key: cord-0922811-ttmqee46 authors: Barden, Agnes; Loeb, Amy E; Giammarinaro, Nicole title: Promoting a Therapeutic Healing Environment: A Retrospective Examination of HCAHPS “Quiet at Night” Across a Large New York Health System date: 2021-11-13 journal: J Patient Exp DOI: 10.1177/23743735211056533 sha: 8624b2c57ba2464386329bbc8639d603eb76b260 doc_id: 922811 cord_uid: ttmqee46 Promoting respite and sleep impacts a patient's health and their inpatient experience. As New York State's largest health system, Northwell Health has been on a journey to create a healing and therapeutic healthcare environment. By establishing leadership accountability, leveraging patient feedback and adopting evidence-based interventions, system and individual adult inpatient hospital improvements have been noted. Between 2017 and 2020, Northwell's overall system HCAHPS “Quiet at Night” Top Box performance increased by 4.7, improving 30 percentile rank points when compared to the Press Ganey national database. This case study outlines Northwell's pragmatic patient-centered strategy and examines the unanticipated impact of limited visitation due to COVID-19 on this HCAHPS measure. Consumerism has empowered patients to rely on publicly reported data, word-of-mouth and previous experiences to inform their healthcare decision-making processes. Personal preferences, emotions, values and intuitions are becoming significant drivers influencing when and where patients seek care (1) . To remain provider-of-choice with high loyalty consumer retention, healthcare organizations must deliver world-class quality and experiences across the care continuum. Through internal performance improvement efforts and leveraging outside industry best practices, patient experience has become a "differentiator that will drive and sustain long-term success (2) ." The Institute for Healthcare Improvement's "Triple Aim" framework includes patient experience, inclusive of quality and satisfaction, as a core tenant strategy to optimize healthcare system performance (3) alongside cost reductions and population health. With this heightened awareness, patient experience measurement and improvement efforts are increasingly prioritized. According to the Centers for Medicaid and Medicare Services, HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), "is a survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience (4) ." Beginning in 2008, HCAHPS performance is transparent and the most positive response, 'Always,' is considered the 'Top Box' response and is publicly reported for consumer consumption (5) . One of the individual survey questions asks patients to rate "During this hospital stay, how often was the area around your room kept quiet at night (6)?" Maslow's hierarchy of needs theory identifies sleep as a basic, biological and physiological human need. According to the theory, meeting those needs are necessary for individuals to attain the next level of need, Safety, which includes health (7) . To provide patient-centered care, healthcare professionals are responsible for promoting rest and sleep, since these components impact a patient's overall health. Northwell Health is the largest healthcare system in New York State, including 21 hospitals, over 750 medical practices and 74,000 + team members. At the height of the initial COVID-19 wave, Northwell cared for more COVID-19 patients than any other healthcare system in the United States. In early April 2020, the daily hospitalized patient census peaked at 3,400 + across all system-based acute care facilities (8) . This article outlines how Northwell pragmatically improved HCAHPS "Quiet at Night" outcomes and explores how this domain performed during the initial COVID-19 wave. Historically, Northwell hospitals have struggled with HCAHPS "Quiet at Night." Challenges include grid-locked real estate footprint, centralized nursing stations with most units operating with semi-private rooms. In 2017, for this question, Northwell overall performed at a Top Box score of 50.8, placing the health system at the 17th percentile when compared to United States hospital peers within the Press Ganey national patient experience database. As a result, the Quiet, Healing Environment Committee (QHEC), was developed in early 2018. Consisting of interdisciplinary stakeholders, the goal was to design and deliver a humanistic overnight experience within 15 of Northwell's adult inpatient hospitals. To address this holistic issue, three sub-committees were formed from the QHEC. The Culture and Education sub-committee created and supported hospital-based structures for performance improvement accountability. Sponsored by the hospital Executive Director/CEO, a leadership triad was engaged inclusive of Chief Nursing Officer, Patient Experience and Support Services Leader. They inventoried site strengths and opportunities, reviewed data and engaged leaders and teams. This group also developed educational curricula for leaders and teams to support this cultural transformation. Adopting evidence-based protocols aimed at reducing noise and supporting patient rest became the focal point for the Care Delivery sub-committee. After a review of literature, identification of internal best practices and engaging patients via Patient and Family Partnership Councils, a "Quiet Healing Environment Implementation Guide" was developed. The document disseminated to the adult inpatient hospital Executive Directors and leadership trios, totaling 60 + senior leaders. It was presented at leadership meetings to initiate the call for action as it provides a 5-step action-oriented approach inclusive of Establishing Structure, Performing a Gap Analysis, Building Awareness, Hardwiring Quiet Hours and Protocol and Ongoing Monitoring for Performance Improvement. It highlights the importance of a hospital-based Night Council, a shared governance model, led by frontline team members, specific to addressing concerns of those that primarily work overnight. Quiet Hours were adopted on each unit/department, primarily from 11pm to 5am. Through Night Councils, interdisciplinary teams sought innovative approaches for peer accountability such as code words when noise volumes were increasing in patient care areas. Unit leaders and teams came together to create care protocols to minimize patient interruptions, nighttime proactive rounding standards and consistent communication, informing patients and visitors of Quiet Hours expectations. Over 800 leaders were educated via an informative 15-min eLearning module, which highlighted why sleep and rest is important to physical health, current state of HCAHPS data and high-level best practices. Frontline team members were educated and engaged in these efforts via unit-based huddles led by the respective leader(s). Sustainment methodologies consisted of ongoing awareness activities, daily leadership rounding, compliance monitoring and data monitoring. Recognition efforts were locally driven, celebrating