By Douglas McCarthy

Issue: The Institute of Medicine (IOM) and other experts have called for a patient-centered health care system that is designed around patients' preferences, needs, and values.[1] Bronson Methodist Hospital, a Malcolm Baldrige Quality Award winner, has been recognized as a leader in promoting patient- and family-centered care.[2] Hence, its experience offers lessons for other hospitals looking for ways to realize the IOM's vision.

Organization: Bronson Methodist Hospital is a full-service, 343-bed tertiary care hospital located in Kalamazoo, Mich. Bronson's 3,200 employees and 700 medical staff provide care to more than 22,000 inpatients and 80,000 emergency department visitors annually. Part of the nonprofit Bronson Healthcare Group, the hospital is affiliated with a local network of primary and specialty care providers, clinics, and community hospitals serving a nine-county area of southwest Michigan.

Objective: Bronson's strategic vision is to be a national leader in health care quality. The hospital's leaders are focusing the organization's strategy and culture around a patient- and family-centered care model in which patients and their families partner with health care providers to achieve the best possible outcomes. One of Bronson's requirements for excellence is that hospital caregivers "honor and respect individual preferences and ensure that patient and family values are included in all clinical decisions."[3]

Key Measures: Bronson has a long history of "listening and learning" from customers, through patient and community surveys, post-discharge telephone follow-up, and focus groups. To better measure patient- and family-centered care, the hospital recently added the following item to its patient satisfaction survey: "The care team involved me and my family as a partner in my care and recovery" (rated on a four-point Likert scale).

Implementation Timeline: Bronson engaged in a decade-long process of organizational change to focus its culture on service excellence, which culminated in winning the Baldrige award in 2005. Since that time, Bronson has intensified its focus on patient- and family-centered care, starting in the maternal and child health area. The hospital is currently adapting and spreading lessons learned from this experience to all of its adult care areas.

Process of Change: Strategically, Bronson has made patient- and family-centered care an integral part of its "Plan for Excellence" (see Figure), a one-page document outlining the hospital's expectations that is distributed to each employee and reinforced through communications, action plans, scorecard measures, and a staff performance management system.

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Instituting a family advisory council was one of the hospital's key interventions for promoting patient- and family-centered care. This council brings together patients, family members, staff, and hospital administrators on a monthly basis to provide guidance on matters ranging from the design of public and family space in a new birth center to hospital visiting hours policies.

The practical impact of patient and family involvement can be seen in the design of a new neonatal intensive care unit. Family advisory council feedback indicated a preference for a curtain, rather than a glass wall, to separate patient rooms from the nursing station. Families felt that a curtain would better enable them to control the level of privacy and community that they experienced in this setting, based on their needs at different times.

The advisory group also identified behaviors that they would expect from caregivers in a patient- and family-centered organization. Based on this input, Bronson has identified specific behavioral expectations for staff in each unit along several dimensions, including:

  • information sharing,
  • dignity and respect,
  • collaboration, and
  • participation.

On a day-to-day basis, Bronson is coaching staff to customize care in a way that meets individual patient and family preferences and values. For example, staff in the hospital's general medical unit work with patients to develop a personal goal that moves them closer to discharge, such as managing pain or sitting up in a chair for one hour. This goal is written on a whiteboard in the patient's room so that family members also can be aware of what the patient wants to accomplish.

Other ways in which caregivers may customize care include adapting their teaching style to meet the needs of particular patients, offering the patient's family the opportunity to "room in" with the patient overnight or remain in the room with the patient during procedures, and asking parents how they want to be involved in the care of their newborn. In the pediatric intensive care unit, families are asked to participate in reviewing the patient's status, goals, and progress when clinicians make their daily rounds at the bedside.

