Children's Memorial Hospital in Chicago is the only freestanding hospital in Illinois exclusively for pediatric patients. Unit 9 West has a total of 30 beds, 22 for pulmonary, allergy, and general medicine patients and an eight-bed transitional care unit for patients on ventilators. Nurses on the transitional care unit closely monitor these patients and assist them in making the transition to home. Common diagnoses among these patients include asthma or other reactive airway diseases; cystic fibrosis chronic lung disease, such as bronchopulmonary dysplasia; and general medical disorders.
Nurses on 9 West recognized that improving communication between resident physicians and staff nurses could improve coordination of patient care, satisfaction, and outcomes. For example, in a study of 1,509 health care professionals (including 1,091 nurses and 402 physicians), Rosenstein and O'Daniel showed that disruptive behavior and poor communication between physicians and nurses affect patient safety, patient and staff satisfaction, and quality of care.1 The Joint Commission has made improved effectiveness of communication among caregivers a National Patient Safety Goal.2 The 9 West staff turned to the unit's Transforming Care at the Bedside (TCAB) committee for guidance in improving communication.
THE PROBLEM
Children's Memorial is a teaching hospital, and residents rotate monthly to 9 West. The pulmonary residents care for the allergy and pulmonary patients, who could occupy any bed on 9 West except the eight beds in the transitional care unit. The pulmonary residents don't cover patients on that unit, who are ventilator dependent.
Because of the frequent change of residents and the short time they worked together, often the nursing staff and pulmonary residents weren't comfortable and confident in sharing patient information and assessments. Although the residents knew general information about hospital policies and procedures, they often didn't know the daily operations and best-practice initiatives on the unit. As on other units in the hospital, residents received no formal introduction to the 9 West staff and the unit's operations.
The hospital was already conducting surveys to assess patient and employee satisfaction. Both Press Ganey patient satisfaction surveys, which we had been doing for eight years, and employee satisfaction and vitality surveys demonstrated that the lack of strong relationships between residents and nursing staff resulted in poor coordination of patient care and decreased satisfaction for patients, families, nursing staff, and residents. (Press Ganey surveys are used by more than 7,000 health care facilities to evaluate efforts to improve performance and patient care.3 The Staff Vitality Survey, part of the Healthcare Team Vitality Instrument [HTVI], assesses nurses and other staff working on health care teams on inpatient units. The HTVI was developed for repeated measurement of staff vitality related to changes tested in the TCAB initiative.4)
PLAN OF ACTION
The unit's TCAB committee, five staff nurses and a nurse clinical manager, devised and tested a change to improve communication between 9 West staff and pulmonary residents. We used TCAB's Plan-Do-Study-Act format to develop the plan and test the change (see Testing and Implementing Changes Using the Plan-Do-Study-Act Cycle in "TCAB: The 'How' and the 'What'" for a summary of our activity).4
We began by posting notification of this focus for improvement on the TCAB board, which is centrally located on the unit. This allowed staff to contribute to the brainstorming.
As a unit, we identified the need to establish communication with residents early in their rotation. We wanted to provide an orientation to the unit, as well as to its policies and best-practice initiatives. We also wanted to provide an informal opportunity for the nursing staff and residents to introduce themselves and talk freely, away from the stress of patient care. Rosenstein and O'Daniel suggested that a good way to improve communication is to "just get people together."5
We developed a standardized resident orientation, which occurred within the first two days that a resident was on our unit. The unit nursing staff volunteered to facilitate the orientation, which included customer service goals (such as in Press Ganey surveys), staff and physician resources, infection control, supply and chart location, frequency of blood draws, discharge process, best practices, and policies and procedures specific to our population. We also developed hand-outs, which covered the same information and which residents could take as a reminder. During orientation, we provided breakfast and allowed time for the nursing staff to mingle with the residents.
The specific TCAB aims that we hoped to improve were team vitality; teamwork; and staff, patient, and family satisfaction. Our plan included measurement of nursing staff satisfaction and vitality by administering the HTVI Staff Vitality Survey before the initiation of the resident orientation and six months into the program. The 9 West staff developed a Resident Orientation Exit Survey to assess residents' satisfaction after their monthlong rotation on the unit. The survey consists of two open-ended questions and two questions with responses on a scale of 1 to 5, with 1 meaning "strongly disagree" and 5 "strongly agree." Because the hospital was already administering Press Ganey surveys on a monthly basis, we planned to use them to monitor patient and family satisfaction.
OUTCOMES
We had planned to collect data monthly from the Resident Orientation Exit Surveys and from the Press Ganey surveys of patients and families and at six months from the Staff Vitality Surveys. However, we received informal feedback almost daily.
Immediately after completing the orientation, residents offered their praises. They hadn't received an orientation on any unit before coming to 9 West, and they expressed appreciation for the "heads-up" on the operations of the unit. They voiced increased confidence and knowledge about specifics of the unit, such as the correct paperwork to fill out. Residents said they felt connected to employees just by meeting a few nurses during the orientation process.
We also received some immediate feedback from the nursing staff. They felt that the residents had better knowledge of the unit and displayed increased confidence in the nursing skills demonstrated on 9 West. Nurses reported that the residents were more willing to ask them questions and incorporate their suggestions into patient care.
Both residents and nurses offered positive opinions about the resident orientation on their respective surveys. On the Resident Orientation Exit Surveys, completed once a month, residents chose either "agree" or "strongly agree" when asked whether the orientation helped them provide the best possible patient care and whether communication with the nurses was effective during their rotation on 9 West. Compared with scores before introduction of the resident orientation, nurses' scores on the Staff Vitality Survey rose greatly on questions related to communication with physicians, comfort in discussing challenging issues, commitment to providing high-quality patient care, and work as a high-functioning team (see Figure 1).
The unit also saw a rise in the Press Ganey score related to coordination of care. Parents and patients rated the degree to which nursing care was coordinated from shift to shift. The score increased from 88.2% in the year before the resident orientation to 90.4% after the change began.
ANALYSIS
The resident orientation succeeded in meeting the goals of increased staff satisfaction and improved coordination of care. The main obstacles in providing the resident orientation were time and scheduling. It was difficult to get all the residents to meet at one specific place and time. Frequent communication with the senior resident, usually through e-mail, about the time and date of the orientation was essential.
It was also difficult to pull the nursing staff away from the patient care area for a stress-free time to mingle with the residents. We learned that the unit leadership needs to provide staff nurses with uninterrupted time away from the unit to attend the resident orientation. This may mean finding 20 to 30 minutes of coverage for the nurses.
Surveys of both nurses and residents provided evidence that the informal meetings had a positive effect on nurse-physician communication. In the past, residents and nurses would wait to discuss a difficult or challenging issue with a member of management. Now they are more inclined to go directly to each other, and they receive responses immediately rather than days later. The nursing staff also have become comfortable and confident looking out for the needs of patients and families by making recommendations on patients' care plans.
Suggestions and feedback from the residents and unit staff have led to some changes in the content of the orientation, including more education on isolation practices as well as policies and procedures related to diagnoses common on the unit. Another change was holding the orientation later in the morning to avoid patient rounds and to enable residents to attend lectures and conferences.
This test of change was successful, and we are in the process of spreading this initiative to all general medical units in the hospital.
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