April 18, 2018

What do ‘patient first’ care models look like?

By: OR Manager

Creating a positive patient experience creates patient satisfaction, which can affect reimbursement. But it’s not just business that calls many OR leaders to focus on patient experience.


Having been a patient who has had surgery, it’s near and dear to my heart,” says Carol Pehotsky, DNP, RN, NEA-BC, ACNS-BC, CPAN, associate chief nursing officer of surgical services, Cleveland Clinic Health System, and senior director of surgical nursing, Cleveland Clinic Main Campus in Ohio. “I find that a lot of our caregivers who come to surgery have a similar story—they feel compelled to work in the perioperative area after their own experiences with surgery.”

But too often, clinicians mistakenly believe that patients won’t remember much of their encounter with surgical staff. Pehotsky says that’s not the case. “We are part of the puzzle when it comes to patient experience, and we need to support the organization’s efforts.” That includes addressing the patient and family experience throughout the surgical continuum. But first OR leaders need to understand a few challenges.


Advocating for patients

OR leaders who want to enhance the patient experience may face resistance from clinicians who are concerned that focusing on patient satisfaction scores comes at a cost to quality. Leaders can dispel this misconception through education.

For example, results from a 2015 study in JAMA Surgery found that patients older than 65 years who underwent inpatient surgery at hospitals with satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems in the first quartile had a lower risk of mortality compared to those at hospitals with scores in the lowest quartile. The researchers also found no significant relationship between patient satisfaction and either major complications or hospital readmission.

Patients who have a positive experience may also reap physiological benefits. “Patients who trust us have less anxiety, so they may need less anesthesia during surgery,” says Pehotsky, although she acknowledges that creating trust can be challenging in the busy perioperative setting. “In preop we have maybe 30 minutes to build a relationship, and in the OR it’s maybe 30 seconds,” she notes. “In that limited period of time, we need to convey our advocacy for them to help build that trust.”

Pehotsky says perioperative staff and leaders have to take that patient advocacy to the next level. “When you go to surgery, you have to fully place your trust in the people who will care for you—that they will be your eyes, your ears, and your voice.”

Building trust—and a memorable patient experience—starts before surgery.


Setting the stage preoperatively

A positive patient experience begins early in the process, according to Mary Stewart, MSN, RN, director of patient experience for SIU Medicine, Southern Illinois University School of Medicine, in Springfield, Illinois. Stewart was previously an ambulatory surgery center (ASC) administrator.

“The front desk or reception area and the call center are the ‘front door’ for patients,” she says. She is implementing a new dress code that includes a t-shirt with the practice logo, so patients quickly recognize they are in the right place.

As part of the new rollout on patient experience for SIU Medicine, classes are required this year for front desk and call center staff. The six classes, taught by Stewart, include topics such as telephone etiquette, how to welcome patients and families, and how to diffuse a stressful situation. Classes will be tied to the employee evaluations in the future as the plan rolls into 2019.

Mary Stewart, MSN, RN

In addition to staff, Stewart works with physicians to help them hone their communication skills. Scheduling this education during grand rounds and offering continuing medical education credit promotes attendance. The education focuses on basic tips such as:

• sitting down when talking with the patient (patients perceive the conversation is longer when the physician is seated instead of standing—even when the length of time is the same)

• using the teach-back method to ensure patients understand what they were told.

At the Cleveland Clinic, patients and families watch a video, filmed onsite, about the upcoming surgical experience. “They see what preop, OR, and PACU [postanesthesia care unit] look like and how patients are drowsy after surgery,” Pehotsky says. “They know what to expect.”

Setting expectations should include pain management, which strongly relates to patient satisfaction. Patients—and family—should know that patients should expect some pain, and that a plan is in place to control it.

Pehotsky says that on the day of surgery, preoperative staff ask outpatients three questions:

• How would you like us to address you?

• What is your biggest concern?

• What do you want your caregivers to know related to the surgical experience?

Staff place a note on the front of the patient’s medical record, so that every caregiver sees the answers to those key questions. This promotes continuity and ensures concerns are addressed.

