Improving patient satisfaction in medical-surgical nursing units

Improving Customer Service on a Medical Surgical Nursing Unit

Quality Improvment Project-Customer service on the nursing unit

The hospital medical-surgical nursing unit is usually referred to as the "catch-all" department for different types of patients. This is because it includes renal patients, cancer patients, cardiac and surgical patient. It also includes other patients who do not particularly fall into any of these specialized units. The medical-surgical nursing unit is a conglomeration of all kinds of adults with all sorts of health problems and thus the nurses in this unit need to be dynamic, quick to respond and are almost on their toes at all times. Patients in the medical-surgical nursing unit are likely to develop changes in their condition quite rapidly and therefore they become more unstable even though they may have been admitted in a stable condition. This is because most patients in the medical-surgical nursing unit have unpredictable conditions and even though they may be predictable, the degree of predictability is quite low.

A lot of care in health care units is given in hospital medical surgical nursing units. There is an estimated 35-40% rate of unexpected deaths that occur in these medical surgical nursing units. Additionally, the staff retention rate of medical surgical nursing units is quite low as a result of the heavy input required from the members of staff often with very low income levels. Therefore, they hop on any new opportunity that gives them the slightest improvement in their working conditions, be it higher pay or an improved working environment. The minimum nurse-to-patient ratio for medical-surgical units is 1:5 but in most health care organizations, the ratio stands at 1:15. This is because of low staff retention rates. Therefore, it is essential for the management of the health care organization to institute drastic measures for the improvement of the care that is provided to patients in medical surgical nursing units. These measures will also help to improve the satisfaction levels of the members of staff and thus increase the staff retention rate.

Nursing indicator

The nursing indicator being looked at here is the patient satisfaction rate. Patient satisfaction is referred to as the perception of the patient regarding the health care received as compared to the care that they expected to receive. It is an important predictor of the overall satisfaction rate of patients with the hospital and the hospital staff and it is an important goal for each health care organization. Dissatisfaction with the care provided with patient leads to lower utilization of the services provided by the hospital and thus decreases the revenue for the hospital. For this reason, patient satisfaction rate is not simply referred to as a measure of quality. Rather, it is the major goal of delivery of health care.

There are four levels of this indicator. The first is patient satisfaction with overall care, second is patient satisfaction with management of pain, third is patient satisfaction with educational information and the last is the satisfaction of the patient with the nursing care provided. All these four levels of this indicator will be analyzed.

In a study conducted by Al-Mailam (2005) on a sample of 420 inpatients in order to determine the extent to which they were satisfied with the care provided to them, it was found that the maximum patient satisfaction levels were the highest scored. 91.9% of the patients reported a satisfaction level of "excellent" while 3.9% reported a satisfaction level of "very good." The study also found that there a positive correlation between the perception of the patients towards the nursing care provided and their overall satisfaction with the health care that they received.

Many governments are also prioritizing the satisfaction of patients with the health care they receive in government hospitals. In the UK, the government placed the patient satisfaction rate as the highest priority indicator and that all accident and emergency departments should strive to achieve a 95% level while the other hospital departments should strive for a 98% level.

Quality improvement model to be used

The lean thinking model will be applied to the improvement of this patient satisfaction indicator. Lean thinking is a way to decrease the waste and increase the efficiency of processes. It is a way to do more work using less effort, equipment, time and space while at the same time giving the patients exactly what they need. Lean thinking in the medical-surgical nursing unit can be applied to optimize the processes involved in delivery of health care to make sure that the nurses involved in provision of health care use the limited resources such as time, money and other supplies to provide the highest quality of health care to the patient. By learning to effectively manage the available resources which are limited, the organization can limit waste and improve the efficiency of provision of health care Sollecito & Johnson, 2011.

There are 14 principles that are applied.

1. Ensuring that the decisions are based on a long-term philosophy even though this may be at the expense of the short-term financial goals of the organization.

