EP - Exemplary Professional Practice

EP35: Quality Care Monitoring and Improvement-Describe and demonstrate the Structure(s) and Process(es) used to identify significant findings and trends in overall Patient Satisfaction with nursing as compared to benchmark sources.

Since 2009, Jersey CityMedicalCenter has reorganized the structure and processes connected with Patient Satisfaction to be in-line with our pillar of Engagement as well as the organizational vision which is to be in the top 10 percentile nationwide in all initiatives hospital-wide. Patient Satisfaction is also very much in-line with our Professional Practice Model which places patients front and foremost in the center of our care delivery model.

There are two (2) organizational committees devoted to Patient Satisfaction. One is the Interdisciplinary Engagement Council which also evaluates nurse, physician and staff satisfaction (Appendix EP35-A). This council takes a universal perspective on Patient Satisfaction to include meals and cleanliness issues. Strategies are developed in this committee to address emerging trends. Rita Smith DNP, RN, NEA-BC Chief Nursing Officer and Dr. Bessette M.D. co-chair this monthly meeting. The Engagement Council is one of four (4) core councils all headed by senior leadership and physicians. The Council membership includes representatives from all areas in the hospital, see list below:

Engagement/Operational Process Council

EP35-Table 1

Senior Management meets separately once per month to discuss progress with the councils. Each council co-chair reports in the Administrative Council, which is held weekly and involves all leadership in the entire hospital, the progress that they have made.

The goal of the Engagement Council is to focus on HCHAPS scores and improving patient satisfaction in the Emergency Department in particular. Major initiatives are to hire a coordinator to oversee patient satisfaction and to find a more valid survey tool to improve responses to surveys. In an attempt to have sufficient responses to survey questions, a company called Navio is currently being piloted in the Emergency Department (ED). This service provides an electronic patient satisfaction survey in the ED. Texted survey questions are sent to the patients that provide an immediate response which allows the organization to respond more quickly. In the first month of piloting this process we improved our survey responses from the usual 30 per month to 174.

Navio is currently being piloted in the Emergency Department (ED)

Recently, a new position was created for a Patient Engagement Manager (EP33-C). Yvonne Selleroli BSN, RN has assumed responsibility for this role. She carefully monitors all trends and works closely with the Nurse Managers of each unit to address specific issues and develop action plans immediately. She collaborates very closely
Yvonne Selleroli BSN, RN Patient Engagement Manager
 Yvonne Selleroli BSN, RN Patient Engagement Manager  

with the Patient Advocate. Currently they are piloting a project, on the sixth and seventh floors (Medical/Surgical), which entails daily rounding on every patient. Ms. Selleroli and Raul Pamplona, the Patient Advocate performs these rounds. The Patient Care Technicians of the specific areas and the Nurse Manager of the unit, frequently join them on these rounds. They interview the patients as to the extent that the organization is meeting their needs and is preparing them for discharge.

The second committee is a Patient Engagement Council chaired by Sennen Cabalfin BSN, RN (OO15). Patient Satisfaction is reviewed, discussed and analyzed in this Council, especially unit specific information. Strategies are initiated in order to improve trended scores (Reference EP35-A). Patient Satisfaction scores are also discussed in other meetings to include the Clinical Management and Quality and Safety Councils (Reference EP35-B). Patient Satisfaction is routinely listed as a metric for DMAIC and other process improvement initiatives.

Vice President rounding is a process that began in April of 2012. Each Vice President is assigned to a particular unit and they visit that unit on a weekly basis and conduct a 5-10 minute huddle with the nursing staff (Appendix EP35-B). The purpose of this process is to remove barriers to patient care. The Vice Presidents talk to the staff about housekeeping needs, equipment concerns, supply issues and technology needs to list a few. These issues are trended and aggregated into a monthly report.

We utilize the Press Ganey survey to trend issues relating to Patient Satisfaction. Each manager or patient care area receives a report with department specific data. (For example of Press Ganey report see Appendix EP35-C). The report provides results for individual questions pertaining to courtesy, competence and compassion so that managers can determine opportunities for improvement. Raw data reports are made available from Press Ganey to managers both monthly and quarterly. Managers can review comments from patients on the surveys in order to obtain qualitative information related to responses. Nurse Managers have access to their individual units through the Press Ganey portal and are able to track their data at any time. Individual units develop strategies to address patient satisfaction, for example, Marilyn Sarnatora MS, RN-BC on 6 East utilizes a Patient Care Technician, Ingrid Lopez, on a daily basis to make rounds on every patient and address any problems or issues that they may have. If the issue is something that she cannot resolve, she will refer it to the appropriate nurse.

The Emergency Department has recently hired a Patient Engagement Coordinator, Khulud Adem, who makes a minimum of 100 post discharge telephone calls on a daily basis to receive feedback from patients and to insure that they do not have any problems. She also rounds on all patients along with Kim Palestis BSN, RN, CEN and Michele Lopez MSN, RN, CEN, Nurse Manager of the Emergency Department. They speak to every patient and try to resolve issues for patients.

The Obstetric Department, usually April Major RN, ILBC, Breastfeeding Coordinator, telephones every patient post-discharge to insure that there are no issues with the infant, breastfeeding or with the patient herself. We also place a Thank You card in their chart, that everyone who provides care signs, and then we mail it to their home when they are discharged.