Stewart says her staff try to make the patient feel that he or she is their only patient. “We encourage staff to use key words to help create that feeling and show that they are listening,” she says. For example, a nurse might say, “I’m going to close the door to give you privacy.”

The pediatric population has unique needs when it comes to surgery, says Ann Shea, BSN, RN, nurse manager for the ambulatory surgery unit (ASU), presurgical testing unit, and MRI at Cohen Children’s Medical Center in New Hyde Park, New York. “As parents or caregivers, you’re entrusting virtual strangers to take your child into an operating room for a procedure under sedation,” she says. “You have to include parents and caregivers as much as possible throughout the entire process.” For instance, parents walk their child into the OR.

For both children and adults, proactive communication about surgical delays is essential. A 2017 study in Perioperative Care & Operating Room Management found that patients who wait less on the day of surgery perceive their care to be better, so alerting patients and families about delays as early as possible can help reduce dissatisfaction.

Patient experience resources

Consider the following when seeking to improve the patient experience.

  • Association for Patient Experience (http://www.patient-experience.org/Home.aspx). Resources on this site include best practices, a forum, and the Journal of Patient Experience. This year’s patient experience summit will be June 18-20 in Cleveland, Ohio.
  • Patient experience experts in your organization. “If hospitals or ASCs [ambulatory surgery centers] have an office of patient experience or those with that expertise, I would encourage [OR leaders] to reach out to them,” says Carol Pehotsky, DNP, RN, NEA-BC, ACNS-BC, CPAN, associate chief nursing officer of surgical services, Cleveland Clinic Health System, and senior director of surgical nursing, Cleveland Clinic Main Campus in Ohio. “You can collaborate on how to influence the experience in the perioperative area.” The patient ombudsman is another resource.
  • Institute for Healthcare Improvement (http://www.ihi.org). This site includes resources related to patient satisfaction and experience, including the white paper, “Achieving an exceptional patient and family experience of inpatient hospital care” (http://www.ihi.org/resources/Pages/IHIWhitePapers/AchievingExceptionalPatientFamilyExperienceInpatientHospitalCareWhitePaper.aspx).
  • Company responsible for the organization’s survey process. For example, Press Ganey (http://www.pressganey.com) offers blogs, videos, webinars, and white papers.

Creating compassion in the OR

Debbie Anderson, MSN, RN, CNOR

“There’s a lot of work to be done in setting up an OR, so it’s easy to be focused on the technical aspects,” Pehotsky says. Remembering the basics helps keep the focus on the patient. That includes nurses engaging the patient in conversation when they enter the OR, greeting him or her by name, and explaining what is happening in preparation for the surgery.

“We also incorporate the patient into our safety check sign in, and when it’s time for induction of anesthesia, we want the nurse at the patient’s side, walking the person through what’s a pretty scary experience,” Pehotsky says.

She adds that the Cleveland Clinic uses bachelors-prepared liaisons to support families while they are waiting. The liaisons don’t give clinical updates, but they are especially helpful in promoting a positive experience and in-service recovery efforts, when patients or families express dissatisfaction with their experience.

What does an excellent patient experience look like in the OR? At Abington Hospital-Jefferson, Abington, Pennsylvania, staff nurses, supported by their managers and an innovation grant from the hospital, implemented the concept of “sacred space” in 2008. The team credits sacred space for fostering patient satisfaction.

“The project was all nurse driven,” says Barbara Schmock, MSN, AHN-BC, an OR staff nurse at Abington Hospital who leads the initiative. “We wanted patients to feel safe and well cared for.”

Staff researched Jean Watson’s theory of human caring and found that it meshed well with what they wanted to accomplish. “We agreed as a team that we would practice this way,” Schmock says.

Creating a sacred space, which is an adaptation of Watson’s theory, includes actions such as dimming lights in the OR when the patient arrives, providing a warm blanket and keeping the patient warm during surgery, reducing noise levels, and playing soothing music.

“Our environment can be stark and cold,” says Debbie Anderson, MSN, RN, CNOR, perioperative director at Abington Hospital. “We wanted to enhance the environment of the OR.”