2. Creation of a continuous process of flow which brings about the problems of the organization to the surface.

3. The use of "pull" systems which help to avoid any kind of overproduction.

4. Leveling out of the workload.

5. Building a culture which stops to fix the problem while getting the patient satisfaction right at the first instance.

6. Standardizing the tasks in the organization which form a foundation for the continuous improvement of the processes and also empower the nurses.

7. The use of visual control to ensure that there are no problems that remain hidden.

8. The use of a reliable and thoroughly tested technology which serves both the patients and the processes.

9. Growth of leaders who have a thorough understanding of the work and culture and are ready to teach others.

10. Developing exceptional teams and people who follow the philosophy of the health care organization.

11. Respecting the extended network of partners and suppliers through giving them challenges that help them to improve.

12. Getting a first-hand view that the nurses have a thorough understanding of the situation and the organization's philosophy.

13. Making decisions through general consensus which have a thorough consideration of all the options available and implementing the decisions made rapidly.

14. Becoming a learning organization through reflecting relentlessly and a process of continuous improvement.

Primary measurement to be utilized

The primary measurement to be used is the processes involved in the attainment of health care. The table below shows a comparison of these measurements for our organization as per other organizations. The goal is to optimize the processes that they achieve the same values as those of other organizations.

Our organization

Other organizations

Steps in provision of health care

25

9

Value-added steps

4

4

Total time spent on each patient per day

70 minutes

20 minutes

% of value-added time

9%-17%

32-42%

Number of patients in each queue

11

3

Handoffs to other health care providers

10

5

Variation in health care provided

High

Low

Ethical dilemmas arising

Ethical dilemmas that can arise in this situation of trying to improve the satisfaction rate of patients to the health care provided involve violation of the ethical principles. First is that the nurses may be unable to exercise veracity since they may feel that it is more beneficial to withhold some information from the patient. Another violation is that of respect for autonomy where the nurse may feel that the patient is unable to make a decision based on informed consent thus violate this ethical principle. These ethical dilemmas will be solved through the use of an ethical decision-making model which ensures that the decision made does not violate any of the ethical principles. There are seven steps of the ethical decision-making model to be followed.

The first step is to identify the problem itself. This is where the nurse tries to get clarity on the situation and to outline the facts, assumptions and hypotheses or suspicions related to the situation. Secondly is the application of the code of ethics that governs the health care providers. For counselors, this is the ANA (American Nursing Association) code of ethics. This helps the nurse to apply the code of ethics. The third step is to determine the nature of the dilemma and to consider which moral principles are violated and which ethical theories describe the dilemma. There is also the review of literature to find ways which have been used in the past to resolve such dilemmas. This is called evidence-based practice Shortell et al., 2001()

The fourth step is to find the potential courses of action and to brainstorm on them to find the most creative way to resolve the dilemma. Fifth is to consider the consequences of all options present and to determine the appropriate course of action. Sixth is to evaluate the course of action that is selected for its ethicality and whether it is appropriate for the situation. It is also evaluated to check its sense of fairness and that it is not a violation of any of the ethical principles. The last step is then to implement the chosen course of action.

The Team

The team which will lead this improvement in patient satisfaction rate will consist of 8 members. One will be the nurse manager who will be the overall and the "senior leader" for this process. he/she will be involved in supervising all members of staff of the medical-surgical unit to make sure they act in a way which complements the achievement of this desired patient satisfaction rate. The other 7 team members will be staff members of the medical-surgical unit chosen based on their experience in the team and their staff motivation level. The team members will then choose a vice-chair to deputize the "senior leader" and a secretary for the team to record minutes for all team activities. The secretary will also be involved in designing posters and other educational material to remind all nurses working in this unit about the importance of improving the patient satisfaction rate. The team members will have an additional monthly allowance that will act as a motivational factor to motivate them to lead the change. They will be meeting once a week on Wednesday during which they will discuss all relevant issues and institute the necessary procedures or changes.

Qualities of the "senior leader"

There are several qualities that the senior leader needs to possess. One is respect to other members of staff. The senior leader needs an inherent acknowledgement that each member of staff is a professional and that even though he or she is the overall supervisor, the subordinates need to feel respected. Secondly, the senior leader needs to have the ability to set clear examples for the subordinates. The senior leader also needs to be well organized and to exercise flexibility and creativity at all times. Organization makes sure that there are clear rules by which the members of staff conduct themselves including shifts, deadlines, milestones, etc.

