The top operational issues undermining patient experience

When we think about improving the patient experience, we often think about proven best practices such as nurse leader rounding or post-discharge phone calls. These practices standardize and enhance communication in ways that improve patient perceptions and support better outcomes. Hospitals across America, including my own, use these best practices every day. They are core components of strategies to move the patient experience needle.

There are also some very significant operational challenges that impact patient experience that are rarely addressed directly in patient experience improvement approaches. Yet, they have an outsized impact on patients' perceptions of their care. These factors include delays that patients experience waiting for inpatient beds in our emergency departments and the need for staff to monitor patients "one on one" in their hospital rooms. Both of these scenarios are common occurrences in hospitals across the country, especially during the winter ”surge season” that we are already beginning to experience. If unaddressed, they can almost singlehandedly neutralize much of the work that we are all doing to improve patient experience.

Data shows that patients who are delayed in the emergency room or post-anesthesia care unit as they wait to get a bed on an inpatient unit rate their experience much more harshly than those who did not experience a delay. This impact is seen across all survey domains. As hospital operators know, this is not an emergency department problem, it’s a throughput problem. Bed delays are patient experience killers and they can negate lots of great work being done by our teams. 

One-on-one monitoring of patients also has an outsized impact on patient perceptions of care. Of course, we must always make sure the patients in our care are safe. Sometimes this requires a member of our team, usually a nursing assistant, to sit at the bedside to assure that a patient with dementia doesn't get out of bed and fall or having to monitor a patient who may be disruptive. This was a challenge even before the pandemic, but rising percentages of patients with behavioral health issues has only made the need for one-on-one observations more frequent and challenging for many healthcare organizations.

How do "one on ones" impact patient experience? They limit the pool of team members on a unit who are available to answer call bells and attend to the needs of patients and families. The result is that, when one on ones rise, perceptions of nursing and responsiveness decline. It's an extremely difficult spot for our unit leaders to be in — needing to balance the safety needs of some patients with the overall needs of all patients on the unit.

I just had the privilege of attending the American Nurse Credentialing Center's annual Magnet and Pathway Conference in Chicago. It was an inspiring week that was attended by more than 13,000 nurses from across the country and globe. I had the privilege of leading a session at the conference on improving the patient experience. The issues I just described above — patient throughput and managing one on ones — were a pervasive theme of our discussion.

Given this operational reality, what can be done to address these very significant patient experience challenges? At NewYork-Presbyterian, we have incorporated these issues into our patient experience improvement plan. When we look at patient experience data at the facility and unit level, we also look at efforts underway to keep patients moving through our system. Tactics such as discharge lounges and increasing our "discharge before noon" rates are part of our plan and discussion. We have begun to correlate "bed hold" and surge data with our patient experience scores so we can learn how to improve patient flow and keep the experience positive and consistent. This is still very much a work in progress, but it is a great step forward in integrating core operating issues with our patient experience improvement work.

We are also looking at how we can use technology to help us monitor patients who need to be watched more closely, so we can free up team members to address the broad needs of patients on our units. This is also a work in progress at our hospital and in a number of others around the country.

The core of the issue here is that patient experience cannot be segregated from the basics of hospital operations. Often, patient experience is seen as an "add-on" or icing on the cake. That cannot be the case. Operational issues such as ED holds and one on one's can dramatically impact and color the entire experience. It's hard for any established patient experience best practice to counter the effects of these dynamics. Therefore, any truly impactful strategy to improve patient experience must integrate these issues. Every organization seeking to improve patient experience should include these issues in their discussions and work.

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