Unlocking the power of real-time family feedback at Children's Hospital of Philadelphia

Deep data is only one element in the blueprint for better patient experience outcomes, and, although key to identifying systemic issues, it does not perform the challenging task of solving them. Patient experience initiatives that lead to transformational change require strong leadership, staff buy-in, and guiding processes. At Children’s Hospital of Philadelphia (CHOP), combining real-time family feedback with robust survey data has proven to be a powerful approach for improving patient and family experience and engaging staff on the 9 South Inpatient Neurology and General Pediatrics Unit.

At a glance: Improving the patient experience

• The 9 South Inpatient Neurology and General Pediatrics Unit and the Patient and Family Experience team at Children’s Hospital of Philadelphia used family consultants to complete family assessments, and the nurse leadership team used iRound to harness the power of real-time feedback, to institute a series of high-impact, low-effort tests of change designed to improve communication among care teams and with patients and families.
• 9 South’s culture transformation hinges on sustained workforce engagement through the integration of patient experience initiatives in daily work. 
• Since the start of this collaboration in February 2018, the unit has seen improvement in a number of patient experience outcomes, including its Overall Top Box performance, which increased from 61.4% to 82.7%. 

At the organizational level, CHOP set out to identify units with low Overall Top Box scores and good n sizes for survey returns. Since 9 South fell into both of these categories, Karen Ross, RN, Senior Advisor of the Patient and Family Experience Team (Pfex) at CHOP, approached the Nurse Manager of 9 South, Alexandra Nelson, and together they convened a cross-functional team that also included a Pfex family consultant and the patient experience advisor to identify opportunities to improve patient experience and the care journey for pediatric patients and their families.  

Since incorporating high-impact, low-effort improvement tools into the daily work of all staff on the floor, 9 South has seen a significant increase in its Overall Top Box scores along with an impressive and ongoing culture shift that better aligns with patient and family needs.  

Involving the family voice in pediatric care

Parents and families of pediatric patients bring unique knowledge and understanding of their children that is critical to providing the best and safest care, according to Ross. To help elevate this voice, CHOP’s Family Centered Care Program comprises staff who are also parents of children who are treated or have been treated at the hospital. Within this program, family consultants partner with staff to provide the family voice in all steps of care planning and delivery. In February 2018, the percentage of the floor’s patients and families giving their Overall Top Box scores for the unit was 61.4%, which was below the mean of 75.2% for other inpatient units at CHOP.

Ross said she knew families had concerns about some aspects of the care experience, citing an example: “In talking to parents, we heard that they felt there was a delay in response to the call bell. In fact, I remember one mother telling me she never wanted to hit the call bell, because she thought it would intercom throughout the entire floor.”

Intervention brainstorming sessions revealed the extent of the undertaking, so Ross and Nelson decided to expand their team. They identified members from both Pfex and 9 South to come onboard, including a senior advisor, a nurse manager, a medical director, leadership and staff nurses, neurodiagnostic leaders, and Child Life Services. With their eyes on interventions designed to improve communication among staff and with families, they decided to start with a communication training that teaches skills to help resolve conflict while avoiding cognitive bias. These sessions were conducted with all staff members, providing them with tools to de-escalate challenging situations with families and effectively respond to family concerns and complaints about their care experiences. 

Next, the team adapted these strategies for improvement into tips of the week to be shared at the 9 South staff ’s daily huddles. Other tests of change included implementing resource boards, consistent real-time check-ins conducted by leaders on 9 South, and the sharing of data via bulletin boards. After launching some of these interventions, the initial hurdle was getting staff buy-in.

According to Nelson, although nurse leaders on the unit were conducting purposeful rounding using iRound technology and appreciated the value of family feedback, “the hospital was at tremendous capacity at this point, so it was difficult to get staff together to review our iRound feedback, comments from the family consultants, and other metrics we were analyzing. Starting an additional project plan about patient and family satisfaction seemed overwhelming; there were many competing priorities.”

In addition to purposeful rounding, daily huddles on 9 South focusing on census, hot points, safety observations, situational awareness, and patient and family experience stories were poorly attended, prompting a Pfex team intervention.  

“Once Pfex started joining our daily huddles once a week, everyone on the floor was worried they were coming in to tell us how to do our jobs,” said Ross. “There was definitely a lack of trust. Staff thought Pfex would add to their workloads without inspiring any meaningful change for patients and families.”

