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The Leaders Perspective: Shared Decision-Making: Why Choose Between Employee Engagement and Patient Experience?

Tuesday, March 12, 2019
Nathan Cunningham, VCU Health

Nathan Cunningham

Cake. To have it, or to eat it. That is the question. Well, sort of. The relationship between employee engagement and patient experience has evolved from a “chicken or the egg” conversation into the realization of a symbiotic relationship. Yet, there is still a belief in the industry that successful improvement initiatives must focus on one or the other. Why not design an improvement initiative that simultaneously improves both? Let’s have our cake and eat it, too.


We found patient experience initiatives that emphasize consistent repetitious patient interactions create an environment of well-managed patient expectations and alleviated anxiety. Consequently, this results in restricted autonomy of the team member in their daily role. Loss of personal autonomy in a job function and lack of inclusion into the decision-making process of patient experience initiatives will often yield disengaged team members.  As we now know, the disengagement of team members manifests itself in lowered retention rates, decreased trust in organizational leadership, and impaired critical thinking in situations of consequence. The keystone to simultaneous improvement in team member engagement and patient experience is organic in nature within team member-driven strategies and shared decision-making.


There is a core fault with modern patient experience improvement practices. As leaders, we are often healthy people, sitting in comfortable chairs, in private conference rooms designing experiences for unhealthy people, sitting in an uncomfortable setting, with limited privacy.  The industry is improving on this core fault as it has made fantastic growth in providing the patient an active voice into the improvement of healthcare. Through surveying, focus groups, Patient Family Advisory Councils, and other avenues, patients now have the greatest impact on healthcare than ever before. And, hospitals are reaping the benefits of this inclusivity and shared decision-making as shown by increased quality, safety, and service metrics. Yet we fail to follow this same shared decision-making principle with our own team members. 


At VCU Health in Richmond, Virginia, a different approach to improving patient experience has emerged. A shift in focus towards the enhancement of team member engagement takes shape in the form of reinforcing a sense of workplace pride while simultaneously harnessing the internal motivating factor(s) that originally brought our team members to the healthcare field. This method naturally empowers the most engaged team members to organize their talents, passion, and efforts to become active stakeholders in the advancement of the organization’s mission. These groups of team members are now actively participating in shared decision-making across the highest levels of our organization. An example of this method is found with our outpatient Patient Access Registration (PAR) team. With engagement scores falling beneath below the organizational average, and CG-CAHPS Office Staff Quality metrics plateaued in the 40th percentile range (benchmarked against Academic peers in Press Ganey database), the PAR team warranted our attention. Our PAR team spans 340+ team members that are crucial to the success of managing over 4,000 outpatient clinic visits per day. They hold a unique role in patient experiences by providing the first and last interaction of each visit. The goal of this work is to empower PAR team members to create (with minimal guidance) peer-produced initiatives targeted at increasing team member engagement. I decided we would implement patient experience targeted improvements after we focused on engagement.


I asked a group of PAR champions to review current patient experiences and team member engagement practices. Considering that everything we do is ultimately for the patient, it was important for me to hear their recommendations about the reconstruction of initiatives that leadership designed without decision-making. This team recommended a PAR-designed monthly curriculum for all PAR team members to participate in their respective clinics. The curriculum revolved around conversation and role-playing to enhance team member communications and engagement. We also empowered these champions with root cause analysis 5-Why training to assist in identifying the opportunities for improvement in their work areas. As a result, we effectively transitioned all patient experience and team member engagement initiatives from leader-driven to peer-driven design development through shared decision-making. We quickly found a number of positive outcomes:

  1. PAR team peer-to-peer recognition increased by 234%. We have a digital recognition program accessible for any team member to direct recognition to a peer. Traditionally, the PAR teams received the bulk of recognition from their supervisors and clinicians. Since the shared decision-making initiatives took place, the volume of peer-to-peer recognition soared.
  2. Turnover rates for the participating team members decreased over a six-month period of shared decision-making practices and using the monthly curriculum.
  3. CGCAHPS scores increased in the participating areas. Office Staff Quality moved above the 70th percentile ranking compared against Press Ganey Academic peer group. Likelihood to recommend the provider office improved by .9% top-box score. We found that our team members were challenging each other to improve patient-centric atmospheres and processes.

I often wonder if I, without the shared decision-making from the PAR Champions, had implemented the exact same curriculum trainings and role-plays, would the success outcomes had been as fruitful. It is difficult, near impossible, to answer this question. But when I candidly mentioned these thoughts to one of my colleagues, she said, “A new initiative loses the perspective of being burdensome when you are the creator of that initiative.” Even though these new initiatives were asking team members to do more and be more involved than they ever had been, it wasn’t viewed negatively. Shared decision-making gave them their opportunity to create, shine, and shape their working culture into what they needed, not what I thought they needed. And fortunately for our patients, these remarkable team members were able to simultaneously improve employee engagement and patient experience.


We recently held an appreciation event for the PAR champions that helped implement this new shared decision-making improvement model, and we surprised them with a cake. And they ate it, too.

Tags: employee engagement, culture, communication, patient engagement, best practices, leadership, quality improvement, perspective
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