TABLE TALK The Growing Role of Patient Engagement: Relationship-based Care in a Changing Health Care System

Patient engagement begins with relationship-based care. (Nurse’s warm-up jacket and cap not shown.)

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s health care providers, we rarely participate in discussions, watch interviews, or read articles about our changing health care system that do not concern patient engagement. The Center for Advancing Health defines patient engagement as Actions individuals must take to obtain the greatest benefit from the health care services available to them. . . . Engagement is not synonymous with compliance. . . . [Engagement] signifies that a person is involved in a process in

which he [or she] harmonizes robust information and professional advice with his [or her] own needs, preferences, and abilities in order to prevent, manage, and cure disease.1 Patient engagement strategies have been shown to improve care delivery and translate into better outcomes related to patient satisfaction and recovery. One author captured the importance of patient engagement with this statement: “If patient engagement were a [medication], it would be the blockbuster [medication] of the century

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and malpractice not to use it.”2 Yet widespread consensus among health care providers about how to engage patients is still being determined. The nursing profession’s role in patient engagement and advocacy is key to the care that we deliver and continues to evolve to meet the needs of patients. For example, before the 1970s, there was not a high demand for patient’s rights.3 In 2006, AORN published a position statement on creating an environment of safety, which set the groundwork for patient-centered care as an important element in defining the perioperative culture.4 A number of ethical, philosophical, and professional considerations related to the rights of patients have led to the nurse’s role as patient advocate. According to one author, the three components of this role are 1. informing patients of their rights, 2. providing patients with information necessary to making informed decisions, and 3. supporting patients in their decisions.5 Regarding the patient’s role in engagement, one author, who is also a perioperative RN, shared his experiences as a surgical patient. In his article, McGowan suggested that almost every patient enters the surgical suite with anxiety and looks to the perioperative team for reassurances. He believes that inaccurate portrayals of surgery in the media “contribute to patients’ perceptions of surgery and not always in a positive way.”6(p493) Critical to the health care provider’s ability to establish trust is communicating in a manner that informs and empowers the patient. For example, he stated that, as a patient, he felt hurried in saying

TABLE TALK goodbye to his partner before the procedure began, which suggests that he perceived a lack of support from those providing his care. According to McGowan, nurses must provide reassurances to patients in their care and “remember the leap of faith that [undergoing care] requires of patients and never [to] take the trust that they place in us lightly.”6(p497) By bringing together this panel of contributors, my hope is that we come to a better understanding of how we elicit our patients’ perspective and involve them in improving satisfaction and health outcomes. We would be remiss if this commentary did not include the patient’s perspective. To that end, a patient is one of the contributors. As you read these commentaries, the clear themes among each discipline and the engagement of key stakeholders can be taken as a sign of the broader inclusion necessary to achieving our desired outcomes. The panel of contributors responded to the following statement: Patient engagement and patient satisfaction are playing critical roles in a changing health care system and the emerging compensation models. This directly impacts both the inpatient environment and the ambulatory care setting. From your perspective, please comment on what you believe is the link between patient engagement and improved outcomes for perioperative patients. CHARLOTTE L. GUGLIELMI MA, BSN, RN, CNOR PERIOPERATIVE NURSE SPECIALIST BETH ISRAEL DEACONESS MEDICAL CENTER BOSTON, MA

Nurse’s perspective Our goal as health care providers is to meet the physical, social, and emotional needs of patients and their family members. This cannot be accomplished without fully engaging patients in their own care or without fully engaging their families.7 According to a white paper on patient and family

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engagement from the Nursing Alliance for Quality Care, “active engagement of patients, families, and others is essential to improving quality and reducing medical errors and harm to patients.”8 As perioperative nurses, it is sometimes difficult to see our role in this process because of the limited