units and departments with improved HCAHPS performance and honoring team members who support the creation in quiet, healing environments. The third sub-committee, Environment and Amenities, sought to examine and reduce contributors to excess workplace noise. Clinical alarms, overhead announcements, equipment, and employee talking were all within scope. This team identified high-quality products that support rest (i.e., eye masks, ear plugs, headphones). Collaborating with system Procurement and Materials Management, a standard amenity order-set was implemented allowing for item standardization and cost reduction based on bulk purchasing models. Marketing teams created branded collateral inclusive of elevator clings, digital messaging, print materials and website enhancements. From development to implementation, the QHEC had been working for approximately two years before the COVID-19 pandemic began. In spring 2020, New York saw unprecedented volume, acuity and mortality related to COVID-19. Intensive care surges required large amounts of patients on ventilators and oxygen support, hospital bed capacity tripled in unconventional areas like conference rooms, and healthcare providers wore protective equipment. On March 18, 2020, the New York State Department of Health (NYSDOH) issued a health advisory, suspending all hospital visitation (9) . Visitation shifted to virtual modalities and team members engineered ways to minimize exposure. In his book, Leading Through a Pandemic, Northwell's President and CEO, Michael Dowling reflected how there was an "eerie quiet" due to the absence of patient voices and visitors (10) while rounding on units. Between 2017 and 2020, Northwell's overall system HCAHPS "Quiet at Night" Top Box performance increased by 4.7, improving 30 percentile rank points when compared to the Press Ganey national database. Twelve out of the fifteen Northwell hospitals (80%) saw a Top Boxincrease of at least 3.5; see Figure 1 . The largest change was within one community hospital who demonstrated a 13.9 Top Box point improvement (51 peer rank points) during that timeframe. When examining 'Quiet at Night' system performance, the highest performing consecutive six months was during the initial COVID-19 peak, March through August 2020. During this time, the mean monthly performance was a 57.0 Top Box percentile score, a 3.25 percentile difference when compared to the same six months in 2019 (pre-COVID). Within those six months, the lowest performing month was June 2020, correlating to when the NYSDOH allowed modified visitation, re-opening the doors to visitors across New York hospitals. Lessons Learned Previous hospital environments were not necessarily designed to minimize noise. Utilizing elements of experience design, there is great opportunity to create hospital environments that prioritize patient rest and healing. Noise pollution and its impact on patients and providers continue to be studied (11, 12) . Clinical alarms are being redesigned to be more therapeutic and help reduce staff alarm fatigue (13) . In reflecting on Northwell's journey, leadership buy-in and support was essential to beginning our cultural transformation. Placing accountability on one discipline and/or one leader may have appeared as a siloed issue or short-term initiative, so by adopting a triad approach, a sense of interdisciplinary teamwork, partnership and shared responsibility was fostered. The QHEC realized that care delivery coordination, environment, equipment, and staff conversations are within control. How we organize and deliver inpatient care needed to be re-examined. The comprehensive Guide provided guidance and evidence-based recommendations promoting a foundational level of system consistency. However, it also allows for unit/department specific considerations within areas such as specific Quiet Hours, team-based nighttime protocols, creative ways for peer accountability and recognition efforts. With the elimination of visitation during the initial COVID-19 wave, Northwell saw an unexpected positive impact on HCAHPS "Quiet at Night." However, performance did not skyrocket to the 99th percentile. These findings lead us to deduct that although visitation contributes to nighttime noise, it may not be the sole contributor. Promoting respite and sleep impacts a patient's health and their inpatient experience. Core causes and contributors to hospital noise must be pragmatically identified and strategically addressed in order to improve the HCAHPS "Quiet at Night" measure. Engaging interdisciplinary care teams, adopting evidence-based interventions, designing for optimal experience and instilling sustainment activities may lead to increased system and hospital performance outcomes. Change does not happen immediately, it requires patience, diligence and a spirt of continuous improvement. Northwell continues to learn, refine its approaches and evolve with consumerism-based demands and expectations. After review by the Northwell Health Human Research Protection Program, case study activities did not meet the definition of human subject research under 45CFR46. Informed consent for patient information to be published in this article was not obtained because patient experience survey data is publicly reported and available. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship and/or publication of this article. Beyond costs and benefits: understanding how patients make health care decisions The consumer has spoken: patient experience is now healthcare's Core differentiator Institute for Healthcare Improvement. The IHI triple aim HCAHPS: Patients' Perspectives of Care Survey Hospital Consumer Assessment of Healthcare Providers and Systems Maslow's hierarchy of needs. Simply Psychology Turned upside down: the role of New York patient experience leaders during COVID-19 Health Advisory COVID-19 Guidance for Hospital Operators Regarding Visitation Leading Through a Pandemic: The inside story of humanity, innovation, and lessons learned During the COVID-19 crisis The effects of hospital noise Hospital noise and patients' wellbeing To Reduce Hospital Noise, Researchers Create Alarms That Whistle and Sing, The New York Times The authors acknowledge the ongoing efforts and dedication of Northwell Health executive directors, nursing, patient experience and support services leadership and team members. The shared work team's passion and leadership is recognized as being the catalyst and role models for change. The authors thank our patients for their candid feedback as well as the Chief Experience Officer, Sven Gierlinger, Northwell system Office of Patient and Customer Experience, QHEC shared work team, Culture Leader group, system partners and Press Ganey Associates. Nicole Giammarinaro https://orcid.org/0000-0002-2202-5028 Ethical approval is not applicable for this article. HCAHPS results are publically reported, aggregate data sets, and this article represents a performance improvement effort.