Using a Nursing Bundle to

Achieve Consistent Patient

Experiences Across a Multi-
Hospital System
Case Study May 14, 2017
Susan M. Robel, RN, BSN, MHA, NEA-BC & Denise A. Venditti, DNP, MHA, RN, NEA-BC,
FACHE

Geisinger Health System

Geisinger Health System has evolved and grown in terms of diverse

cultures, demography, and size over the past 4 years. We addressed
inconsistent patient experience by creating a nursing bundle that
helped make patients experiences more consistent, and more
consistently excellent, improving overall patient satisfaction and
Geisingers performance on standard assessments of patient
satisfaction.
KEY TAKEAWAYS
1. Measure what you treasure (data are critical). We are measuring our HCAHPS and
nursing bundle scores on a monthly basis.
2. Give frequent feedback (both recognition and coaching). The Patient Experience team
and leadership acknowledges positive feedback via personal notes and recognition and
coaches employees and leadership on the specific behaviors and process required for
each element of the nursing bundle. For example, if the coach sees team members
interacting with a patient without introducing themselves, he or she reinforces that
expectation.
3. Have a well-stocked toolbox for leaders and staff. Our toolbox includes videos of
employees performing C.I.CARE well in multiple scenarios across the system.
4. Be persistent but patient changing culture takes time. Consistently reward effective
communication and bundle compliance and focus on continuous improvement.

The Challenge

Geisinger Health System (GHS) is one of the nations largest health service
organizations, caring for more than 3 million residents throughout 45
counties in central, south-central, and northeast Pennsylvania and southern
New Jersey. This physician-led system has approximately 30,000 employees,
including nearly 1,600 employed physicians, 12 hospital campuses, two
research centers, and a 551,000-member health plan.
We addressed inconsistent patient experience by creating a nursing bundle
that helped make patients experiences more consistent, and more
consistently excellent.
Over the last 4 years, GHS has added seven new hospitals, all with their own
cultures, traditions, demographics, and employees. To create a consistent
experience for patients, we needed to decide on, and implement, best
practices for our nursing staff. This challenge was related to
the ProvenExperience initiative, begun in 2015 under our new president and
CEO, David T. Feinberg, MD, to offer partial or even full refunds when
Geisingers care does not live up to patients expectations.
The Goal
Our goal was to develop and adopt a consistent nursing bundle across all of
our sites. A bundle, as defined by the Institute for Healthcare Improvement, is
a structured way of improving the processes of care and patient outcomes: a
small, straightforward set of evidence-based practices generally three to
five that, when performed collectively, consistently, and reliably, have
been proven to improve patient outcomes. This definition allowed us to focus
on the most critical elements of the bundle.
The Execution and the Team

We created a team comprising chief nursing officers (CNOs) and key nursing
leaders across the system. This team identified evidence-based practices that
were proven to provide the best experiential and clinical care outcomes. Each
CNO was charged with vetting the best practices and eventual nursing bundle
plan with managers and frontline registered nurses. This process assured
support, buy-in, and input from all levels within the organization.

Click To Enlarge.
 Purposeful Hourly Rounding: The care team enters every patients room
each hour, rather than waiting for the patient to call, and addresses pain,
toileting, and positioning.
I.CARE: All care team members are expected to connect (knock prior to
entering a patients room), introduce themselves and their
role, communicate what they would like to do (e.g., give
medications), askpermission (if it is a good time for the patient), respond to
questions, and end with excellence (e.g., Is there anything that I can do for
you before I leave the room?). The C.I.CARE model was originally
developed under Dr. Feinbergs leadership at UCLA.
Whiteboard: A whiteboard in every patients room, visible from the bed,
shows the date, the names of the care team for the day, anticipated discharge
date, and goals for the day.
Bedside Shift Report: Nurses ending their shift discuss the progress toward
achievement of goals with the nurse coming on duty, the patient, and any
family present.
Nurse Leader Rounding: The unit nurse leader will round on each patient at
least once during the hospitalization and leave a business card with the
patient.
Metrics

We developed a set of customized questions for the patient satisfaction

survey we distribute to patients, addressing key components of the nursing
bundle. To date, from baseline data approximately 6 months ago, GHS has
improved in the above-noted components being consistently (always)
performed. These responses came directly from the feedback provided by our
patients from the custom questions.
To date, from baseline data approximately 6 months ago, GHS has improved
in the noted components being consistently (always) performed. These
responses came directly from the feedback provided by our patients from the
custom questions.

