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Patient Experience

Creating a PX Pathway

Since the launch of the ‘triple aim” and the initiation of the Affordable Care Act, the impact of patient satisfaction on the healthcare industry bottom-line has taken on new priority. The connection between employee engagement and patient experience also continues to emerge. Surveying patients after discharge is big business and there are multiple vendors available to provide HCAHPS and other additional customized questions sets for facilities of all sizes. But even with all the offerings, there are still challenges to reach an acceptable sample size for meaningful data analysis and process improvement. The impact of short-stay versus extended-stay patients on these surveys is an interesting element to explore.  

Have you stopped to think about the ratio of surveys that are completed by the 1-3 day stay population compared to the 1-3 week stay patients? Patients going home after one day will have a 7 times greater chance of being offered a survey than those going home after 1 week. Patients discharged after three days would have a 21 times greater chance of being surveyed than those going home after three weeks. Do you have any idea which patients are completing the surveys at your facility? Have you been able to trend different ratings for these two populations?  Logic, and my 20 years in obstetrical nursing tell me that we have far fewer opportunities to positively or negatively impact patient experience if they are with us for a shorter period of time. It might be easier to meet their expectations for 1-3 days than it is when patients and families are with us for weeks.  

These two populations have vastly different patient experience needs and creating a single patient engagement process to address both may be a missed opportunity. At Nobl, we believe that all leader patient rounds need to be meaningful to the population and to the leaders completing them. We assist specialty leaders and department heads to drill down on the specific needs of their populations, but we seldom see organizations that thoroughly assess or study the progress of extended stay patients with similar medical diagnoses or surgical procedures as they journey through the health system. This is a missed opportunity for purposeful and proactive leader rounding and service.  

Anticipating the typical needs for a group of patients can create a custom experience for them – a proactive Patient Experience (PX) Pathway. To understand the concept of a “pathway” it might be helpful to consider a familiar clinical example such as orthopedic surgery “joint camps.” Over the years total joint replacement programs learned that the right teaching prior to surgery, planned progression through the acute phase of care, and level-setting of therapy requirements after discharge resulted in faster and more effective recoveries. If we take a similar approach to the patient experience, we might offer the right things for all patients within a group before they must ask. We can map an ideal patient experience by combining observations, trended data, and responses to specific rounding questions for a large sample of patients within the identified group. There might even be an opportunity to conduct ethnography research by embedding patient experience staff to “walk hand-in-hand with patients” throughout the course of treatment to record every aspect of the journey. This expert outsider might notice the things that the patient and family take for granted, but which contribute greatly to the patient experience.  

The flexible options within the Nobl platform make it easy to record and trend observations (audits), to customize rounding question and evaluate responses and comments, to share praises for what is working well, and to act upon concerns that need to be addressed. Being able to capture all these data points in one platform that also has integration to previous round results and comments, and even patient satisfaction survey responses from previous encounters with the health system creates a strong base for a PX Pathway.  


Consider the following five steps to get started on a proactive PX Pathway

1.  Refer to your patient census and select the top diagnosis related groups that result in high volume, low length of stay populations that will increase the odds for a higher rate of patient satisfaction survey completion. Try to map and capture their needs first. The element of survey volume from a highly satisfied group can impact patient experience quickly.  Imagine this group as the “low hanging fruit” for service excellence. Biggest benefit for least effort.  

2.  Begin patient experience mapping for this group. HCAHPS data at the unit level is helpful to see what is working already so the actions driving those scores can be maintained.

“In reviewing your unit level HCAHPS data consider finding areas of opportunities by reviewing the results that have an n size of 30 or greater, performing under the 50th percentile and most strong correlate to the Likelihood to Recommend score” shares Katie Haifley, Co-founder and CMO of Nobl. 

Lower scores can become the basis for customized leader rounding question sets for these patients. Leaders can drill down on things like dietary preferences or service barriers; room temperature, cleanliness, comfort, features and amenities; and staff workflow. Seeking permission for a staff member to spend a shift or a day with patients, to observe all interactions with the staff and the environment can reveal surprising results. This is a great way to really appreciate the number of interruptions, noises, or delays that occur, as well as the things that bring delight to patients.  

3.  Once you have followed a small sample of patients from your selected group, bring your clinical stakeholders together to review the results. This group of experts can assist to breakdown the patient’s hospital stay into phases into which the data results can be assigned. This helps to map out specific proactive actions that can be tested within each phase to provide an improved experience.  

4. Determine the best stakeholders to design the new provisions for each phase and set a timeline to gather or develop the resources needed for implementation. When all is ready, launch the new processes with a small sample of patients who belong to the group. Actively round on these patients specific to the new features, and assess the impact of the changes on the patient experience and well-being. This direct feedback will help to validate or reject the actions that may be impacting the HCAHPS or patient experience scores.  

5.  Utilize your quality improvement model, such as PDSA – Plan, Do, Study, Act – to work through each phase of changes and continue to fine-tune what works. Over the course of 6-12 months, a streamlined menu of what works, and when, can be added to the patient journey through your facility. When you finish with one patient diagnostic group, move on to the next, or share the process and success of this approach across service lines, training leaders and staff to develop their own proactive PX Pathway. 

You might be amazed at what you can learn and achieve with proactive PX Pathways. A Pathway organizes for all caregivers, including those new to your organization, the best actions to delight a patient group before they must ask. It is a model based on review of data, not scripting or general inquiries. 

Lastly, never forget that patient experience is about relationships, and all relationships are made better by listening, supporting, engaging, asking, revising, and listening some more. 

Written by Teresa L Anderson, EdD, MSN, NE-BC, Nobl Chief Nursing Officer

Nurse Leader Rounding Ebook