Aurora St. Luke's South Shore

Presentation Notes

Poster presented at: Building Bridges Southeastern Wisconsin Nursing Research Conference; April 19, 2024; Milwaukee, WI.


The importance of patient experience has been heightened since the implementation of the Patient Protection and Affordable Care Act in 2010, which included Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) performance into the value-based payment program (CMS, n.d.). Essentially, this means hospitals must meet or exceed patient experience benchmarks to receive the highest payments for the services provided. In an effort to exceed these patient experience benchmarks, a southeastern Wisconsin hospital implemented an all leader rounding program in April 2023 with an aim to round on all patients at least once during their stay. This hospital was consistently achieving a patient experience six month rolling composite score between 50-60 against a goal of 100 or greater. The areas of focus on the HCAHPS survey included how well nurses and providers listened and explained information to their patients. A review of the literature demonstrated that nurse leader rounding could be an effective tool for improving patient experience (Littleton et al., 2019). Knowing the task burden placed on nursing leaders, the hospital expanded the initiative to include all leaders within the hospital. The leaders were educated on rounding strategy and a standardized script and questionnaire tool. The leaders were then divided into two teams and given specific rounding room assignments. The percentage of patients rounded on and HCAHPS scores were monitored monthly, and the HCAHPS composite score improved from 52 to 108 by the end of November 2023. The non-nursing leaders were challenged with consistently rounding, but the number of rounds conducted by nursing leaders dramatically increased. The long-term sustainability of such a program is still being evaluated, but initial results are promising.

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