Also, a C.I.CARE competency tool was developed to provide ongoing

training as needed, to hold all employees accountable to the process, to coach
and mentor, to provide an ongoing competency check, and to use for annual
performance evaluations. Senior leadership rounding was kicked off at the
system, hospital, and department levels to ensure appropriate setting of
expectations and role models. System leaders round together quarterly across
the system using videoconferencing and share patient and employee stories
that illustrate both successes and opportunities for improvement. All leaders
are expected to attend 75% of scheduled rounds. Hospital leaders round
monthly using the same process. Department leaders are expected to round in
their accountable areas daily. The overall Nursing Bundle compliance is
being measured by the HCAHPS Nursing Communication scores. Since our
C.I.CARE and bundle implementation, scores for GHS have consistently
increased by up to 3 points and 10 to 15% over the 6-month period.
 Click To Enlarge.
Where to Start

Because each of our hospitals was starting at a different place, we needed to

establish a baseline against which we would be able to measure
improvement. We created the Patient Experience Bundle Gap Assessment
Tool to assess initial performance of the elements of the bundle at all
campuses.
Communication has become a major focus for the entire health system, not
just nursing, and everyone, from the organizations top leadership on down,
has been trained to use the C.I.CARE communication framework.
We also created a nursing competency tool that our facilities could use both
for initial training on the bundle components and for ongoing assessments of
competence. The program includes an annual competency review for each
nurse. In this program, the nurse will be observed demonstrating the elements
of the competency tool such as knocking while entering a patients room,
conducting a patient report at the patients bedside with the patient and
family, and making sure that the whiteboard is up to date in each patients
room.
Approximately 25 to 30% of Geisingers patient complaints come from
communication failures. As a result, communication has become a major
focus for the entire health system, not just nursing, and everyone, from the
organizations top leadership on down, has been trained to use the C.I.CARE
communication framework, Dr. Feinbergs first mandatory initiative. The
entire organization of 30,000 people received this communication
training over 4 months, from March through June 2016.
Lessons Learned

Executive leadership must make patient experience a strategic priority via

goal-setting, day-to-day behaviors, and culture.

It is just as important to train the top leadership as to train frontline

employees.

Monitoring performance is essential. Ongoing results and progress, monthly

and quarterly, are shared with our board, our CEO, all levels of leadership,
and fellow employees to track performance and celebrate successes.

We are improving our performance by adding other tools, such as an

inpatient welcome letter that helps set expectations by educating patients on
the nursing bundle elements and providing photos and contact information
for the nursing leaders in each department.

This case study originally appeared in NEJM Catalyst on April 13, 2017.
DASAR-DASAR KOMUNIKASI DOKTER-PASIEN
ELDA NAZRIATI

HARAPAN DAN KENYATAAN KOMUNIKASI DOKTER-PASIEN

Komunikasisalahsatukompetensidokter
Komunikasimenentukankeberhasilanmenyelesaikanmasalahpasien
selamainiterabaikan,
dianggaptidakpentingbaikdalampendidikanmaupundalampraktikkedokteran

HARAPAN DAN KENYATAAN KOMUNIKASI DOKTER-PASIEN

 Dokterdi Indonesia merasatidakcukupwaktuuntukberbincangdenganpasien
bertanyaseperlunya, mendapatkaninformasi yang tidakcukupuntukmenegakkan diagnosis
danmengambiltindakanmedis
Pasienmerasadalamposisilebihrendah takutbercerita, hanyamenjawabpertanyaandokter

Evidences

After only 18 seconds doctor interrupt patients story (with their own medical agenda
questions)
After only 23 seconds doctors fail into hypothesis (Workshop on SPs, 2005)

(and as consequences: does not want to listen to patients story anymore)

(Beckman &Frankel, 1984)

Evidences

Indonesian patients still feel reluctant to be actively involved in a communication with health
professional; which will lead to ineffective and inefficient communication session,
(Kim YM, et al, 2002)

Komunikasidokter-pasien

tercapainyapengertiandankesepakatan yang
dibangundokterbersamapasienpadasetiaplangkahpenyelesaianmasalahpasien.
Perlukanpemahaman

- jenis komunikasi (lisan, tulisan/verbal, non-verbal),

- menjadi pendengar yang baik (active listener),
- penghambatproseskomunikasi (noise),
- pemilihan channel yang tepat
- mengenal mengekspresikan perasaan dan emosi.