Embracing high-impact, low-effort improvement tools

Realizing that a culture shift was in order for the 9 South unit, Pfex guided their efforts with the CHOP Improvement Framework, a formula for defining and diagnosing a problem, testing and implementing changes, and sustaining those changes. They also began framing high-impact, low-effort improvement tools as an integral component of every staff member’s daily work. Finally, they developed a phrase to anchor all improvement efforts: “It’s not one more thing, it’s how we do our thing.”

As mentioned, Pfex kick-started the initiative by holding group sessions and providing tip sheets to share at their weekly visits to the 9 South daily huddles. To boost staff-buy in, Pfex kept each tip sheet to one page and presented it as a guiding resource to improve patient experience rather than a mandated task. Also, by working so closely with 9 South leadership, Pfex could get a sense each week of what obstacles staff were facing and adjust tips accordingly.

“We’ve gotten the most engagement from the conversations that spring up around these tips of the week,” Ross explained. “Reviewing the tip itself does not take up a lot of time at the meeting, but out on the floor, staff can see the value added from minor shifts in how they present something to a patient.”

The resultant uptick in staff engagement has translated into perceptible advances in patient experience and patient satisfaction. For example, through a minor language tweak, 9 South established a simple, actionable way to respond to immediate patient and family needs. Instead of saying, “Let me know if you need anything” upon leaving a room, staff are taught to ask, “Is there anything I can get for you right now?” Nelson noted that nurses and other employees will utter the first phrase while rushing out the door, and patients sense how busy they are. The small modification in the tone and wording of this question shows that they really do intend to be useful when they ask this question, rather than check a box on a protocol guideline, she explained.

“After we had been implementing tips of the week for about eight months, families started asking us, ‘Do you train all your staff the same way? They are always asking if there is something they can get for us.’ It also started showing up in our Press Ganey and purposeful rounding comments. Hearing and reading how that small language change made an impact was validating,” Ross said.

After the cross-functional team adjusted their strategies for improvement, it became obvious that issues in communication were at the root of the lower patient and family experience scores for 9 South. Harnessing real-time feedback from family consultants, 9 South and Pfex worked together to create resource boards in the family lounge and throughout the floor, containing information such as the cafeteria’s hours of operation and directions to parent resource centers. And because any staff member could easily direct families to the boards, this lightened the burden on nurses who were usually called upon to explain the same information, Ross noted.

With respect to purposeful rounding, some flexibility in use of the technology was introduced. Specifically, leadership nurses were empowered to tailor the conversation with patients and families in the moment, sometimes asking all 10 questions and other times not. Striking a balance between standard work and responding to the individual needs of each patient was crucial for both patient experience and bedside nurse engagement, ultimately opening channels for deeper communication and connection, said Nelson.

Getting the most out of survey feedback

To continue amplifying the family voice in their pediatric patient care, the Pfex team is striving to keep both data and direct feedback at the forefront of patient and family experience innovation, Ross said. One way they are doing this is by asking families about the survey question regarding the staff’s response to concerns and complaints to get more insight into families’ perceptions and expectations around staff responsiveness. For example, they ask: What does this question mean to you? Who would you go to with concerns or complaints? What would you like to see happen to resolve this issue? After collecting responses from 10 to 15 families, the Pfex team used the data in a team meeting to identify tests of change to improve outcomes for this survey question. As a result of implementing these new strategies, 9 South saw statistically significant improvement with a positive centerline shift in performance.

“We wanted to break down the concern and complaint question because, as an employee, you interpret things all the time. But when you hear the perspective directly from the patient and family, you realize that you may have a completely different understanding of what was going on and what they were thinking about,” Ross said. “We didn’t want to lead in the direction of making changes that didn’t mean anything to them, so we asked.”

Since staff began implementing these and other tests of change, 9 South’s Overall Top Box scores increased from 61.4% to 76.7% in February 2019, higher than many of CHOP’s inpatient units. Most recently, for eight of the nine months since that time, the unit’s performance on this measure has been above the centerline, reaching 82.7% in October. This steady upward growth has incited the Pfex team to take these initiatives to other units throughout the organization, starting with the Nursing Shared Governance Council, Ross explained.

As 2020 approaches, culture change is a top priority for Ross and Nelson. They hope to continue to facilitate communication between departments and care teams and foster partnerships between nurses and family consultants. By envisioning these engagement strategies within the larger goal of influencing experience outcomes, the 9 South Inpatient Neurology and General Pediatrics Unit at CHOP is well on its way to achieving its goal, they said.

“When we began this work, it was so easy to make excuses about why we couldn’t impact our numbers: We were so busy; we didn’t have enough staff; we were in the middle of a high census,” Nelson recalled. “But then we were able to prove that we could maintain and sustain higher scores, even with higher patient volumes, because we put the work and investment into believing that it was important.”