TABLE TALK time for interaction and the drive for increasing efficiencies. Perioperative leaders should promote a culture that carefully balances efficiency, patient safety, and patient participation by establishing processes to support this philosophy. Strategies that are developed to create this balance should establish a model for engaging patients and should ensure that perioperative nurses receive education on communication techniques or methods that they will use when interacting with those in their care. At AnMed Health, Anderson, South Carolina, perioperative leaders have adopted strategies that offer a framework for successful engagement. Two techniques that we use to guide personnel in their interactions with patients and families are teachback (http://www.teachbacktraining.org) and Ask Me 3TM (http://www.npsf.org/for-healthcare-profe ssionals/programs/ask-me-3). Teach-back is a research-based health literacy intervention that improves patient-provider communication and health outcomes.9 By using interactive communication, the nurse prompts the patient to explain, in his or her own words, the information that the nurse has provided. This method allows the patient to process health information in a context that is meaningful to him or her, and it demonstrates the patient’s understanding to the health care provider. “Asking that patients recall and restate what they have been told is one of the 11 top patient safety practices based on the strength of scientific evidence.”10 Teach-back is a particularly powerful tool to use when providing postoperative discharge instructions. By using this technique, nurses can be reasonably sure that the patient and his or her family members understand the postoperative care that will be needed at home. This can help reduce the risk of complications related to miscommunication or misunderstanding of instructions. Ask Me 3 is a teaching methodology that is based on health literacy principles and often is used in combination with the teach-back approach. Partnership for Clear Health Communication developed this technique with the intent of helping all patients

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comprehend their particular health condition and what they should do about it. There are three questions11 that patients are encouraged to ask any health care provider: n

What is my main problem?

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What do I need to do?

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Why is it important for me to do this?

The use of these techniques adds structure to patients’ interactions with their health care providers, thereby increasing patients’ engagement in their own health. AnMed Health introduced these methods in 2010, first in the surgical services and pediatric departments, as part of an overall health literacy and patient education initiative. Before implementation, perioperative nurses received indepth training from the facility’s training and organizational development department on both techniques. Although these methods may seem simplistic, both have proven effective in our facility for allowing patients the opportunity to be part of the conversation rather than passive receivers of their medical information. The nurses in surgical services directly teach patients to ask questions and recall information. Nurses also use other communication methods, such as handouts and pamphlets, to reinforce the delivery of information regarding care. These methods of patient engagement start when the patient arrives for surgical assessment several days before surgery and continue through postoperative discharge. Although strategies provide a foundation for patient engagement, it is nurses who establish relationships with patients to make them partners in their care. Nurses, in their role as committed patient advocates, are uniquely positioned to embrace the concept of active patient engagement. Therefore, it is vitally important that perioperative leaders not only provide the education and support necessary for nurses to gain competency in patient engagement practices but also actively participate in those processes themselves. At AnMed Health, it is an expectation that nurse managers and directors visit with patients on a daily basis. Patient rounding by AORN Journal j 519

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leaders sets an example for personnel but also provides one more step in cementing the patientprovider relationship that is so important to patient outcomes. Helping personnel embrace “hardwire processes” that are related to patient engagement is not simple, but perioperative leaders should be persistent and supportive because these efforts are known to be effective in improving postoperative patient health.12 Here are some key tips for nurses who are getting started on this journey or who are renewing their focus of patient engagement.

TABLE TALK work these into the conversation. Use teachback and Ask Me 3 whenever possible. n Take a surgery schedule with you so that you know the patient’s name, the scheduled surgical procedure, and the name of the surgeon. n If you are a director, ask a manager to accompany you for a few days. If you are a manager, ask staff nurses to join you from time to time. n Manage up your team! Make sure you relay to the patient what a wonderful team will be providing his or her care.

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Set aside a predetermined time each day to round on patients. You can do this by putting an appointment on your calendar. Allow enough time to make the visits meaningful. n Determine ahead of time the major points you want to convey to the patient so that you can

MARTHA STRATTON MSN, RN, MHSA, CNOR, NEA-BC DIRECTOR OF NURSING, SURGICAL SERVICES ANMED HEALTH ANDERSON, SC

Surgeon’s perspective The Institute of Medicine report To Err is Human: Building a Safer Health System13 documented significant breaches in safe patient care. Many of the breaches involved poor communication, a lack of professionalism, and an inability to work as a team. These deficiencies are major impediments to establishing good physician-patient relationships and must be addressed by the profession. Doing so is especially critical as the health care industry focuses on both increased patient engagement and measured outcomes. As surgeons, we have always been cognizant of results (ie, outcomes). We have now been served notice that we shall be rated and paid by the outcomes we achieve. In many ways, however, we are very reliant on others to achieve the best results possible in any given patient encounter, perhaps on none more so than the patient. Thus, educating and empowering the patient through effective communication is now more important than ever. By engaging with the patient in his or her own care and providing education, health care providers can show their dedication to safe patient care and 520 j AORN Journal