PENTINGNYA KOMUNIKASI YANG BAIK DOKTER-PASIEN

Berkorelasidenganperbaikan outcome (keberhasilanterapi):

Memperolehinformasi yang akurat
Kerelaanpasienmenjalanipengobatan
Memperkecilkesalahanpengobatan
Meningkatkanketegaranpasienmenghadapipenyakitnya
Meningkatkankepuasanpasien :
Pemahamankomunikasimultietnikdanmultikultural
Hubungandokter-pasien yang baik pasienpercayapadadokter
Memperkecil claim malpraktis
Mengurangikesalahfahaman

AspekHukum (UU 29tahun 2004 tentangpraktikkedokteran)

Kontrakterapetikdimulaisaat anamnesis
Tindakanmedisharusmenggunakan informed consent berdasarkaninformasi yang
diberikandokter

KewajibanPasien
1. memberikaninformasi yang lengkapdanjujurtentangmasalahkesehatannya;
2. mematuhinasihatdanpetunjukdokterataudoktergigi;
3. mematuhiketentuan yang berlakudisaranapelayanankesehatan; dan
4. memberikanimbalanjasaataspelayanan yang diterima.
HakPasien
1. Mendapatkanpenjelasansecaralengkaptentangtindakanmedis
2. Memintapendapatdokterataudoktergigi lain (second opinion)
3. Mendapatkan pelayanan sesuai dengan kebutuhan medis;
4. Menolaktindakanmedis; dan
5. Mendapatkanisirekammedis

KewajibanDokter/DokterGigi
a. memberikanpelayananmedissesuaidenganstandarprofesidanstandar
prosedur operasional serta kebutuhan medis pasien;
b. merujukpasienkedokterataudoktergigi lain yang mempunyaikeahlianataukemampuanyang
lebihbaik, apabilatidakmampumelakukansuatu
pemeriksaanataupengobatan;
c. merahasiakansegalasesuatu yang diketahuinyatentangpasien, bahkan
jugasetelahpasienmeninggaldunia;
d. melakukanpertolongandaruratatasdasarperikemanusiaan, kecualibilaia
yakin ada orang lain yang bertugas mampu melakukannya;
e. menambahilmupengetahuandanmengikutiperkembanganilmukedokteranataukedokterangigi.

HakDokter/DokterGigi
a.
memperolehperlindunganhukumsepanjangmelaksanakantugassesuaidenganstandarprofesidanstand
arproseduroperasional;
b. memberikanpelayananmedismenurutstandarprofesidanstandarproseduroperasional;
c. memperolehinformasi yang lengkapdanjujurdaripasienataukeluarganya
d. menerimaimbalanjasa.

4 kelompokpasien yangtidakperlumendapatinformasisecaralangsung,

Pasien yang diberi pengobatan dengan placebo yaitu merupakan senyawa

farmakologistidakaktif
Pasien yang akandirugikanjikamendengarinformasitersebut, misalnyakarenakondisinya
Pasien yang sakitjiwadengantingkatgangguan yang tidakmemungkinkanuntukberkomunikasi
Pasien yang belumdewasa

Pendekatankomunikasidokter-pasien

Disease centered communication style ( doctor centered communication style)

berdasarkankepentingandokterdalamusahamenegakkan diagnosis,
termasukpenyelidikandanpenalaranklinikmengenaitandadangejala-gejala.
Illness centered communication style (patient centered communication style)
berdasarkanapa yang dirasakanpasiententangpenyakitnya yang secara individu yang
merupakan pengalaman unik. termasukpendapatpasien, kekhawatirannya, harapannya, apa
yang menjadikepentingannyasertaapa yang dipikirkannya.

Illness
(scripts )
Disease

LITERATURE REVIEW
Data

DiseaseFramework is doctors traditional & central agenda (including investigation of sign &
symptoms and differential diagnosis)
 IllnessFrameworkis individual patients unique of sickness experiences (including ideas,
concerns, expectation, feelings, thoughts, and effects).

(Stewart & Roter 1989)

DIAGNOSIS
Fear
Questions
Meaning of this for future life?

Problem

KEPENTINGAN DIAGNOSIS DOKTER

Anamnesis (History Taking)
Proses Penalaran Klinik
(Clinical reasoning)

KEPENTINGAN PASIEN
Worries
Concern
Expectation
Impact
QUESTIONS

Bentukkomunikasidokter - pasien

Sasaran : pasien, sejawat, tenagakesehatan lain, instansi lain

Metode / bentuk

- Oral : autoanamnesis, alloanamnesis

Tertulis : surat-suratketerangan, persetujuantindakan

Nonverbal : ekspresi, sikaptubuh, dll
Tingkat kesulitan:
Tidakdenganpenyulit
Denganpenyulit
AplikasiKomunikasiefektifdokter-pasien
1. SikapProfesionalDokter : mampumenyelesaikantugassesuaifungsi, mampu mengatur diri sendiri
(ketepatanwaktu, pembagiantugas) mampumenghadapiberbagaimacamtipepasien,
bekerjasamadenganprofesikesehatan yang lain sikapprofesionalpentinguntukmembangun rasa
nyaman, aman, danpercayapadadokter komunikasiefektif

