Treat Me With Respect
Our patients have told us that they want three things from us, and in this order: Don’t hurt me, heal me and be nice to me. Every one of these is important, and in this podcast we are discussing the last of these: be nice to me.
Here at Nationwide Children’s, family-centered care is important. Every one of our staff members strives to include our patients and their families in the care plan as much as we can. This directly correlates to that what our patients have told us they want: be nice to me. We took this, made it part of our strategic plan, and now refer to this component as “Treat Me With Respect.”
The ultimate goal for our “Treat Me With Respect” attitude: when parents give us feedback, we listen. Then, we take that feedback, let it guide how we interact with families, and thus empower them. We want our patients and families to leave us with a sense of having been an active participant in their or their child’s care.
Listen in as Linda Stoverock, Chief Nursing Officer, and Kerry Rosen, Director of Outpatient Cardiology Services, talk more about why Treat Me With Respect is so important, and the measures that our entire staff take every day to ensure we are doing just this with all of our patients and families.
Watch this video to learn more about Family-Centered Rounds.
[Respect – Aretha Franklin]
Dr. Rick McLead: Welcome to Children's on Quality. That of course was the Queen of Soul herself, Aretha Franklin from a 1990 recording. R-E-S-P-E-C-T is the topic for this edition of Children's on Quality.
With me to discuss our Treat Me With Respect program are the two leaders of the initiative; Linda Stoverock Stoverock RN, Chief Nursing Officer at Nationwide Children's Hospital and Kerry Rosen MD, Director – Outpatient Cardiology Service.
Welcome to Children's on Quality.
Linda Stoverock: Thank you.
Dr. Rick McLead: Linda Stoverock, let me begin with you. Tell our listeners about the Treat Me With Respect program and what prompted its initiation.
Linda Stoverock: When we started our work with safety, we recognized the important role that the parents have in it too. And we say that there are three things that parents want, it's; to not hurt their child – so we call that Don't Hurt Me, Heal Me – which is to make their child better, and Be Nice To Me – our Treat Me With Respect. And they want them in that order from what the statistics and research out there say; all three are important, but that's the order they want them in.
And so we're really trying to amp up our service now with our Treat Me With Respect.
Dr. Rick McLead: What would you see as the ultimate outcome, the goal for this particular project?
Linda Stoverock: The ultimate goal is that when parents give us feedback or they're talking to other people – they always feel they leave this organization with their being participants in their child's health care.
Dr. Rick McLead: Dr. Kerry Rosen, I thought we are a pediatric institution. A big part of what I understand is Treat Me With Respect is this whole concept of family centered care. What's family centered care all about?
Dr. Kerry Rosen: That's a great question. Family centered care actually has four main principles and include:
Treating patients and families with respect and dignity.
Having the families be active participants in their care.
Seeking out two – way or by directional information sharing – meaning we're not just telling the families what we think, but we need their input to take the best care possible of their children.
And also, collaboration – collaboration at all levels of the patient's care. Where we want to collaborate with the family, not just provide medical care.
Dr. Rick McLead: Well this seems like a big challenge. Linda Stoverock, what do you see as the barriers to creating a family centered care program?
Linda Stoverock: Most of the time it's the rush that people get in to as we are thinking about the next several steps we have to deal in our day's work and we forget to stop and see did the family really understand and did we hear what they were saying as to their perception of the child's problem or the child themselves in case of our adolescents and young adults.
And so, we have to slow ourselves down and really talk to the family and the patient about what their individual goal is or the plan that they want to achieve and then how do we meet that, how do we get transparent and really listen to them.
Dr. Rick McLead: Kerry, what are some of the changes that you planned with the Treat Me With Respect program?
Dr. Kerry Rosen: So, some of these changes are already underway over the last couple of years or even recently. You know one of the big shifts compared to decades ago, when we used to do rounds, we would have the mindset that we would be talking about the family or about the patient and maybe rounding in the hallway or separate from them. We want to shift the mentality to rounding and caring about the patient to actually talking with them. So having the family in the middle of rounds or having the family and patient participate in rounds and not have the medical team talk about the patient but actually talk with the patient. So that's a big picture shift in towards the Treat Me With Respect.
Couple of other things that we're doing to engage the family is actually inviting the families to be in active participant with rounds. We actually have hang tags that we put on the patient's doors that we're trialling and piloting right now. Then actually gives the family the choice – we're going to be rounding, do you want to participate? Do you want us to do this in the hall?
And also just recently, we have a new introductory video that the families will see during their sort of check-in process. So part of their checking-in to their room after they're being admitted is a video that we're using that will actually introduce family centered rounds, so the families know that this is an important part of their care.
Dr. Rick McLead: What's been the initial response to this?
