Anything But Routine- Lovelace Westside Hospital Transforms Care at the Bedside

16 Dec 2012

The demands on physicians, nurses, and staff in medical surgical units can be intense. Juggling complex patient needs, making the rounds, following documentation requirements, and managing staff turnover in a fast paced environment can leave little time for meaningful patient interaction or evaluating and improving patient satisfaction.

The care team at Lovelace Westside Hospital in Albuquerque, NM, faces the same challenges. But its health professionals are determined to devote the time and attention necessary to improve the quality of care and patients’ experiences. The hospital is part of the Lovelace Health System, which includes six hospitals employing nearly 4,000 people throughout New Mexico and a health plan that serves 230,000 members.
Lovelace Westside Hospital also is part of the Transforming Care at the Bedside (TCAB) initiative, which engages nurses and other frontline staff—with the support of hospital leadership—in the pursuit of patient centered approaches that deliver high-quality, affordable care. As caregivers who spend the most time with patients and their families, the TCAB team of nurses at Lovelace Westside Hospital considers patients and family members as full partners in delivering care, not just recipients of it.
Initially developed and led by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement, TCAB is offered at Lovelace Westside through Aligning Forces for Quality, RWJF’s signature effort to improve the overall quality of health care in the United States.
Through TCAB, the care team at Lovelace Westside set a goal to increase its score on the federally sponsored HCAHPS patient satisfaction survey, particularly in the areas of pain management and call button response time. Also known as the CAHPS® Hospital Survey, it gauges patients’ perspectives on multiple factors related to their care experience. It also can give health professionals a blueprint for improving the quality of care.
To reach its goal, the Lovelace Westside Hospital team established “purposeful” rounding, or regular check-ins with patients. Research shows that hourly rounding within hospital units decreases call light use and the number of falls. It also improves patient satisfaction, team communication, and efficiency of care, like relocating equipment and supplies or redesigning medication processes.
Rounding is by no means a new concept, but Lovelace Westside Hospital’s effort takes it to a new level. Through purposeful rounding, nurses visit patients in their rooms every hour during the day and every two hours at night. Through rounding, nurses are more able to address patients’ needs proactively and ask them about their overall experience, including satisfaction with call button response and educating them about managing their own care once they are discharged.
To ensure the visits are as productive as possible, the TCAB team originally developed a form that included 15 topics for nurses to cover with patients. However, the team soon realized that with a ratio of six patients for every nurse, a visit during rounds could last just a few minutes. As a result, compliance with the form became a challenge because it was considered too long and cumbersome.
“Frankly, our original form wasn’t purposeful,” said Rebecca Gallegos, director of inpatient services at Lovelace Westside. “You can’t accomplish a lot if you provide too much for someone to do or too many things to check for. When we made it more specific, we saw the improved results.”
To streamline the process and improve compliance, the team refined the checklist based on the “3 Ps”—pain, potty, position—to determine accurately and quickly what a particular patient might need.
We were rounding according to plan, and when there wasn’t compliance, we reminded staff constantly,” said Gallegos. “Slowly, we saw it take hold. We saw improvements, but we also learned how to make adjustments to serve patients better. For example, at first we conducted rounds hourly—day and night. Patients didn’t like nurses going in their rooms so often at night, so we extended visits to once every two hours.”
Rounding also can avert crises. For example, a staff member walked into a post-surgical patient’s room during rounding and discovered the oxygen was not connected properly. The patient was sleeping, and the problem could have gone unnoticed for too long. The need for oxygen is greater in the first 24 hours after surgery to help address respiratory issues and pain management. Thanks to diligent rounding, the oxygen was reconnected and a potential emergency avoided.
Since Lovelace Westside Hospital launched its purposeful rounding, it has seen improvement in its HCAHPS ratings. All the scores that were a primary focus for improvement through the rounding effort reached the 90th percentile, well above the national average. Program managers attribute improvements, such as the decrease in call button use, to the fact that patients know someone will be visiting their room frequently.
The hospital also saw an increase in its patient rating for courtesy and respect. “One of the biggest results we saw was a sense of increased respect for nurses,” said Nancye Cole, chief operating officer and chief nursing officer at Lovelace Westside. “The more often nurses were in the room, the more respect we saw from patients and families.” 
Patients’ and families’ increased perception of nurse courtesy and respect were reflected in the HCAHPS survey results. As anyone working in the health field can attest, change is hard, but purposeful rounding has been worthwhile.
“We took TCAB to heart. It’s not just a term, it’s a methodology, and it has to be followed in order to work,” said Cole. “We know hardwiring something is very difficult, but we want this kind of interaction with patients to be the normal course of business.”
TCAB’s impact on the culture at Lovelace Westside is evident. Employee satisfaction has more than tripled to 95 percent, and perceptions of organizational engagement with staff have more than doubled, to 97 percent.
The approach now has become a hospital-wide standard for patient interaction, and it is being considered for further expansion within the entire Lovelace Health System. The team at Lovelace Westside Hospital also shares its approach during national TCAB conferences, emphasizing the ‘3 Ps.” Cole said it may seem obvious, but many nurses overlook the simple questions that can make a big difference.
Cole shares an analogy to drive home the point. “When you’re at a restaurant and you order your food and a waiter brings it to you, he or she typically asks a set of key questions to make sure you have everything you need to enjoy the meal,” said Cole. “But, if the waiter walks away without asking the key questions, you have to get their attention if you need something. The same goes for nursing care. If you ask pertinent questions to see if there is anything else you can do for patients, including the ‘3 Ps,’ you give them time to reflect on what they need, and you can improve their experience.”
Lessons Learned
  • When we saw a drop in scores this past May and June, we quickly reviewed cause. We implemented both the new EMR and a new call light system, which turned out to be inaccurately wired. The nurses seemed to rely on the new call light system instead of their purposeful rounding; it didn’t work. Technology is not always the answer! Patients want to have their caregivers respond quickly. If the system isn’t working, don’t give up on the active rounding independent of the call lights.
  • It is natural for leaders to want to “control and drive” processes on their units, but TCAB is really not designed that way. The true success of TCAB is to be frontline nursing-driven—peers engage peers much easier than directors and managers.
  • TCAB really can be used across the entire hospital, not just by nurses. We have spread it to the ED and the OR. It is a type of shared governance that empowers the frontline.
  • It is imperative the chief nursing officer lend his or her support to make an impact on a higher level. We are best cheerleaders not only for our staff, but also for other facilities and our corporate bosses.