Results: Although it is too early to measure results from these efforts, past results suggest that Bronson's ongoing culture change interventions are having a positive impact. For example:

  • The hospital's patient satisfaction ratings remain consistently high at 95 percent overall, and 100 percent in the obstetrics and neonatal intensive care units. This positions Bronson in the top 5 percent in the Gallup Organization's national hospital survey database. On a survey question measuring inpatient loyalty, Bronson performs at the 98th percentile. Gallup reports that its patient loyalty measure is "statistically linked to financial and growth metrics and overall sustainability" of a hospital.[4]
  • Employee turnover was 9.5 percent overall and 7.3 percent for registered nurses in 2006. For comparison, a 2000 survey of 693 hospitals reported an average nurse turnover rate of 21.3 percent.[5] Bronson's registered nurse vacancy rate was 5.5 percent in 2006, as compared with the American Nurse Credentialing Center's benchmark of 10.6 percent. Bronson estimates that it has saved $3 million over five years through higher nursing staff retention.

Lessons Learned: Bronson is focusing on patient- and family-centered care because hospital leaders believe it is the right thing to do for patients. "We've learned there are things we can do to transform the delivery of care from 'doing things to patients' to 'doing things with patients'—collaborating with them on their care," says the hospital's CEO, Frank Sardone. "We think that we can improve the patient experience measurably by incorporating patients' and families' ideas and input in the process."

Second, Bronson sees this approach as the best way to drive improvement as it seeks to reach the level of perfection in performance, says Michele Serbenski, executive director of corporate effectiveness and customer satisfaction. "When you're already a high performer, it's hard to make people understand why they should do things differently. Sometimes you can't go any farther unless you truly engage the person that you're trying to make better." For example, she notes that patient- and family-centered care is complementary to patient safety goals that encourage patients to ask clinicians about handwashing and medications.

Bronson is careful to distinguish patient- and family-centered care from superficial concerns about hospital amenities such as entertainment options for patient rooms. "It's not about amenities and marketing; it's about process and relationships and partnering and involvement—the way you deliver care," says Serbenski. "If patients told us they wanted amenities, then that would be on our list of what to do," she notes. But Bronson has found that patients are most concerned about the quality of their care and how quickly they will be able to go home.

Organizational change of this magnitude requires persistent effort and leadership. "It has to start at the very top, with the board of directors and senior staff making it a strategic imperative," says Serbenski, and "it doesn't happen overnight." The small steps that are taken each year build up to foster the culture, processes, procedures, accountability, and standards necessary to support and sustain transformation, she says.

The biggest challenge to achieving the promise of patient- and family-centered care is changing the culture within which care is provided, says Sardone. "People assume they are already providing care in that manner. It takes time and education and drilling down to specific behaviors and what impact those have on patients and family," he says. Serbenski adds: "It's not a formula; it has to be adapted to every individual patient need by each care provider."

For example, it takes time for physicians and other clinical staff to become comfortable with the idea of relinquishing some of their control over decision making. "It's very empowering for the staff to understand that they can still do their jobs—and perhaps do their jobs even more effectively—with the input of the patients," he observes.

Bronson is wrestling with the best way to measure the impact of its efforts. Because the hospital's existing patient satisfaction survey did not directly capture the core concepts of patient- and family-centered care, Bronson recently added a new question that gets to the heart of partnership between caregivers, patients, and family members (see Key Measures). Hospital leaders hope that the new Hospital CAHPS survey will provide additional insights that will enable them to better understand patient needs and preferences in future.

Implications: Bronson's experience suggests that the challenges to achieving patient- and family-centered care are chiefly organizational in nature. "That's the good news," says Serbenski. "There isn't something external that's a disincentive for doing this. It's something that every health care organization should be doing."

For Further Information: Visit Bronson's Web site, www.bronsonhealth.com, or contact Michele Serbenski at [email protected]

References
[1] Institute of Medicine (2000). Crossing the Quality Chasm. Washington, DC: National Academy Press.
[2] Baldrige National Quality Program (2005). Bronson Methodist Hospital: 2005 Award Winner. U.S. Department of Commerce, National Institute of Standards and Technology.
[3] Bronson Methodist Hospital (2007). Plan for Excellence. Kalamazoo, Mich.: Bronson Healthcare Group.
[4] Gallup Healthcare Group (2007). Patient Engagement. Princeton, N.J.: The Gallup Organization.
[5] HSM Group (2002). Acute Care Hospital Survey of RN Vacancy and Turnover Rates in 2000. Washington, DC: American Organization of Nurse Executives.