National Nurses United

Rounds+Scripts_FNL with art 11/6/10 2:06 PM Page 22 essentially requiring hospitals to participate in programs which purport to measure patient satisfaction or risk losing funding. Second, hospital marketing departments are rolling out programs designed to elicit more positive responses on patient satisfaction surveys, whether it's forcing RNs to make hourly check-ins with patients for appearance's sake or literally putting words in nurses' mouths with pat scripts crafted to promote their workplaces. Nurses everywhere are protesting this hospitality and service model for their profession. They say it's not only insulting and demoralizing to be told how to talk to their patients, but that these programs override their ability to plan and implement care based on their patients' unique needs, that they interfere with their real work, threaten their autonomy and nursing judgment, and raise concerns about their job security. Most importantly, scripting and rounding programs are not an acceptable substitute for safe staffing levels. As patient advocates, say nurse leaders, nurses should not just accept these changes. By banding together and with the help of their union, they can fight back to protect both their patients and their profession. "When people come into a hospital, they're there because they need sophisticated nursing care – not because they need room service," said DeAnn McEwen, a critical care RN at Long Beach Memorial Medical Center in Southern California. McEwen is also a co-president of the California Nurses Association, chair of its Professional Practice Committee, and a nurse representative. "These practices deskill and dumb down nursing care and they're an attempt to override the independent professional clinical judgment of the direct-care registered nurse." O f course, it's all about the money. For years, medical centers have relied on patient perception and feedback to improve care and attract patients. But starting in 2006, caring about patient opinions became a near mandate when federal reimbursements became linked to participation in satisfaction surveys. In that year, the Centers for Medicare and Medicaid Services (CMS) implemented a rigorous national feedback system for quality and perception of care at American hospitals called the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS. Developed since 2002, the federal Office of Management and Budget approved the use of HCAHPS for public reporting purposes in 2005, and CMS rolled it out the following year. The first statistics were available in 2008. While participation is not mandatory, CMS began in 2007 docking annual payment increases by 2 percent from hospitals that don't submit data. And starting in October 2012, HCAHPS scores will be among the measures used to calculate incentive payments to hospitals under one of the new healthcare reform laws passed by Congress in March. HCAHPS scores are now available online at the CMS website and on websites like HospitalCompare.hhs.gov. The HCAHPS survey contains 27 questions that judge a hospital's quality, including mortality, effectiveness of treatment, pain management, and discharge information. But it also contains subjective questions: What did you think of the hospital's cleanliness and quietness? What did you think of the responsiveness of hospital staff? Would you return to this hospital? Would you recommend it to others? 22 N AT I O N A L N U R S E These questions reflect the healthcare industry's treatment of patients as customers, as consumers of a product, and of beliefs in studies dating back to 1988 that claim to find a correlation between customer satisfaction and measurable quality of clinical care. A 1995 study found that health outcomes could be improved by so-called "psychosocial interventions" — such as politeness, friendliness, and gentleness on the parts of nurses and doctors. In an influential 1999 study, Pensacola, Fla.-based Baptist Hospital saw both its clinical scores and its income increase when it instituted patient satisfaction techniques that included asking staff to be friendlier to patients. (Not coincidentally, the administrator for Baptist Hospital at the time, Quint Studer, went on to found the Studer Group, a consulting firm that is a leading seller of rounding and scripting programs.) And as recently as 2004, researcher Kelly Worthington announced that people who enter a hospital for medical care are part patient and part customer, adding, "acknowledgment that the person is also a customer affirms that person's right to personalized service that meets all their expectations." But other studies are more skeptical about any direct link between patient satisfaction and clinical outcomes. In a 1991 paper by Hannu Vuori, chief of epidemiology statistics and research for the World Health Organization, Vuori says that there is no evidence in the literature that measurement of patient satisfaction has improved quality of care. Researchers can find little literature on the topic, and even physician administrators have commented that patient perception data are not objective measurement tools. Despite the tenuous connection, hospitals are embracing the idea of catering to patients as if they were pampered guests. Hospitals are moving beyond marketing themselves based on medical excellence and compassion. Many are now following the hospitality model, reinventing themselves as upscale hotels, with marble lobbies and cascading waterfalls. W hether or not it should, the trend is shifting toward basing more of a hospital's Medicare and Medicaid compensation on patient satisfaction marks. To cater to hospitals' pursuit of better scores, there's now a booming business underway to develop and sell programs not only to increase patient satisfaction marks, but conduct the actual surveys. For just $1,495, your hospital can buy a training DVD developed by the consulting firm Studer Group explaining the "recommended behaviors and actions" of hourly rounding, the program that Garza's workplace instituted. Studer Group, based in Florida, also sells another popular program that hospitals adopt called AIDET, which is intended to reprogram how nurses talk to patients so that they have "a better patient experience." AIDET stands for "acknowledge, introduce, duration, explanation, and thank you" – five things RNs are supposed to do every time they come into contact with a patient. The AIDET training DVD is yours for $2,150, according to Studer Group's online store. An extra $60 gets you 25 participant guides and pocket cards for your nurses. In-person trainings by Studer Group "coaches" are more expensive, of course. Press Ganey, based in Indiana, is another major healthcare consulting firm that advises hospital clients how to implement rounding programs and other methods of improving patient satisfaction W W W. N A T I O N A L N U R S E S U N I T E D . O R G O C TO B E R 2 01 0

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