To do so, nurses and others painted murals on the walls of the OR—scenes of nature in cool colors to promote calmness and relaxation.

Barbara Schmock, MSN, AHN-BC

But sacred space is more than murals and music. It fosters a positive connection between caregiver and patient to create a trusting, healing relationship.

“[Sacred space] is very patient focused,” Schmock says, adding that administrative support, as well as buy-in from surgeons and anesthesia providers, is key. Anderson provides meeting time for staff to discuss sacred space strategies and how to reinforce the concept. For instance, new nurses now learn about sacred space in orientation.

One effective strategy is having nurses be with patients during anesthesia induction. “We had to learn about the levels of anesthesia so we knew when patients were more aware of the interventions so we could time them appropriately, and we had to share with anesthesia the research showing that ringing phones and answering the phones while caring for patients can be detrimental,” Schmock says.

The team also had to overcome resistance from staff who felt there wasn’t enough time to practice in this way. But Schmock says they soon found that sacred space became part of their practice because they did it every day.

The initial project cost of $20,000 was funded by Abington Hospital’s internal foundation. The funds were used to buy CD players for each OR, purchase paint, pay the nurse artists, and send staff to education programs. Nowadays, computers in most ORs can play music, so start-up costs for those wanting to implement sacred space would be much less today, according to Schmock and Anderson.

How have patients reacted? Anderson says they regularly comment about the environment on surveys. In fact, the concept has expanded to other areas of the hospital—the PACU also has murals, and staff are applying other sacred space concepts.

“We are taking ordinary care and making it exceptional care,” Schmock says. “Patients feel like they are at the center of care.”


Facilitating recovery

Ann Shea, BSN, RN

Ensuring a smooth transition from the OR to the PACU is another facet of the patient experience. “There’s constant collaboration between the OR, PACU, and ASU, so we can get parents reunited with their children as soon as possible after the procedure,” Shea says. The PACU and ASU also communicate with inpatient units to ensure continuity of care.

Stewart gives another example of how to facilitate a smooth transfer. The ASC where she last worked had two circulators assigned to each OR, so that one could accompany the patient to the PACU, give report, and then return to help with room turnover because the ASC had no cleaning staff. In most cases, the circulator was the same nurse who had seen the patient preoperatively, which helped with consistency of care.

In the PACU at the Cleveland Clinic, Pehotsky says nurses need to remember that with faster-acting anesthetic agents, patients may waken from anesthesia more quickly than in the past and may remember more of their experience in the PACU.

“We remind nurses that just because patients aren’t engaging in conversation yet doesn’t mean they can’t hear you,” she says.

Allowing family to visit the patient in the PACU also contributes to a positive experience. “If a patient will be in the PACU for much longer than an hour, we send for the family,” Pehotsky says, adding that visits are limited to two family members for about 5 minutes.

While bringing the family to the patient, the nurse describes how the patient will look and provides information such as recent analgesia administration. “It’s all about managing expectations,” Pehotsky says. Because family members often complete the patient satisfaction surveys for ambulatory surgery patients, visitation can also help improve satisfaction scores. To protect patient privacy, families do not visit if an admission is expected in a nearby area.


Going home

At Cohen’s, a family-centered approach to discharge has enhanced patient satisfaction. The process includes the use of an inexpensive application called Elimiwait. Once the discharge is ordered, a “ticket” is sent to valet services, and the car is placed in the queue for pickup. While the car is being retrieved, nurses review discharge instructions, answer questions, and help the parents dress the child.

After Elimiwait was added to the valet service, the time from the discharge order to when the child and family left in the car decreased from 34.45 minutes to 14.5 minutes over 3 months, a 55% reduction. Ultimately, the time dropped from 14.5 to 6.19 minutes, another 57.3% reduction.

This small change, implemented in 2015, had a big impact. Before this initiative, a parent had to leave to retrieve the car within a short time of being reunited with his or her child after surgery.

“Something as simple as getting a car involved a whole series of events for the patients, the parents, the nurses, and the ancillary staff because they had to calm the child down for something that didn’t necessarily have to happen,” says Jennifer Simonetti, MSN, RN, CPN, perioperative nurse educator and Magnet program director at Cohen’s.