The senior leader also needs to be able to make decisions effectively and to resolve any workplace conflicts arising. The senior leader also needs to be able to motivate and empower their staff so that they feel valued and respected in the hospital. The senior leader needs to be honest, fair and consistent in their decision making so that the members of staff do not feel any kind of favoritism or discrimination. Lastly, the nurse manager needs to be an effective communicator. This involves them being able to pass information with ease and in a clear manner Sheridan, Vredenburgh, & Abelson, 1984()

Managerial attributes and actions to be employed

The senior leader or sponsor needs to apply delegation where they distribute the various tasks that need to be done equally to all his subordinated based on their qualifications and levels of experience. Secondly, the senior leader should have influence which enables them to guide their followers towards the achievement of their goals and to build trust by communicating in a way which is friendly. Third is negotiation where they should be able to identify the concerns of the subordinates and to be willing to find the best way forward that maximizes the result. The senior leader should also have goal-oriented and have a clear vision. This helps him or her to establish the criteria for success and to reinforce their performance goals. It also helps them to communicate the vision of the change to the subordinates in a way that gains their commitment.

Evidence-based practices

To improve the patient satisfaction rate, it is important to first understand the various aspects of provision of health care which make the patients feel that the healthcare they have received is insufficient. It is important to do a review of the events in the medical-surgical unit using a root cause analysis. Figure 1 below shows the results of one such analysis.

Figure 1: Root cause analysis of improper administration of IV medication

By reviewing the results of the root cause analysis, it is possible to institute 5 steps in the achievement of a higher patient satisfaction rate. First is to identify the opportunities available and then second is to prioritize them. Third is testing the most potential solutions for the problem then fourth is evaluating these potential solutions. Lastly is the implementation of the solution that provides the most benefit.

Another way to ensure that patient satisfaction rates are improving is the use of patient feedback surveys through forms. These are a high-level screening tool helped to provide detailed information on the root causes of dissatisfaction of patients. The patient feedback survey is designed to identify the opportunities for improvement of the health care provided then to use the decision making model to come up with the appropriate decision that fits the situation at hand Glickman, Baggett, Krubert, Peterson, & Schulman, 2007()

A drill down analysis will also help to generate an understanding of the capabilities, underlying factors, activities and other metrics which will be used in the detailed analysis to find the relationship between the various aspects of provision of health care and the patient satisfaction rate.

Among other things, the hospital should also have a compliments and complaints management system to help handle patient feedback and to make sure that the hospital is able to reduce the number of complaints and increase the number of compliments Glickman et al., 2007.

This should be used alongside the patient feedback survey form.

Cost-effectiveness of the approach

The suggested approach is extremely cost effective. First, it does not utilize much of the financial resources of the hospital. This approach only requires the hospital to print patient feedback forms. The only other expenditure that arises from the implementation of this approach is to pay allowances for the team members who are implementing this approach in order to motivate them. However, this cost is insignificant when compared with the positive outcome that the organization gains as a result of implementing this approach. Additionally, this approach does not require the hospital to employ any new members of personnel thus it is extremely cost effective.

How the approach mitigates risk and improves health care outcomes

As a result of the involvement of nursing staff in the development of this plan and its implementation, there will be a motivation for them to provide quality health care to the patients which will improve the overall nursing care of the patients and lead to an increase in the patient satisfaction rate. Moreover, the nurses are allowed and expected to exercise their own independent judgment in the making of critical decisions which makes them feel they have a role to play in the decision-making process and this acts as an extrinsic motivation factor towards the provision of quality health care.

This approach is also bound to succeed because it promotes mutual respect for the competence and knowledge of all members of the medical-surgical nursing unit and a mutual concern for the health care provided to patients. It nurtures a good camaraderie between the nurses in the unit and therefore fosters teamwork between them and they are able to achieve more as a team Pentecost, 2007()

As a result of optimizing the process of providing health care to patients, the hospital will be able to get to better certification levels by meeting the certification standards such as Balridge's Award and ISO certification. This will increase the number of patients visiting the facility since they will feel more comfortable getting their healthcare from a highly accredited facility.

