About Englewood Hospital and Medical Center


2010 Press Releases



Taking the Helm (courtesey of Advance for Nurses)

Unit-based teams at Englewood Hospital and Medical Center are improving the patient experience and charting a new course in performance excellence
By: Lilyan Cohen, BSN, RN, & G. Elaine Patterson, EdD, MA, FNP-C; Courtesy of Advance for Nuses (Vol. 10 • Issue 2 • Page 7A)

Facilities value high patient satisfaction scores, and Centers for Medicare & Medicaid (CMS) encourages them. Increasingly more, nurse leaders want to achieve them too to ensure the patient is as safe as possible and has a great outcome.

Englewood Hospital and Medical Center is no different. We developed a unit-based performance excellence team to address the patient's experience on our 48-bed cardiopulmonary unit (6 Dean). We chose to use the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores to measure our performance.

HCAHPS was developed to create a measure of how patients perceive hospital care, which CMS determined would be a publicly reportable measure of quality (Press Ganey).

CMS not only wanted a tool which would provide consumers with valuable information when choosing a hospital for care but would also provide additional information for already established hospital quality improvement initiatives. The HCAHPS survey asks questions about the hospital experience and the frequency of patient staff encounters, using a 4-point scale - never, sometimes, usually and always. While the survey uses 10 domains to survey the patient experience, our unit chose those that were aligned with our organizational goal: to be the premier hospital in Bergen County.

Tapping the Experts

With the support of the senior leadership at Englewood Hospital and Medical Center, Englewood, NJ,and the help of Mary Beth Edmond, MBA, RN, senior nurse executive from Juran, a global healthcare performance improvement and quality management organization, our first step was to pick the team.

We chose unit staff from all disciplines and from all three shifts. According to the Studer Group's toolkit, every employee's interactions with patients affect the way patients perceive their hospital stay. Because of this, the team consisted of frontline staff that included RNs, nurse assistants, rehab, respiratory, doctors, transport, dietary, unit secretaries and environmental services.

Problem & Goals

We kicked off our first meeting July 8 with Edmond; Edna Cadmus, PhD, RN, NEA-BC, senior vice president for patient care services; Madelyn Pearson, MA, RN, NEA-BC, vice president for patient care services; Eva Matos-Botex, MA, director of organizational development; and Carlos Maceda, FACHE, director of material management. We spent the morning discussing the problem, goals and how we would achieve those goals. We started by developing statements that concisely expressed where we were and where we wanted to be.

Problem Statement: Based on the Press Ganey report on May 20, 2009, Englewood's HCAHPS patient experience scores for 6 Dean were below the Bergen County, NJ, benchmark for this question: "Would you recommend this hospital?"

Goal Statement: To meet or exceed the highest percent scores for Bergen County on "How would you rate this unit overall?" and "Would you recommend this hospital?"

Life on the Unit

We reviewed the relevant HCAHPS metrics of "response to call lights," percent of "always" responses on room and bathroom cleanliness, percent of "always" on area around your room quiet at night, pain management, explanation on new medications, compliance with discharge instructions, and communication with doctors and nurses.

Edmond gave an overview of Lean Concepts, Value Stream Mapping, Voice of the Customer, 8 Deadly Wastes and more. In the afternoon Edmond, Matos-Botex and I made rounds on 6 Dean for more than 3 hours looking in the store rooms, checking supplies, room layout, nursing station layout, chart organization and noise level.

We weren't allowed to talk about solutions, which was hard to do when you are slowly walking through the unit and finding waste and hearing some of Edmond's ideas she had used in the past.

Edmond and Matos-Botex were able to see real-life examples on 6 Dean: a patient being treated by a rapid response team and three staff helping; a patient on a stretcher in the hallway calling out; and another patient trying to climb out of bed.
The noise level was high, and people were moving fast about the unit.

Checking the Map

We have now completed eight full-day sessions with Edmond and the team and two sessions on our own, and I have to say the unit staff is engaged and excited about making changes and improving the patients' experience.

We started by creating a value stream map, which shows every step taken for a patient admission, continued stay and discharge steps. This helped show the complexity of unit function, as well as identified areas for improvement and streamlining processes.

We collected data on call-light response time. We did patient surveys to identify the "voice of the customer." We presented evidence-based research on communication, handoff, call-light response time improvements, physician/patient communication and patient/nurse/physician communication. We shadowed various disciplines and identified waste in their daily tasks with ideas for improvement.

Charting a Course

When we were done with the data collection, Edmond helped the group define which items we should focus on and established a time frame for each. We formed five smaller groups as follows, most with 30-day plans. Each team was led by a member of the 6 Dean staff.

We decided to concentrate on:

  • staff education;

  • patient education;

  • hospitality;

  • unit noise level; and

  • interdisciplinary communication.

Matos-Botex, Maceda, Edmond and I helped facilitate each group's goals and activities.

Wind Beneath Our Sails

The small groups worked hard and had a lot of fun in the process. At the end of the 7th day each small group had accomplished most of its goals and was already thinking ahead to goals for our next meeting in September 2009.
The accomplishments so far are as follows:

The interdisciplinary communication team created a board for two patient rooms with the goal of keeping patients informed of tests, treatments, daily goals, pain management and expected discharge. This trial is already getting some favorable patient comments.
The staff education team created a 6 Dean newsletter and a performance excellence board for the staff lounge. We discovered staff needed training on HCAHPS data, as well as training in the five fundamentals of communication: (AIDET) Acknowledge, Introduce yourself, Duration, Explanation and Thank you (Studer Group).

The hospitality team utilized the patient rounding sheet to add an item to address room comfort. They ordered waterless shampoo with a warmer to address patient comfort during prolonged hospital stays. Further education on AIDET accompanied these changes.
The noise team obtained earphones for use with the TV, ordered pillow speakers and eliminated overhead paging except in emergencies. In addition, they dimmed the lights after 10 p.m., closed patient doors after midnight and instituted quiet hours between midnight and 5 a.m.

The patient education team is working on a clinical pathway for heart failure patients which will include a piece for the patient to refer to during their hospitalization and a patient handout on "Questions to Ask Your Healthcare Provider," which will be incorporated into the admission packet. Keeping patients informed is a key component to patients' perceptions of caring behaviors (Studer Group).

Continuing Success

We continue to meet monthly as a team and display our scores on our performance excellence board in the staff lounge weekly, monthly and quarterly. Our October scores placed us in the 99 percentile and staff is very excited. We will celebrate this success and will continue to work toward sustaining our goals.


Meade, C.M.; Bursell, A.L. & Ketelsen, L. (2006). Effects of nursing rounds on patients call light use, satisfaction and safety. American Journal of Nursing, 106(9), 58-70.

Press Ganey. Partners In Improvement: FAQs. Retrieved Nov. 25, 2009 from the World Wide Web: www.pressganey.com/cs/faqs
Studer Group. (2007) Studer Group Toolkit: HCAHPS. Aligning actions to create a culture of "always." Retrieved Jan. 18, 2010 from the World Wide Web: www.mhafoundation.org/AM/Template.cfm?Section=Uploads&Template=/CM/ContentDisplay.cfm&ContentID=62818

Lilyan Cohen is director of patient care of the cardiopulmonary unit at Englewood Hospital and Medical Center, Englewood, NJ. G. Elaine Patterson is associate professor of nursing at Ramapo College of New Jersey, Mahwah, NJ. Englewood Hospital and Medical Center is an affiliate of Mount Sinai School of Medicine and a member of the Mount Sinai Health System.