Sarasota (Fla.) Memorial Hospital, an 829-bed acute care facility, is in a popular retirement area and more than half our patient population is covered by Medicare. Our fastest-growing patient age group is the 80-and-over segment, but analysis of our patient satisfaction data revealed that this segment is by far the least satisfied with their experiences at our hospital. We describe the steps we took to address the unique needs of our eldest patients. While their satisfaction is still not as high as we would like, it has improved significantly, and we have learned a lot from our efforts to provide more differentiation in our formerly “one-size-fits-all” patient experience.
Editor’s note: Ms. Reynolds passed away during the editing of this paper. Her co-authors honor her memory with its publication.
The 80-and-over segment of the population is predicted to triple over the next 20 years in the United States. Three out of four older adults have more than one chronic condition, and individuals with multiple chronic conditions use a vast majority of health care services.
Sarasota Memorial Hospital was an early adopter of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and has been the top performer in its four-county region since HCAHPS results were first publicly reported. By 2012, we had segmented the data by unit, by patient type (medical / surgical / OB), by major diagnostic category, by geographical proximity to our hospital, and by gender, but we hadn’t yet looked at it by age, even though Sarasota Memorial Hospital serves one of the oldest populations in the country. (Patients 80 and older accounted for one in four of our inpatient admissions in 2017.)
When we analyzed our 2012 HCAHPS scores by age, we were shocked to discover that for the 80-and-over population, Sarasota Memorial Hospital achieved CMS National Average patient satisfaction in only 2 of the 10 publicly reported measures. (In contrast, we met 9 out of 10 for the 18–49 population, and 7 out of 10 for the 50–79 population.)
Clearly the patient experience was dramatically different for our oldest patients, and we needed to improve.
We sought to adopt strategies and tactics to improve patient experience for patients aged 80 and older. What’s good for the patient is good for the organization and the community, too. Empathy, focus, and communication with our oldest patients (and their caregivers) creates better experience and outcomes for all our patients.
The team for the PEACE Project included the three authors: Karen, a clinical nurse specialist; Shawn, who is responsible for compiling and reporting all the CMS patient experience data, and who initially discovered the 80+ gap; and Mackenzie, who coordinates many of the hospital’s population health initiatives.
We also received vital input from the HCAHPS steering committee, made up of our Chief Nursing, Medical, and Operating officers and senior leaders of clinical and facility areas, our Senior Advisory Council, Sarasota Memorial Health Care System’s Board of Directors, and the Medical Executive Quality Committee. The PEACE Project also had the strong support of our CEO.
We were able to begin this project with little to no additional expense, by reimagining some daily operations and focus. We structured our efforts around the Kotter Eight-Step Change Model, first published in 1996 by Harvard Business School Professor John Kotter. The eight steps are:
- Establishing a Sense of Urgency
- Creating the Guiding Coalition
- Developing a Vision and Strategy
- Communicating the Change Vision
- Empowering Employees for Broad-Based Action
- Generating Short-Term Wins
- Consolidating Gains and Producing More Change
- Anchoring New Approaches in the Culture
We felt this model provided clear imagery for all levels of staff to understand, and also started with winning hearts and minds in order to influence change. We felt that appealing to the hearts of the frontline staff would be the best way to get their attention and to get them to buy into our project. The HCAHPS age-segmented data cited above provided the basis for establishing our sense of urgency.
We created a guiding coalition by presenting the age-segmented data to several groups: our HCAHPS Steering Committee, our Senior Advisory Council (a longstanding group of 10 dedicated community members and representatives from area organizations serving seniors), our Medical Executive Committee, and the system Board of Directors. All these groups supported developing a strategy to improve our performance.
With unanimous support from all groups, we formalized our strategy by creating the PEACE Project (Patient Experience for Acute Care Elders), a pilot program to improve the hospital experience for our oldest patients. We conducted the pilot on three nursing units with the highest concentration of patients age 80 and over. We also included a fourth unit, the orthopedic unit, that has the highest volume of patients, including patients 80 and over.
Each pilot unit identified a “geriatric resource nurse” to serve as the primary project contact for that unit. This formula helped staff achieve a sense of ownership with the project. The PEACE Project team was made up of the managers of the selected pilot units, seven geriatric resource nurses, and a member of the Senior Advisory Council, along with Karen, Shawn, and Mackenzie.
The PEACE Project team met monthly. At the initial meeting we introduced the data, which yielded literal “aha’s” from the clinical managers of the pilot units, who had been trying to reconcile lower HCAHPS scores with the positive feedback heard from most patients during daily rounds. The team discussed feedback received from the Senior Advisory Council, the responses to specific HCAHPS questions, and anecdotal feedback from the units, and also reviewed the resources at our disposal.
Our Senior Advisory Council members were not surprised by the differences in HCAHPS scores for patients 80 and over. Several members spoke of their own difficulty managing multiple chronic conditions while caring for a hospitalized loved one who also had one or more chronic conditions.
We identified three specific areas for improvement; their common theme was better communication. The three categories were: general communication between nursing staff and patients and family members, conveying the correct use of medication, and ensuring that both patients and caregivers understand discharge instructions.
To help our employees understand firsthand the challenges older adults face during and after hospitalizations, we utilized empathy training. We employed multiple methods to help staff understand the challenges of aging. Glasses simulated several age-related eye conditions, arthritis simulating gloves and a sewing kit demonstrated the difficulties with dexterity, and a bottle of different “pills” showed the struggle to open bottles and correctly identify medications.
