Like some people, I can tell a story about a not-so-great hospital encounter. But I also can describe exemplary hospital encounters — when efficient and safe, evidence-based care was delivered by nurses who provided tender attention and doctors who listened and patiently explained their diagnoses.
My oldest child's first few years of life were filled with at least one life-or-death diagnosis, a "simple" heart operation that proved anything but, and many visits to multiple specialists during which my husband and I saw the vast spectrum of care, from extraordinary to excruciating. To some people, the Institute of Medicine's Six Aims may seem like a talking point or abstract policy recommendation. But for the people at the heart of our health system — the patients and their families — the six pillars are of real-life concern. They can make the difference between successful outcomes and unsuccessful ones. They can help make a hospital stay a satisfying — even exceptional — experience.
Four Weeks, Three Hospitals
My firstborn, Wesley, was delivered by emergency cesarean section at a small Chicago hospital, now shuttered. After a week in the neonatal intensive care unit at this hospital, he was still severely jaundiced, feeding poorly and lethargic. Sensing something was wrong, the attending physician ordered a nursery-to-nursery transfer to a large hospital in another part of Chicago. Wesley spent three weeks there — a hospital stay that dragged as staff struggled to diagnose his problem.
At our request for a second opinion, Wesley was transferred to a large academic medical center in another part of Chicago. A top specialist at this hospital finally diagnosed our baby's condition as idiopathic neonatal hepatitis. Our son spent only one night at this hospital before he was discharged with vitamins and medications. We had follow-up appointments there throughout the first year of his life, as his initial malady slowly but steadily cleared.
Four weeks, three hospitals: This was my son's first month of life. Wesley had several other medical issues and he and I, occasionally with my husband, spent much of his newbie life visiting several pediatric specialists at a fourth hospital. We became regulars at this hospital, which is dedicated to treating children and home to most of the clinicians treating our son.
Twenty-one years, a handful of surgical procedures, including one to repair a hole in his heart, and hundreds of hospital visits later, Wesley sees "just" two specialists annually now — an ophthalmologist and orthopedist — both of whom have followed him since the early months of his life.
Applying the Six IOM Aims
Thinking back to my son's early years, I am grateful for the excellent inpatient and outpatient care at hospitals, which helped make him a happy and healthy young man today. When he received exemplary care, the hospital was following at least five of the IOM's Six Aims for improving health care — safe, timely, efficient, effective and patient-centered. (The sixth aim, equitable, wasn't something we could discern as individuals.) Likewise, when we felt care was inadequate, it typically fell short of one or more of the aims.
Safe: Neonatal and pediatric intensive care units are incredibly busy places, filled with machines and apparatuses and physicians and nurses caring for the youngest and tiniest of patients. At every hospital where our son stayed, precautions were taken to ensure patient safety. For example, my husband and I had to "scrub" from our fingernails to our upper arms and wear a paper gown before visiting our child. Though I worried a time or two during our many hospital visits, Wesley remained free of any health care–associated infections.
Timely: A long wait, particularly difficult with a toddler or infant, can negatively impact the overall patient-family experience. A couple of our specialists had hospital waiting rooms packed with patients and long wait times. On those occasions, the round trip to and from the hospital, with waiting time, could take half a day — all for a 15-minute visit with the doctor. The positive experiences at certain clinics show that, with good planning, long waits can be shortened, an extra bit of work that makes the clinic run more efficiently while endearing the doctor to a patient.
Efficient: The third (and last) children's hospital we visited during Wesley's first month was a model of efficiency. It was a welcome change from the previous hospital, where test after test was ordered and results kept coming back negative. A few tests were repeated, apparently a result of communication failure among different clinicians who saw our child.
My husband prevented that from happening in one case. Noticing a nurse practitioner at our son's bedside preparing to do a spinal tap, he asked her: "Hasn't that test already been done, and didn't it turn up negative?" "Yes," she answered. My husband inquired further: "Why is the test being repeated? How many spinal taps have you done before?" The NP ended up not doing the spinal tap.
With Wesley undergoing one test after another, perhaps we had prevented at least one unnecessary procedure. Costs could be eliminated and patient care improved with more holistic monitoring of each patient's history.
At the last hospital — where efficiency and professional accomplishment reigned — we were relieved that no tests were ordered. Specialists at that hospital reviewed the tests done at the previous hospitals, examined Wesley and told us he was going home the next day. He would be coming back for follow-up treatments, and his progress would be monitored carefully. The joy of hearing those words — that we all were going home after four weeks of mystery and worry — is impossible to describe.
Effective: When the second hospital narrowed the causes of Wesley's initial problems to jaundice and poor feeding, we began investigating the best doctors to treat him. That led us to the specialist at the third hospital, where we discovered that a battery of previously ordered tests could have been ruled out before they were performed. Hearing the specialist talk about the hospital's work in treating children with similar symptoms reassured us that Wesley would be receiving evidence-based care and that — at last — someone seemed to know how to help him get well. This reliance on data and willingness to trust the work of other health care professionals made us feel more confident in the care he was receiving.
Patient-centered: One source of great comfort to my husband and me, as new parents during that first long month our son was hospitalized, was being able to call the hospital's NICU to check on his health or learn of the latest test results. After a long day at the hospital, checking in with one of the nurses late in the evening helped us stay connected to Wesley and his care.
When our son finally received a diagnosis by a top specialist in the field, my husband and I — being seasoned health care consumers by now — asked many questions and took lots of notes. The specialist listened to our questions and answered patiently. This type of engagement helps ensure follow-through with a medication or therapeutic regime and can improve compliance and outcomes and prevent readmission.
Toward an Exceptional Patient Experience
The Institute for Healthcare Improvement's recent report,"Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care," states that "respectful, empathetic relationships in combination with clinical quality are essential to achieving exceptional experiences." We have developed this kind of relationship with several of the physicians and nurses who have treated our son and, when the clinical quality is high, the entire experience can indeed be "exceptional."
Before Wesley was born, I had not spent much time in hospitals. Four weeks after his birth, I was a discerning patient parent, having experienced exceptional patient care and, at times, less than that. Many patients and families receiving care in hospitals today are not aware of the IOM's Six Aims, but they know quality care when they receive it. If all health care leaders and providers work to achieve these aims, experiences throughout hospitals and health care systems will be uniformly better.
Cynthia Hedges Greising is a communications specialist with the Health Research & Educational Trust, an AHA affiliate.
AHA's Hospitals in Pursuit of Excellence promotes quality improvement in health care and provides a variety of resources, including hospital case studies that apply the six IOM aims in such disciplines as care coordination, efficiency and patient safety. Visit www.hpoe.org.