provide the patient with the feeling of not only being cared for but cared about. The surgeon must recognize his or her role as a critical member of the preoperative, intraoperative, and postoperative teams. A major component of this role is serving as an educator to both the patient and team members to explain the purpose, plan, and expected outcome of the surgical procedure. Each member of the team (eg, surgeon, anesthesia professional, perioperative RN) must work together to ready and empower the patient for the surgical encounter. Silos are no longer effective or appropriate. As part of their engagement, patients and their family members must be made aware that they also have a responsibility to act as their own or as a relative’s advocate and become part of the surgical team. Thus, their goals and expectations must be verbalized and understood by other members of the team. I believe that having well-informed patients and family members will lead to greater satisfaction and will improve outcomes dramatically. Yet, the world of health care becomes more frenzied by the day, which has led to perioperative

TABLE TALK personnel experiencing increased workloads and greater stress. A sad fallout as a result of these conditions is increased unprofessional behavior on the part of members of the perioperative team. When team members behave unprofessionally or give the impression that they do not care about the patient, it does not go unnoticed by patients and serves only to sour their perception of the surgical team, or at least some of its members. This weakens their sense of engagement and increases the possibility of a poor outcome.14 Addressing the link between stress levels and professional behaviors is critical for physicians and nurses if we are to successfully engage with our patients. I believe that patients simply want to be part of their own solution. A happy and relaxed patient and surgical team are more successful than are an

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unhappy and a stressed patient and surgical team in achieving the desired positive outcome. Patients want to understand what is happening to them and to be informed about their care in a language that they can understand. This means that they want to be cared for in a safe environment by competent professionals whose goal is a quality, cost-effective outcome. In the end, we must not forget that patients do not care how much we know until they know how much we care. GERALD B. HEALY MD, FACS PAST PRESIDENT, AMERICAN COLLEGE OF SURGEONS PROFESSOR HARVARD MEDICAL SCHOOL BOSTON, MA

Anesthesiologist’s perspective There can be very little argument that there is indeed a link between patient engagement and outcomes in the perioperative setting. This link prevails across all settings of care, from hospitals to ambulatory surgery centers to office surgery suites. As a physician who has practiced almost exclusively in the ambulatory surgery center setting, I have no doubt that the patient plays a pivotal role throughout the perioperative continuum in the outpatient environment. Perhaps because of the nature of the types of procedures we perform (ie, those that are largely elective) and the relatively short duration of the care provided (ie, usually less than 24 hours), the extent to which personnel can engage the patient and provide personalized, patientcentered care is amplified in the ambulatory surgery center setting. Consequently, it is critical for the physician to carefully assess the degree of patient, as well as family member, engagement when considering the most suitable location for the surgery to be performed, regardless of the particular surgery and anesthetic planned. A patient who is either unable or unwilling to actively participate in his or her

own perioperative care, regardless of the reason, is at an increased risk for poor outcomes. Furthermore, such a patient may be an unsuitable candidate for outpatient surgery. As an example, a patient who is not motivated to thoroughly administer his or her prescribed intestinal prep before a colonoscopy can adversely affect the likelihood of an optimal procedure and is at significant risk for cancellation entirely, thereby defeating the opportunity for critical diagnosis and treatment. Similarly, because patients are sent home relatively quickly after outpatient procedures, adherence to discharge instructions and attention to possible signs and symptoms of surgical complications are crucial to a safe and timely recovery. Although the relationship that perioperative team members have with the patient is intuitively important, relationship-based care can place a considerable burden both on the provider and on the recipient of heath care in the outpatient setting. For health care providers, it can be very difficult for personnel to proactively ascertain the commitment and ability of a patient to monitor and participate in his or her own care, thereby making it difficult for

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health care providers to help facilitate patient compliance with the requisite postoperative selfcare regimens. For the recipient of health care (ie, the patient), it can be very difficult to process and attend to all the information communicated during what is often a physically challenging and emotionally charged time. Despite these difficulties, the extent to which patient engagement can be leveraged during any given episode of care will almost certainly enhance the outcome. As definitive as I believe the relationship between patient engagement and outcomes is, the relationship between patient engagement and patient satisfaction appears to be a bit less well established or understood. The two are inexorably intertwined, but the precise nature of the interaction is considerably less clear. Are engagement and satisfaction a cause or result of outcomes, or are there other factors at play? I believe that, by clarifying the factors that affect clinical outcomes, both patient engagement and satisfaction will begin to be better understood. Although the very topical concept of patient satisfaction recently has become the focus of an inordinate amount of attention by the media and by payers, I believe that much more research is needed to determine the precise role that patient satisfaction, or the patient experience, plays in health care delivery and outcomes. At this time, however, the precise nature of the patient-provider relationship remains not only complicated but also largely uncharted. Clearly, this is a fertile area of exploration