Dr. Kerry Rosen: From…
Dr. Rick McLead: From the parents.
Dr. Kerry Rosen: From the parents? I think across the board the families embrace and really not only like but in some respects expect to be a more active participant.
Dr. Rick McLead: Why haven't you been doing this all along?
Dr. Kerry Rosen: It's a great question you know. We're kind of brought up as medical providers, doctors, and nurses – we learn to do things a certain way and I'll point to you, you said you've been doing this a while and how you were taught to interact with patients and families decades ago is probably different than how our current medical students and student nurses are learning to interact with families.
Dr. Rick McLead: It was routine to go into a conference room. It's sit down for an hour and a half with our attending physician and discuss all the patients and historically we almost never went to the bedside to actually interact with families etcetera. That was sort of what the house is after residency interns would do but, the actual teaching round was done with the attending in the conference room.
So, this is a major change from how it has been done historically. But you know sometimes we need to have conversations about patients that maybe we need to discuss prognosis, we're not quite ready to share that with the family. How would you do that, if there's something of a particular sensitive nature that needs to be discussed as a team and yet not upset the family as you have the conversation about what this diagnosis means etcetera?
Dr. Kerry Rosen: A principal concept when just dealing with family centered care is you understand the degree to which the family wants to participate. So on a sensitive topic like that, I think it's important for the team to understand what degree the family wants to know, how much they want to participate in rounds, how much for example the teenage patient may want to know or not know about the condition. And it's kind of a blanket answer, but I think we really have to be aware and sensitive of how much the patient wants to be engaged.
Now digging in deeper to your question, if somebody has a diagnosis of cancer – who better than the patient or family to know that you have cancer? I mean there's a degree or sort of honesty and transparency that has to be put on the table. I think in some parts we may be doing a disservice that we hold that information from them. It's actually honest, it's transparent, we're involving them in the process and I think that is a better way to go about their care.
Dr. Rick McLead: Linda Stoverock, there are sometimes some cultural issues that could impact how we share with them? Any thoughts about?
Linda Stoverock: There are some cultural issues, but they shouldn't impact the care. It's what we need to understand about the cultural issues and how do we learn and embrace those as part of the care. And one of the things that we really work here with our diversity initiatives and inclusion is providing information to all of our health care providers about what those cultural issues are and so we'd put resources out there, but you can't make a blanket statement that everyone from a certain culture is going to behave or want things a certain way. And so, you really again, have to have a conversation with the patient and family and see what their beliefs are and explore those and then come to agreement on a plan.
Dr. Rick McLead: What about some of the educational needs for the family as we bring them in to this role. What kinds of things do we need to educate them about?
Linda Stoverock: One of things that we're really trying to work on is making sure that when we give education information to patients and families, that we'd stop and ask them to tell us what it meant to them in their words. In other words, teaching it back to us – so that we can identify where there's maybe still a gap and we're on different pages with the language that we're using and that we break it down into components that they can take home then and enact to make sure that their child stays well.
Dr. Rick McLead: It was pretty common for new house officers to engage in conversation in families using clearly medical language and especially abbreviations. So have we done anything specifically with regard to how we educate our trainees into the proper way to communicate with families?
Dr. Kerry Rosen: I think that's a great point and that's a challenge that we as the physician-supervisors need to role model for the students and residents on ways that you can discuss a medical issue but actually discuss it in language that the family will understand. So, I think that's a soft scale, if you want to call it that, that's certainly is a challenge in this whole process.
Dr. Rick McLead: Linda Stoverock?
Linda Stoverock: I just want to add to that, that again it goes back to that listening and asking for clarification because something as simple human language that's used everyday is rounds, yet we had a parent talked to us and tell us that they didn't know what rounds meant. To us it's everyday communication, it's not medical jargon. And so again, it's that point of really stopping and asking for clarification and really what does the family understand that we just said.
Dr. Rick McLead: So when the families send us nice complimentary notes about how well we done, we kind of have a feeling that we're on the right track. But, I'm a QI guy so, I want to know how you going to measure this. So, what are the tools you're going to use to measure your performance with regard to the whole Treat Me With Respect program?
Linda Stoverock: So, there're several measurements, but one of them we really do count are not just the comments but when we send out surveys from our families, we look at that information and we try to improve on our scores that they give us – that's the number one way.
But then when we put in a new program such as rounding – we're out there measuring to see did we do it, what's the bundle of care the things that we change? So we're looking to say, did the team round and invite the family to participate? Was the nurse at the bedside also to help participate in those rounds?
If we put out a new card for the families to tell us, do they want the round in the room or outside the room? We'll be checking to see how often that happen. So, all of those have a metric that we try to look at and make sure we're going the right direction.
