The CNO of a Pennsylvania hospital recently wrote to my organization after her facility's successful Magnet(R) survey regarding the impact of Relationship-Based Care (RBC) and its accompanying educational workshop, "See Me As A Person," a 2-day workshop that teaches a set of four practical and repeatable practices that facilitate a therapeutic relationship with patients.1 "It's ASTOUNDING the number of patients who take the time to write comments on our surveys regarding relationships with staff and how the connection that occurs during bedside report is truly creating the connections and feelings we've envisioned. Patient satisfaction was our Achilles' heel in this organization...Since we've incorporated 'See Me As A Person'...we've moved consistently from single digit percentile rankings to the 71st last quarter." (See Table 1.)
RBC is a care model that focuses on three crucial relationships for the provision of humane and compassionate healthcare: with the patient and family, with colleagues, and with oneself.2 It serves as a framework to transform organizational culture. Councils of frontline staff members create innovative actions to implement the principles of RBC, which establish:
* a positive, healing culture for everyone
* clear responsibility for primary caregiver relationships in all clinical disciplines
* work allocation and patient assignments that maximize continuity of care and service
* systems of effective communication and collaboration within and across departments and services
* management and leadership that ensure a healthy work environment and empowerment
* effective systems improvement processes for optimal patient care delivery.
Leveraging relationships
There's an increasing body of research documenting how much relationships matter. Healthcare thinking has advanced beyond the time when many considered that the patient experience was subjective and had little impact on clinical effectiveness. A systematic review of 55 research studies demonstrated a consistent, positive association between patient experience, patient safety, and clinical effectiveness for a wide range of disease areas and settings.3 The authors argued that patient experience must be considered one of three essential pillars, along with clinical effectiveness and patient safety. These pillars should be considered as a group rather than in isolation.3
Another study of patients treated at 10 different university hospitals demonstrated that four Hospital Consumer Assessment of Healthcare Providers and Systems questions were significantly associated with the 30-day readmission rate. Higher scores on "nurses listening" and "doctors explaining information" were linked to decreased readmissions.4 In a study of 2,200 healthcare facilities, Press Ganey found that organizations with the highest percentages of engaged employees were also succeeding in seven critical areas of patient experience.5 This is just a sample of the research that validates the interconnectedness between staff teamwork and relationships, the patient experience, and clinical quality/safety.
Why start with self-care?
Many healthcare staff members find themselves in states of frustration and exhaustion, running from task to task and feeling disillusioned about their roles. For this reason, RBC implementation starts with reinspiring and replenishing direct care staff members and management.
The strongest impact of RBC can be seen at organizations in which staff members have been reconnected with the joy and meaning of their roles. Tens of thousands of people in RBC organizations have attended a 3-day inspirational workshop called "Reigniting the Spirit of Caring." This workshop begins with deep learning about self-care. A caregiver's self-awareness and sense of body-mind-spirit balance are key precursors to his or her ability to be a healing presence for others. Consider the impact of inspiration from verbatim staff comments after attending this workshop:
* "This has been an amazing and emotional experience that has completely reaffirmed my commitment to my work and that nursing is truly a calling."
* "I feel that this was one of the most important events in my career and I think I'm a better person for it."
* "It gives me strength to continue my positive outlook; even in the times when others are being very negative."
Inspiration has proven to be an essential beginning step, followed by a carefully structured process to empower frontline staff members to form unit-level shared governance councils that are trusted to create innovative changes to build caring into the daily infrastructure of their work.
A healthy culture
The second aspect of RBC is care for colleagues. The engine that drives the culture and success of any department is a strong and stable team functioning in a healthy work environment led by a supportive and effective frontline manager. The manager's leadership style can make or break the effectiveness of RBC implementation.
Managers set the climate for healthy interpersonal relationships. To create a healthy team and open, honest communication, a classic set of coworker behaviors is needed. The "Commitment to My Coworkers" represents best colleague practices for RBC. Unit-based staff councils can use these behaviors as agreements in their meetings and as part of their RBC implementation. (See Table 2.)
Engaging staff in innovation
Effective managers empower their staff members to lead meaningful change through shared governance. In RBC, the work of unit-based shared governance councils is to gather input from all colleagues and create a comprehensive action plan to implement the principles of RBC. These principles set the stage for implementing the best evidence-based caring practices for patients, colleagues, and oneself. Managers should ensure that their councils have access to all data and outcomes for their department so that data drive the innovative changes led by council members and the impact of their work can be measured.
Councils achieve remarkable unit outcomes when they're enthusiastically supported and trusted to lead changes. The following are a few examples of the many outcomes achieved by unit-level councils:
* Councils at multiple organizations have tackled hourly rounds to make them more effective, with outcomes including decreased falls, increased scores on responsiveness to call lights, and improved pain scores.
* A Chicago hospital implementing RBC in all of its nursing departments reported reduced hospital-acquired infections, showed steady improvement in overall patient satisfaction with care quality, and achieved nurse job enjoyment scores significantly above the average for Magnet hospitals.
* An ED council in Chicago demonstrated increased adherence to six safety measures.
* A Dallas facility showed progressive increases in employee engagement, physician satisfaction, and top box patient experience scores over 3 years.
Deep insights
The ultimate work of RBC is to create a compassionate, healing environment for patients and a care delivery system that facilitates knowing the patient and his or her needs. A caregiver's most important gift of compassion to patients and their loved ones is the ability to listen, be genuinely curious about them, ask about them as people, and follow what's learned about their needs, rather than imposing a standardized clinical pathway on them with no personalization.
The patient care delivery system is the structure that organizes workflow and roles, and impacts both the patient relationship and the degree of interprofessional collaboration. How one designs this system sets the stage for highly professional practice and effective relationships or, alternatively, task-based care. The delivery system within RBC is based on primary caregivers for each discipline. The patient has consistent caregivers and knows the name and role of the primary caregiver for each discipline who's accepted responsibility for leading his or her care. This primary caregiver collaborates with the interprofessional team to establish a comprehensive care plan in full partnership with the patient or his or her designee.
Cumulative outcomes
Organizations committed to a comprehensive implementation of RBC have seen strong outcomes. Comprehensive implementation includes educating and inspiring people; preparing leaders with the skills necessary to lead an empowered team; using unit-based staff councils to prepare a comprehensive action plan; and having a coordinating council to oversee, measure, and sustain outcomes. The measurable outcomes that are repeatedly seen in these organizations include improved patient experience, adherence to core measures, increased safety, employee retention and engagement, and financial success.
RBC has the potential to change organizational culture. When that new culture is based on a common mission and values, with people respecting each other and working in partnership, and with a deep focus on what matters most to patients, positive outcomes follow in all aspects of the organization.
REFERENCES