AplikasiKomunikasiefektifdokter-pasien
2. SesiPengumpulanInformasi :
- Mengenalialasankedatanganpasien
- Penggalianriwayatpenyakit

Model :
Patient takes the lead (through open question
by the doctor)
Doctors takes the lead (through closed
question by the doctor)
Negotiating agenda by both

Van Dalen, 2005

AplikasiKomunikasiefektifdokter-pasien
3. SesiPenyampaianInformasi

Materi : Tujuan anamnesis danpemeriksaanfisik,

Kondisisaatinidankemungkinandiagnosis,rencanatindakanmedis, pilihanterapi, prognosis dll
yang diberiinformasi : pasien, keluarga/walijikakondisipasientidakmemungkinkan
Menggalipenyakitpasien (history taking)

Active listening
Open ended question
Appropriate respon

Active listening

Look
Nod (mengangguk)
I see
Repeat phrase
Summarize
Pauses
Minimize questions
Reflect feelings

Physical sorounding

Tempatkomunikasi :
tenang,
privacy terjaga,
jarakpasien-dokter
Gangguantelepon
Aktifitaspenganggu
dll
linguistic

Merencanakanprosesdanlangkahkomunikasi

Langkah-langkahKomunikasi

S = Salam sapa, tunjukkanadawaktu

A = AjakBicara duaarah, dorong agar

pasien mau dan dapat mengemukakan pikiran dan perasaannya., hargaipendapatnya,

fahamikecemasannya, mengertiperasaannya.

J = Jelaskanjelaskanhalyangmenjadiperhatiannya, yang ingindiketahuinya, yang

akandihadapinya, luruskan persepsi yang keliru.
I = Ingatkan ingatkanhalpenting, klarifikasiapakahpasientelahmengertibenar,
mengulangkembalipesankesehatan yang penting.

Elemen esensial komunikasi dokter pasien (Boelen at al,2002) :

1. Membuka diskusi :

Memberi kesempatan pasien menyelesaikan statement pembukanya

Mendapatkan perhatian penuh dari pasien
Mempertahankan hubungan personal

2. Mengumpulkan informasi

Menggunakan open-ended dan close ended Question dengan tepat

Menyusun,mengklarifikasi, dan menyimpulkan informasi
Mendengarkan dengan aktif menggunakan teknik nonverbal (eye contac) dan verbal
3. Memahami pandangan pasien

Menggali faktor kontekstual (keluarga, kultur, usia dan seks, sosio ekonomi, status, dan
kepercayaan)
Menggali kepercayaan, perhatian, dan harapan tentang sehat dan sakit
Memahami dan merespon ide, perasaan, dan value pasien

4. Memberi informasi

Menggunakan bahasa yang dimengerti pasien

Mencek pemahaman pasien
Memberi kesempatan pasienuntuk bertanya.

Komunikasidokter-pasiendenganpendekatankedokterankeluarga (Boelen et al 2002)

Mengggalipeyakitdanpengalamansakitpasien
Memahamipasiensebagaimanusiaseutuhnya (karakteristikbiopsikososiokultural)
Mencariinformasisebagaidasaruntukmanajemenpenyakit
Memperhatikanfaktorpencegahandanpromosikesehatan
Meningkatkanhubungandokter-pasien
Bersifatrealistisdengankondisipasien

Time manajemen

Sampaikanwaktu yang tersedia

Jikapasienmerasakurangjanjikanwaktu lain untuktambahan
Tanyakanpasienakanmulaidarimana
Fahamkanpasiensecarabijaktentangkesibukandokter
Komunikasidenganpenyulit

Pasiendenganemositinggidan personality yang sulit (ketergantungan, narsis, kompulsif, dll)

Komunikasisulitpadaorangtuadananak (issue sensitif, ketidaksetujuan, komplekskomunikasi,
dll)
Kelompokdewasakhusus (lanjutusia, remaja, dll)

Referensi

KonsilKedokteran Indonesia, 2006. Komunikasiefektifdokterpasien. Jakarta

Adler BR, Rodman G, 2006. Understanding Human Communiacation. Oxford University
Press New york
Elizabeth Macdonald, 2004. Difficult conversations in medicine . Oxford University Press
New york

TERIMA
KASIH