Dr. Rick McLead: One of the complaints that I do hear about that we do and always do a good job of communicating what the plan is during a hospitalization, and one of the interventions I'm aware of from the Cardiac Intensive Care Unit is the whole concept of a journal board. Kerry, could you explain that journey board concept?
Dr. Kerry Rosen: Sure, a journey board is a part of a road map for the patient's care from the time they get admitted throughout the hospitalization to discharge. So, it actually literally looks like a road map or even like the Game of Life sort of game board where there are spots along the way that the patient has to sort of journey through to get through their admission. So for example in a patient who's had heart surgery, there're steps through the ICU and transferring to the floor, but families need to do a lot of things to get to the point of being discharged like passing their car seat test and parents learning CPR and learning their medications, learning how to mix up the formula correctly.
So all of those are sort of check boxes on the journey board and by the time a patient is ready to be discharged, the vision is, have all of the boxed checked on your journey board? The families reviewed it and reinforced by the nursing staff, taught and the communication will be much better throughout their hospital journey.
Dr. Rick McLead: What's the plan for spreading that from the ICU to the rest of the hospital?
Dr. Kerry Rosen: So that's already happened. This actually started in the Heart Center and the Cardiac ICU and then on our Cardiology Floor. But now several other floors, if not all of the floors are instituting or using a journey board that's actually specific to their patient population. You know what a heart surgery patient might need is certainly different than what a cancer patient might need. So there are disease-specific and floor-specific journey boards that are being used throughout the hospital.
Dr. Rick McLead: Well, we have nearly 25,000 admissions a year and over a million outpatient visits each year. So our staff are working pretty hard at taking care of all these patients, yet there are some simple things that they can do to be family centered. Linda Stoverock, what are some thoughts about things the staff can do that really don't take any more time?
Linda Stoverock: They are so simple, Rick. And one of the first things is just every time you go into the room to meet a family and stop and introduce them and tell them what role you have, we've got so many people here with different jobs going in and out of rooms, that is hard for a family to keep straight, "Who's the doctor?" "Who's the nurse?" "Who's the housekeeper?" "Who is the medical student?" And, "Who's the nursing student?"
And so each one of us is accountable for letting them know who we are and what we're there to do and what the goal is. And then the second thing is just stop and sit down when you're having that conversation rather than looking like you're leaving out the door with your hand on the doorknob ready to go on to do your next thing. Stop, eye contact, listen, and then before you leave, ask if there are any other concerns that you can address while you're there.
Dr. Rick McLead: Well Kerry, when I joined the staff at Children's Hospital more than 30 years ago, there were maybe 25 full time hospital-based specialist, now we have literally hundreds of medical specialists and more than 11,000 physicians are on our medical staff. We also have new providers like the Advance Practice Nursing staff; communication among all these providers is a bit of a problem. So any thoughts on how we can do a better job as team members to communicate what's going on with patients?
Dr. Kerry Rosen: Actually circling back to a family centered care concept that kind of permeates all the care we provide is part of the answer. Not just family centered care where we have the family involved, but we've also worked towards having the bedside nurse involved with the in-patient rounding procedure. Like Linda Stoverock just described, we're all busy, the nurses can be busy, they can be taking care of two or three patients. So we really make an effort that the family here is the plan on the discussion on rounds, we make an effort to get the bedside nurse freed up from what they're doing at that time, so they're part of the discussion. So that helps with not just one way, but two way, three way communication, so everybody hears the plan at the same time.
That as opposed to people just coming in and out and hearing different stories, it goes a long way. Another quick example is – over the last several years when nurses actually change shift from day shift to night shift, what we are doing now is actually the nurses are doing that at the bedside and with the family participating. So they're sharing their information about what's the plan for the next 12 hours – not in a conference room or the break room, but right there in the patient's room with the patient and the family. So these are all the things that we could do to communicate better, so the family and the team members all know what's going on and everybody's on the same page.
Dr. Rick McLead: Do you think the electronic record has helped communication better or in some ways made it worse?
Dr. Kerry Rosen: I could probably give you an answer in both directions. It probably has helped because it's easier to access information, so it's easy to quickly look up wherever you're at, what's going on. But on the other hand, you may just rely on dropping a quick note and not really talking to the patient and family and talking back to the other team members and really having a dialog and communication. So, I think in some respects it helps and some respects it may create other challenges.
Dr. Rick McLead: Well, that's all the time we have for this edition of Children's on Quality.
Children's on Quality is produced by Kelly Nightingale. Our theme music was composed by Ryan McLead.
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Dr. Rick McLead: Next time on Children's on Quality, we will be discussing the Nephrology Quality Projects.
Until then, this is your host Dr. Rick McLead McLead wishing you the best of good health.