Abstract 
Franciscan Health System includes St. Joseph Medical Center in Tacoma, St. Francis Hospital in Federal Way, St. Clare Hospital in Lakewood, St. Elizabeth Hospital in Enumclaw, St. Anthony Hospital in Gig Harbor; Franciscan Hospice House in University Place; Franciscan Medical Group clinics and providers in Pierce, King and Kitsap counties; and the Franciscan Foundation. Franciscan is part of Catholic Health Initiatives (CHI), a national non-profit health organization with headquarters in Englewood, Colo. The faith-based CHI system operates in 19 states and includes 73 hospitals; 40 long-term care, assisted- and residential-living facilities; two community health-services organizations; and home health agencies. In fiscal year 2010, CHI provided nearly $590 million in charity care and community benefit, including services for the poor, free clinics, education and research.
Introduction
What was the challenge, opportunity or issue you were addressing?
Low scores on quietness revealed a significant opportunity to improve the patient experience
In examining satisfaction performance at St. Francis hospital, an opportunity presented itself. The 3rd Medical/Telemetry unit received feedback from patients via discharge satisfaction surveys that the noise on the unit was unacceptably loud, and the noise level made it difficult for patients to rest. Additionally, the unit’s HCAHPS score for “quietness at night” was 39% for FYE 2009. The noise level was distressing for patients, and therefore did not support the facility’s goal to provide patients with a healing, patient-centered environment.
What did you do to address it?
Developing and implementing a solution through the Transforming Care at the Bedside (TCAB) program
The 3rd Medical/Telemetry unit is a participant in the Transforming Care at the Bedside (TCAB) initiative. TCAB is a nurse-led quality improvement program sponsored by the Robert Wood Johnson Foundation (RWJ). The premise of TCAB is that front line staff has the best ability to identify solutions to unit-based problems, to offer innovations, and to effectively solve problems at the unit level.
To provide some background on TCAB, the program was launched with 10 original hospitals across the United States. Since it’s inception, approximately 130 hospitals nationwide have participated. A new grant opportunity was initiated in 2009 to include an additional 16 hospitals through the effort, Aligning Forces for Quality, a collaborative effort with RWJ, the Institute for Healthcare Improvement (IHI), and the American Organization of Nurse Executives (AONE). St. Francis Hospital was a recipient of one of those grants and began its participation in the effort in Cohort I of the program in 2009. The main themes of the TCAB program include: safe and reliable care, vitality and teamwork, patient-centered care, value-added care processes, and transformational leadership. The TCAB process follows a standard PDCA (Plan, Do Check, Act) Model.
The TCAB team at St. Francis (picture left) is composed of members of the 3rd Medical/Telemetry staff including RNs, CNAs, and unit coordinators. The team is actively supported by nursing management and administrative staff. The improvement team meets weekly to discuss current problems on the unit and all unit staff members are encouraged to propose ideas, participate in TCAB meetings, and trial projects.
To address the specific issue of noise, the TCAB team solicited ideas and suggestions from the front-line staff. Every idea was initially piloted on a small scale, i.e., one nurse would try one idea with one patient for one shift. If the idea proved successful, it would be tested with more nurses and patients through a series of PDCA cycles. Ideas would be adapted or changed based on the feedback of patients and staff before being considered for adoption on the floor.
Through the collection of numerous ideas and the implementation of many PDCA cycles aimed at reducing noise levels, the concept of a “Culture of Quiet” was developed. A significant realization for the TCAB team was that a single intervention would not successfully improve noise on the unit. Rather it would take an integrated effort, incorporating many innovations to successfully target this problem.
To test this proposition the TCAB team ran trials over a nine-month period in its quest to achieve a “Culture of Quiet”. Both direct feedback from patients and resulting HCAHPS scores supported the notion that no single intervention would improve the perceived noise level for patients. Rather it was a combination of interventions that would contribute to success.
The result of this work was a robust selection of actions that would support the development of a “Culture of Quiet”. They included:
- Placement of white noise machines in patient rooms
- Signs on the entry doors of the unit to remind staff and guests to monitor their noise level
- Use of “library voices” by all staff, 24/7
- Peer-to-peer accountability for “Culture of Quiet”. The staff encouraged and reminded each other to use library voices at all times
- Staff turned down Voceras and pager volumes at night
- Volume of overhead music on the unit was reduced and/or turned off
- Door to the nutrition room was closed and the use of ice machine was limited at night
- Frequently used doors on the unit (e.g., clean supply room) were padded so they would close quietly
- Entry doors to the unit were left open at the change of shift to avoid use of the loud automatic door openers
- Overhead hallway lights and nursing station lights were dimmed during night shift
- Volume of the overhead call-bell system was reduced
- Volume of the unit telephones was reduced at night
- Wheels on rolling equipment were changed to reduce potential noise
- Ear plugs were offered to all patients
- No audible television volume was allowed at night. Rather patients were required to use headphones when watching TV in the evening with headphones provided by staff
- Patient messaging was implemented – “A quiet unit is important for your healing. We are doing these things to make the unit as quiet as possible during your stay.”
- Collaborated with and educated other hospital departments regarding the “Culture of Quiet,” so when other staff members enter the unit they are both aware of and respectful of the “Culture of Quiet”, use library voices, and minimize noise.
What outcomes were achieved?
An effective implementation of a “Culture of Quiet” and an increase in the HCAHPS “quietness at night” score
In examining the score improvements catalyzed by the plan, HCAHPS “quietness at night” scores increased from 39% for FYE 2009 to 58% for 4th quarter 2011 (ended June 2011). In discharge patient satisfaction surveys, very few patients reported a “loud” unit, and former complaints were replaced by compliments about the lack of noise during their stay.
Implementation of the “Culture of Quiet” has also built teamwork on the unit, as the care team worked together to develop, test and implement interventions to reduce noise. Team communication also improved as staff now hold one other accountable for the use of “library voices” at all times. Finally the project allowed 3rd Medical/Telemetry to effectively collaborate with other hospital departments to ensure that the work of all departments on the unit supports the commitment to a reduced noise level and a positive patient experience.