You are the newly hired Director of Performance Improvement at the Brownville Memorial Hospital. You were hired to improve the hospital’s compliance with federal, state, and local regulations. Additionally you are responsible to ensure that all standards related to quality assurance, patient protections, infection control, safety, risk management, and staff education are followed. You report directly to the hospital Chief Executive Officer (CEO) and you oversee the Quality Assurance and Performance Improvement (QAPI) staff.
The CEO wants the hospital to upgrade to a higher patient centered medical home (PCMH) recognition level in 18 months. He has given you your first project which is to improve patient and family ratings on the hospital satisfaction survey. As you review previous Press Ganey Satisfaction Surveys you note that patients and families consistently rated the hospital staff poorly on providing information that made it easy to understand and improve their health. Many survey comments stated that patients “found the health information they were given confusing and did not know how to act on it.”
Brownville is a 500 bed hospital situated in a large metropolitan area with more than 750,000 residents, many of whom are Black, Asian, and Hispanic. 35% of the residents are foreign-born and speak a language other than English at home. The median household income is $35,000 per year and more than 30% of residents did not graduate from high school. The hospital provides primary care, specialty care, and support services to area residents with a large direct patient care staff (including physicians, nurses, physician assistants, medical assistants, nursing assistants, social workers, therapists, technologists, technicians, phlebotomists, and pharmacists).
To begin your first project, you have decided to develop and implement a long-term staff education program that will focus on “health literacy.” You and your staff will be rolling out this program to all hospital staff members. The first activity will be a workshop for all existing and new staff. You will deliver the workshop in person to small groups (40 staff members) over the next 2 months.
Your key areas of concern are that all staff (address 2 key areas for assignment):
● communicate clearly with patients
● utilize the patient friendly health education materials available and disseminate take-home materials
● address language and cultural differences (with support from translation services available through telephone)
● help patients to remember how and when to take their medicines
● encourage patients to ask questions
Therefore, you will develop a 20-minute (maximum) workshop presentation that clearly explains health literacy, key communication principles, and addresses 2 of your key areas of concern. You have decided to give the CEO a preview of your workshop at your next meeting so that he knows that you are dedicated to performance improvement.
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