because patients, especially those undergoing surgical or other invasive procedures, will most definitely play an increasingly important role in the responsibility for their own perioperative care. Only through further exploration and evidencebased research will the precise nature of the link between patient engagement and outcomes be more clearly elucidated. As a result of this focus of endeavor, I anticipate that the concept of relationship-based care will become more clearly established as an important determinant of patient satisfaction. One important concept that surely will emerge as an important area of continuing endeavor is to arrive at clear, consistent, and universally accepted definitions of terms such as engagement, satisfaction, and outcome. Only after these definitions have been refined and promulgated can we begin the subsequent task of accurately quantifying, or measuring, all the variables therein. Patient engagement and patient satisfaction, therefore, are an evolving and positive focus of health care, especially as we strive to improve the quality of the perioperative services that we provide to our patients. Surely, any efforts directed toward improvement on behalf of our patients are mission critical for us as health care providers in the inpatient and in the rapidly growing outpatient settings. DAVID SHAPIRO MD, CASC, CHCQM, CHC, CPHRM, LHRM ANESTHESIOLOGIST TALLAHASSEE, FL

Chief nursing officer’s perspective I could not be happier with the growing focus on patient satisfaction as a measure of quality. Measuring patients’ perceptions of their care helps us, their care providers, to understand their emotional and spiritual health during all phases of perioperative care. By referring to spiritual health in this context, I am not discussing patients’ religious state of mind but rather the health of the human spirit that is inside all of us. Human beings are complex

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creations who need to feel safe while also being safe to thrive. Maslow’s hierarchy of needs demonstrated that, after an individual’s physical needs are met, the individual ascends to more complex needs to achieve self-actualization.15 Understanding the needs of our patients to thrive both physically and spiritually is critical to helping them face whatever risks they encounter from disease or injury.

TABLE TALK As a nurse I have always viewed my practices as providing a combination roles, that of scientist and care provider. The scientist role allows me to focus on assessing the physical needs, signs, and symptoms of those patients in my care so that I can develop and implement suitable interventions. The care provider role allows me to focus on enhancing the spiritual health of my patients. I believe that we are unable to be expert caregivers if we do not care for all the needs of our patients, both physical and spiritual.16 Unfortunately, over the years, as the cost of providing care has grown, our health care systems have continually shifted the focus of care delivery to developing processes and systems that deliver physical care in as efficient a manner as possible. In the surgical environment, we all have experienced the ongoing push for efficiency and the multiple meetings to discuss reducing turnover time and cost per procedure. It was not until the Institute of Medicine published its report, To Err is Human: Building a Safer Health System,13 which estimated that 100,000 lives are lost each year because of medical errors, that society demanded a response to patient outcomes in the form of safer care delivery models that respect health care efficiency but not at the expense of safety.16 I believe the response to the Institute of Medicine report aligns with Maslow’s theory. Nurses and other members of the health care team have looked to improve structures and processes to meet the physical needs of the patient first. For example, in the OR, perioperative personnel embrace safety initiatives such as the time out and the Surgical Care Improvement Project.17 We have looked to reduce variations to decrease human error from inexperience with a certain supply or piece of equipment. Additionally, both the “captain of the ship” doctrine and bullying behavior that were tolerated for so many years have been replaced with huddles and debriefings about the plan of care, so that all team members can be equal partners in providing care. Despite these efforts, we still face challenges with outcomes. I believe that the realization must be that problems related to mediocre outcomes

