience a strategic priority via goal-setting, day-to-day behaviors, and culture.

It is just as important to train the top leadership as to train frontline employees.

Monitoring performance is essential. Ongoing results and progress, monthly and quarterly, are shared with our board, our CEO, all levels of leadership, and fellow employees to track performance and celebrate successes.

We are improving our performance by adding other tools, such as an inpatient welcome letter that helps set expectations by educating patients on the nursing bundle elements and providing photos and contact information for the nursing leaders in each department.


This case study originally appeared in NEJM Catalyst on April 13, 2017.

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