After the app was implemented, parents were more satisfied with their experience, even if the time from discharge to door was longer than expected. “In the summer months, they don’t have to cool down their car for their child, in the winter they don’t have to clean off their car, and if it’s raining they don’t have to worry about an umbrella; the car comes ready to go,” Simonetti says. “It’s one less thing they have to worry about when they’re bringing their child home.”

The project team included nursing staff and administrators, physicians, valet staff, ancillary support staff, and representatives from concierge and hospital operations. “It was a very collaborative effort,” Simonetti says.

Education included a step-by-step overview of how to input the valet ticket for both nursing and valet staff. “We wanted everyone to have an appreciation for the time frame and for each other’s roles,” she says.

Another change: Parents can pick up postoperative prescriptions at the hospital’s pharmacy so they don’t have to stop at a pharmacy on the way home or go there after taking the child home.

“They don’t have to have that separation from their child in the immediate hours postop,” Shea says. “It has been a huge satisfier for the parents.” The next step is to have the medications delivered to the unit so families can stay at the bedside with their child.

Follow-up calls after surgery close out the patient experience. Pehotsky says that during follow-up calls, nurses ask, “Is there anything that didn’t go well with your stay that we could learn from, or is there anything great about your time with us that you would like us to recognize?”

These questions, along with analysis of comments from patient satisfaction surveys, help identify areas of improvement and reinforce what staff are doing well.


Finding room for improvement

Frontline staff have perhaps the best insight into strategies for improving satisfaction. At Cleveland Clinic, perioperative staff participate in a patient experience committee that reviews survey comments and targets improvement areas.

For example, staff “walked” the map given to patients and families to identify areas of confusion and how it could be more user-friendly.

“Getting caregivers involved doesn’t just pay dividends in the business of patient experience,” Pehotsky says. “I watch people on that committee give better care because they’ve been able to put on the hat of a patient or family member for a moment of time.”

One challenge for perioperative staff is they don’t hear what Pehotsky calls “the rest of the story” once the patient leaves the surgical area. To address that issue, OR leaders work with surgeons to share patients’ stories once or twice a year with the nursing teams. Although the preference is to have the patient at the meeting, usually either the surgeon presents, or the patient creates a video that is shown.

Even the best intentions for a positive experience can go awry. When that happens, Pehotsky says staff and leaders rely on their service recovery training. “We also work with the patient ombudsman,” she adds. “This person helps us get to the heart of the matter and see how we can prevent something from happening in the future.”

Stewart emphasizes that ongoing communication to keep patients and families informed goes a long way toward establishing a positive relationship, which makes service recovery easier.

Sometimes the intervention is simple, such as offering family coupons for free coffee when the surgery is running late. “We also try to explain ‘why’,” Stewart says.

For example, families may be angry because they can’t see their loved ones in the PACU, but once they know it’s because another patient is not doing well, they often calm down.

The focus on patient experience isn’t going away anytime soon. “Whether it’s the front desk, physicians, or nurses, [the patient experience] is important for the future of medicine,” Stewart says. “It’s the way of payment reform and quality metrics.”

The good news is that centering care on the patient serves to remind staff and leaders why they do what they do. “It’s good patient care, and it’s good business,” Pehotsky says. ✥

Cynthia Saver, MS, RN, is president of CLS Development, Inc, Columbia, Maryland, which provides editorial services to healthcare publications.



Sacks G D, Lawson E H, Dawes A J, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality. JAMA Surg. 2015;150(9):858-864. https://jamanetwork.com/journals/jamasurgery/fullarticle/2330656.

Schmock B N, Breckenridge D M, Benedict K. Effect of sacred space environments on surgical patient outcomes: A pilot study. Int J Human Car. 2009;13(1):49-59.

Tiwari V, Queenan C, St. Jacques P. Impact of waiting and provider behavior on surgical outpatients’ perception of care. Periop Care Operating Room Manag. 2017;7:7-11. http://www.pcorm.com/article/S2405-6030(17)30008-0/pdf.

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