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cannot be solved if we do not involve the patients in their care. As McGowan stated in his article, a patient who is made to feel valued and part of the care process is a patient who has a better chance to experience an optimal outcome.6 Engaging patients strengthens the health of their spirit. A healthy spirit is critical to patients’ successdyet, up to this point, everything the health care industry has been focused on has been to address patients’ physical needs and not their spiritual needs. It is only now that we are responding to that oversight by enhancing physical care with relationship-based care. Let’s face it, receiving health care can be one of the most dehumanizing experiences in a person’s life. We strip patients of their clothes, their valuables, and their family and friendsdand we may even paralyze them with anesthesiadso that a group of strangers whom they have never, or only briefly, met can perform a surgical or other invasive procedure on their body. I have had surgery only as a child, but still I have wondered many times as I put the safety strap on my patients about the leap of faith that is required of those who undergo surgery. The stress of a surgical procedure must be enormous, and that stress can hinder a patient’s ability to thrive throughout the perioperative course. To me, this is why it is so important to engage our patients and make them feel valued during the perioperative process. I believe that patients enter a hospital believing that we know how to provide physical care, but what they hope for, and are concerned about, is whether we will value them as human beings. When an individual feels valued, he or she feels stronger; and the stronger the patient is, the better the chances are for a great outcome. I frequently see evidence of how important spiritual care is to patients. In my 30 years as a nurse leader, almost every letter I receive from patients discusses how my nurse team members either did or did not make them feel valued. Except for incidents of a clear-cut error, patients rarely discuss the physical aspects of care or their outcomes. It is clear to me that they want to share their perception of the quality of the AORN Journal j 523

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spiritual care they received. For someone to stop and take the time to write a message of thanks or concern means that their spiritual care is something they value very much; and, if this is important to them, then it should be equally important to us as their care providers.

TABLE TALK WILLIAM J. DUFFY RN, MJ, CNOR, FAAN REGIONAL VICE PRESIDENT, CHIEF NURSE OFFICER, PATIENT CARE SERVICES LAKE SHORE REGION PRESENCE HEALTH CARE CHICAGO, IL

Patient’s perspective My perspective as a surgical patient in an ambulatory setting is a bit unique because of my professional background. For the past 42 years, I have worked for a major surgical organization and have witnessed the development of statements, guidelines, and protocols to meet the organization’s mission to improve quality in surgery, trauma, and cancer care and to have fewer complications, better outcomes, and greater access for patientsd all at lower costs. In my view, this laudable mission should include cooperative efforts from both patients and perioperative team members. For example, soon I will begin my term as the first patient to serve on the Board of Directors of the Council on Surgical and Perioperative Safety (http://www.cspsteam.org), a coalition that previously comprised only representatives from professional societies. I have been a surgical outpatient on three occasions: for a torn meniscus repair, a cystoscopy, and a colonoscopy. All three interventions had excellent outcomes, and my recovery was within the normal, prescribed time frames for each. Although I have had additional surgical experiences as an inpatient at a large Midwestern teaching hospital, all three of the outpatient procedures were performed in either a mid-size suburban hospital or in the surgeon’s office. In all three instances, I was impressed with the level of preoperative and postoperative care that personnel provided. During these experiences, I was encouraged to ask questions about the surgical procedure and was given written information as well. I felt a part of the process and was treated as a unique individual and not as an anonymous patient or just another procedure.

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I believe that patients must be their own advocates or, if required, have someone with them to serve in that role. No matter how routine a procedure is for the perioperative team, it is perhaps the first time for the patient. Not to be flippant, but I liken the surgical experience to attending a Broadway play. The cast and crew may have multiple performances under their belts, but most members of the audience are there for the first time and expect the best. Unlike anticipating a delightful evening at the theater, however, the patient may be fearful or anxious about the procedure and outcome. These emotions usually are linked to not knowing or understanding how the perioperative phases of care will go. In my experience, patient education is instrumental to preoperative planning and postoperative recovery. As stated earlier, the written and verbal explanations were very helpful and spoken in terms that were understandable to me as the patient. My questions were encouraged and willingly answered, and I felt valued as a human being. In an outpatient setting, the nursing team does not have much time with patients; therefore, effective educational tools are far more focused and time sensitive before and after the procedure compared with the inpatient setting. In particular, I found the postoperative follow-up telephone call after discharge very helpful. The nursing team made sure that I understood and was following the postoperative instructions. At-home care regimens can include, but are not limited to, caring for the surgical wound and pain management.18 In addition, the postdischarge call provides a great deal of comfort, as it did for me. The subsequent follow-up visit with the surgeon is critical to postoperative care. It is

TABLE TALK during this visit that more extensive questions may be addressed. Good follow-up leads to peace of mind for the patient. For me, this appointment provided great follow-up and peace of mind. An engaged patient is usually a satisfied patient. As the health care system in this country changes and new compensation models are developed, patients will probably have more concerns and questions, and health care professionals, particularly the perioperative team, should be prepared and ready to guide and understand the patient’s