Karen worked with the resource nurses to understand and role-play Teach Back, a method of determining whether staff have explained things in a way the patient understands by asking the patients to state in their own words what they need to know or do about their health. In addition, an enthusiastic resource nurse used her iPhone to record short video vignettes with PEACE Project members role-playing examples for communicating with patients 80 and over. Learning and practicing empathy and communication skills specific to older adults creates a culture of caring and the foundation for better patient experience.
In an effort to remain budget-neutral, or close to it, while making a meaningful impact, we also identified three current programs that we could enhance specifically for the 80-and-over population.
HealthSquare, our consumer engagement space in an area mall, offers free health and wellness content to our community through lectures, active programs, and referrals. We added tailored content for older adults to the community lectures, with subjects including anticoagulation, injury prevention, medication list management, memory clinics, “Ask a Pharmacist,” and information about community resources available to older adults.
The active programs included Wellness Walks, a free program that met weekly for a group walk and an educational talk by one of our hospital’s clinical experts. Another active program was a unique partnership with the local library — a walking and talking book club called Footnotes. Qi gong and chair yoga also became a part of the HealthSquare program.
HealthFront, a team stationed on the hospital’s first floor, helps with wayfinding and trouble-shooting, and walks patients and visitors to their destinations when necessary. With their high-visibility green shirts, HealthFront team members address the significant challenges of navigating our 1.5 million square-foot facility and are a key component of our patient satisfaction program. To support our 80-and-over patients, HealthFront supplemented its supply of wheelchairs with “transport chairs,” which serve a similar function but are more streamlined and less “clinical” looking than a wheelchair, and allow our older patients to be transported easily without feeling disabled.
HealthConnection, a warm, welcoming space on the first floor of the hospital, makes health and wellness resources available to patients, staff, and community members. They can attend educational lectures, gather for support groups, ask any health care–related questions, or relax with virtual reality headsets and a library of VR videos that include travel to other countries or sitting on a beach or a farm.
Because HCAHPS data and nurse rounding feedback showed a need for resources to help patients’ caregivers, who are often 80 or over as well, we added a “caregiver connection” component to the HealthConnection space, with resources and tools specifically for caregivers. For example, the health coach has event calendars for local senior community centers and a tablet designed to search for specific continuing care facilities.
While still only meeting the national average on two HCAHPS measures for the 80+ population, we have seen marked improvement in several areas, and are narrowing the gap between our performance and our goals. Somewhat surprisingly, because we know we have much work yet to do, we’ve realized a 7-point top box improvement in Overall Hospital Rating. We gained ground in all except three measures (cleanliness, pain management, and care transitions), and gained dramatically in communication about medicines. The table shows the change in our HCAHPS scores in the 80-and-older group between 2012 and 2017.
Where to Start
Although Sarasota Memorial Hospital has been highly ranked regionally and nationally in patient experience, we are constantly looking for ways to improve. This 80-and-over patient experience gap was hidden in our data; it took a very experienced and dedicated data dive to find it. Sarasota Memorial Hospital has an unusually high volume of patients 80 and older, but many U.S. health care systems will face the same phenomenon in the next several years. It behooves all systems to look at their HCAHPS data closely to get started.
Lessons Learned and Next Steps
- Segmenting patient satisfaction data by age can reveal gaps in the patient experience that are not captured by overall numbers.
- Changing the culture takes a long time, and needs the understanding and enthusiastic participation of both top leaders and unit leaders.
- For our eldest patients, quality of life must at least equal quantity of life, and may sometimes be more important. Empathizing with their unique needs is essential for improving their satisfaction.
- Often there are already programs or services in place which, with a little creativity, may be enhanced or modified to address an area of opportunity.
- Take advantage of staff enthusiasm. Many PEACE Project team members felt a personal passion in improving our care to our eldest patients. and were excited to share ways that they were able to make a difference for one of their patients.
Improving care for one group of patients can improve care for all. There was a concern that tailoring patient experience tactics for one age group could disrupt system-wide patient experience efforts by distracting our workforce. Sometimes the competing initiatives can find common ground and simultaneously thrive, ultimately helping more patients.
For example, Sarasota Memorial Hospital put full efforts into becoming a trauma center shortly after the launch of the older adults/PEACE Project initiative. The complexities of adding new staff, services, and patient flow initiatives necessary to become a trauma center, coupled with sudden remarkable inpatient volume increases due to a weakened competitor hospital, resulted in the PEACE Project becoming a lower priority temporarily. However, over 30% of the trauma patients for our hospital are 80 and over, so having the trauma center reinforces our focus on improving the experience for our 80-and-over patients.
The PEACE Project is about to enter a new phase. Because improving care for our over-80 patient population affects the entire hospital, Sarasota Memorial Hospital leadership approved a proposal to join Nurses Improving Care to Healthsystem Elders (NICHE), a nursing education and consultation program designed to improve geriatric care in health care organizations, and committed $14,000 to cover the program’s annual fee and resource nurse trainings.
Operated through the NYU Rory Meyers College of Nursing, NICHE provides many resources and research for nursing and interdisciplinary teams to achieve organizational goals for the care of older adult patients. Sarasota Memorial Hospital leadership appreciated what the PEACE Project was able to accomplish with few added resources and agreed that the NICHE program will further our ability to expand upon what we’ve learned on our own.