As a result of improving the patient satisfaction rate, the nurses also learn to be culturally competent. Culture is also an important concept in medical-surgical nursing units. This is because the lives, beliefs, customs, patterns of behavior and practices of human beings directly affect their health. As a result of the medical-surgical unit being composed of patients with all kinds of conditions and from various backgrounds, it is important for the nurse to be culturally competent in order to be able to respond to the patients' issues effectively despite their cultural backgrounds.

The nurses also manage to educate the patients on the various aspects of their health care such as medication being provided, procedures being conducted, risks involved and how they can monitor their own condition before and after they are discharged. This is referred to as patient teaching and is also an important aspect of health care in medical-surgical nursing units. Patient education ties in with cultural competence of the health care providers since the health care providers need to be culturally competent in order for them to be able to communicate with the patients effectively McLaughlin & Kaluzny, 2006.

Cultural competence also helps the health care providers to understand the learning needs of each patient as well as their preferred style of learning.

Impact of the team on the nurse sensitive indicator

The team will help in the improvement of patient satisfaction level as a nurse sensitive indicator in various ways. First is that it will help to identify the activities and process in the provision of health care that create value to the patient and those which are critical for improvement of the quality of health care provided. Secondly, the team will help to determine the sequence of the activities which are involved in the provision of health care. This will help to identify where the hospital needs to add value and which activities need to be eliminated. Third, the team will help in the collection and analysis of data from the patient feedback forms which are integral in learning the root cause of the various activities and in finding out where the process needs to be improved. The team also helps in keeping the focus on the process flow which is the most important aspect in the lean thinking improvement model.

Table 1: Monthly data points for the nine-month period

M1

M2

M3

M4

M5

M6

M7

M8

M9

Steps in provision of health care

25

20

15

12

11

10

9

9

9

Value-added steps

4

4

4

4

4

4

4

4

4

Total time spent on each patient per day

70 mins

50 mins

40 mins

35 mins

30 mins

25 mins

20 mins

20 mins

20 mins

% of value-added time

9%

17%

22%

27%

32%

37%

42%

42%

42%

Number of patients in each queue

11

10

9

7

5

4

3

3

3

Handoffs to other health care providers

10

9

8

7

6

5

5

5

5

Variation in health care provided

High

Medium

Medium

Medium

Medium

Medium

Low

Low

Low

M1-M9 refer to month 1 to month 9.

Months 6-9 are for the sustenance of the change and that is the reason why they have equal values of the various indicators.

Positive attributes of the team process in creating the improvement

There are several positive attributes of the team process that will help in creating and implementing this improvement in the patient satisfaction rate. First is the motivation to improve. Since the process is designed and implemented by a team of nurses, they will feel that they own the change and thus will be able to give more input towards making the process more successful.

In the medical-surgical unit, the nurses are from different backgrounds, cultures, race, tribe, etc. And because each person is an individual, conflicts are bound to arise. It is the responsibility of the team to resolve such disputes that may arise and make sure the appropriate actions are taken to hinder the arising of these conflicts. This is done through formulation of policies and guidelines, acting as a mediator in dispute resolution and organizing team building activities to strengthen understanding and communicative behavior among employees. Amba-Rao, 1994()

The team will also help to implement the change theory and apply it to this strategy in order to make it a success. This comes through the various members of the team having different understanding of the change theory and therefore this helps in overcoming the shortcomings of this theory.

Negotiation is also an important aspect of ensuring the success of this change as a result of there having to be compromises made by both the management of the hospital and the staff working the medical-surgical nursing unit. The team will help in collective negotiation where they will have a better negotiation power than if it were individuals negotiating.

The senior leader will help in mobilizing resources for the team to enable it achieve the required change. The senior leader being the overall head will be able to meet with the management and negotiate for allocation of the required resources to the team for them to be able to institute the change.