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perspective. Health care providers also should be aware that any of us may become a patient on any given day; that alone should dictate a desire to promote and provide optimal patient education. BARBARA L. DEAN FORMER DIRECTOR, EXECUTIVE SERVICES AMERICAN COLLEGE OF SURGEONS PATIENT MEMBER, BOARD OF DIRECTORS COUNCIL ON SURGICAL AND PERIOPERATIVE SAFETY CHICAGO, IL

AORN perspective The contributors to this “Table Talk” all have provided clear support of the link between patient and family member engagement and clinical outcomes. The growing importance of patient engagement to the health care system role is recognized in section 302119 of the Affordable Care Act,20,21 a statute the Centers for Medicare & Medicaid Services Innovation Center operationalized in 2011 through its Partnership for Patients.22 As a public-private endeavor, the Partnership comprises a broad and inclusive network of members (eg, physicians, nurses, hospitals, associations, federal and state governments, patients) who have joined together to improve the quality, safety, and affordability of health care for all Americans.23 AORN was one of the first associations to join the Partnership and pledge its support to achieving outcomes that are consistent with the mission and vision of AORN. Members of the Partnership are committed to reaching two goals: making care safer and improving care transitions. The desired outcomes of these initiatives are a 40% reduction of preventable hospital-acquired conditions and a 20% reduction of 30-day readmissions, both by the end of 2013 as compared with 2010 data.23 As a major vehicle for improving patient care, the Partnership leverages three key elements:

1. Hospital engagement networksdto identify solutions for reducing hospital-acquired conditions as well as share and spread successful practices to other hospitals and health care providers. (See “Resources: Partnership for Patient Affinity Groups.”) 2. Community-based care transition programsd to test models of improving care transitions from the hospital to another setting, and to aid in reducing the readmissions rate for high-risk Medicare beneficiaries. 3. Patient and family engagementdto focus on the importance of the relationship among health care professionals and patients and their family members in preventing health caree associated illness as well as to help patients heal without complications through improved transitions across health care settings and reduced readmissions.23 Regarding the Partnership’s third key element, the importance of patient engagement is consistent with AORN’s Perioperative Patient Focused Model (Figure 1), which is a framework grounded around the principle that the patient is the focus of all nursing interventions to achieve optimal patient outcomes. This model clearly illustrates the patientcentered goal of perioperative nursing practice, which is to assist patients and their family members

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coordinates patient care continually throughout the patient’s perioperative experience and assists the patient and family members with identifying options for care. The Perioperative Standards and Recommended Practices also indicates that the perioperative RN uses ethical principles to determine decisions and actions, such as by acting as a patient advocate and encouraging patient self-advocacy. Additional AORN resources include AORN position statements and tool kits. AORN position statements serve to articulate the Association’s official position or belief about specific perioperative nursingerelated topics. In particular, several position statements convey and support the importance of the relationship among perioperative nurses, patients, Resources: Partnership for Patient Affinity Groups and their family members Information shared via the Partnership for Patients hospital during the perioperative engagement networks often comes from Affinity Groups with period. A number of AORN clinical focuses, such as health careeassociated infections, meditool kits also provide recation safety and pharmacist engagement, patient and family sources for engaging pamember engagement, and product safety and resource managetients and their family ment. AORN, the American College of Surgeons, the American members. These resources Society of Anesthesiologists, and the American Association of include the following: Nurse Anesthetists collaborated with the Partnership to create the n AORN Position Procedural Harm Affinity Group,1 which endorses successful Statements practices related to surgical safety, such as use of the World Health

with achieving a level of wellness equal to or greater than the level of wellness that the patients have before undergoing their operative or other invasive procedure. AORN provides resources for improving patient and family engagement, such as Perioperative Standards and Recommended Practices.24 This publication includes references to involving the patient and family members during patient assessment, developing expected outcomes of care, including the patient in the implementation of the care plan, verifying that interventions reflect the rights and desires of the patient, and involving the patient and family members in the postprocedure evaluation process. The perioperative RN

Organization’s Surgical Safety Checklist.2 Members of the Partnership and the Affinity Group make information available to the Partnership’s hospital engagement networks (eg, through web events, conference calls, shared tools), so that health care professionals have direct access to resources that can be used in providing optimal preoperative, intraoperative, and postoperative care to the surgical patient.

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Care of the Older Patient in Perioperative Settings (https:// www.aorn.org/Wo rkArea/DownloadAsse t.aspx?id¼21926)

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Creating a Practice Environment of Safety (http://www.aorn.org/ WorkArea/Download Asset.aspx?id¼21919)

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Patient Safety (http:// www.aorn.org/Work Area/DownloadAsse t.aspx?id¼21930)

1. Procedural Harm Affinity Group. Healthcare Communities. http://www.health carecommunities.org [membership required]. Accessed February 12, 2014. 2. AANA, ACS, AORN, ASA and the Council on Surgical and Perioperative Safety (CSPS) endorses the use of the World Health Organization’s Safe Surgery Checklist and the implementation of The Joint Commission’s Universal Protocol [news release]. Denver, CO: AORN, Inc; 2012. http:// www.aorn.org/uploadedFiles/Main_Navigation/Advocacy/Supporting_ Documents/Issues/PfP%20Affinity%20Group%20Joint%20Statement.pdf. Accessed February 6, 2014.

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Perioperative Care of Patients with Do Not Resuscitate Orders (http://www.aorn.org/ WorkArea/DownloadAsset.aspx?id¼21917) n AORN Tool Kits n Correct Site Surgery Tool Kit (http://www .aorn.org/Secondary.aspx?id¼20846) n Workplace Safety Tool Kit (http://www.aorn .org/Clinical_Practice/ToolKits/Workplace_ Safety/Workplace_Safety_Tool_Kit.aspx) n Just Culture Tool Kit (http://www.aorn.org/ Secondary.aspx?id¼20848) n Patient Hand Off Tool Kit (http://www.aorn .org/Secondary.aspx?id¼20849) n

Additional resources are available from the Nursing Alliance for Quality Care (http://www .naqc.org), of which AORN is a member. This alliance comprises 22 national organizations and consumer advocacy groups that are committed to improving the quality and safety of health care for all Americans. Goals of the alliance include the active engagement of patients, family members, and others to improve quality and to reduce medical errors and harm to patients; a second goal is that nurses at all levels of education and across all health care settings must play a central role in fostering successful patient and family member engagement. To meet these goals, the Nursing Alliance for Quality Care created the following: guiding principles25 to support nurses’ efforts in fostering patient engagement and n the Fostering Successful Patient and Family Engagement white paper8 to propose a strategic plan that both encourages nurses’ support of patient engagement and identifies how organizations and individual nurses can be active in implementing the plan. n

AORN believes that patients and their family members are essential partners in the care that health care professionals provide to perioperative patients. In addition, involving patients in aspects of their care is necessary to developing a safe perioperative culture. AORN president Victoria

Figure 1. AORN Perioperative Patient Focused Model. Reprinted with permission from aorn.org. Copyright ª 2014, AORN, Inc, Denver, CO. All rights reserved.

M. Steelman, PhD, RN, CNOR, FAAN, has embraced the concept of patient engagement by appointing a task force to make recommendations for infusing the principles of relationship-based care into new and existing resources to aid in the care of the perioperative patient. Members of the Patient Engagement Task Force will share their results at the AORN Surgical Conference & Expo 2015. LINDA K. GROAH MSN, RN, CNOR, NEA-BC, FAAN EXECUTIVE DIRECTOR AND CHIEF EXECUTIVE OFFICER AORN, INC DENVER, CO

Editor’s note: Ask Me 3 is a registered trademark of the National Patient Safety Foundation, Boston, MA. References 1. A New Definition of Patient Engagement: Why is Patient Engagement Important? Washington, DC: Center for Advancing Health; 2010. http://www.cfah.org/pdfs/ CFAH_Engagement_Behavior_Framework_current.pdf. Accessed January 13, 2014.

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2. Kish L. The blockbuster drug of the year: an engaged patient. HL7Standards.com e-newsletter. 2012. http:// www.hl7standards.com/blog/2012/08/28/drug-of-the -century/. Accessed January 13, 2014. 3. Malik M. Advocacy in nursingda review of the literature. J Adv Nurs. 1997;25(1):130-138. 4. AORN position statements. AORN J. 2011;93(5):545-549. 5. Schroeter K. Advocacy in perioperative nursing practice. AORN J. 2000;71(6):1207-1222. 6. McGowan R. A surgical patient’s perception of trust. AORN J. 2011;93(4):493-497. 7. A Leadership Resource for Patient and Family Engagement Strategies. Chicago, IL: Health Research & Educational Trust; 2013. http://www.hpoe.org/Reports-HPOE/ Patient_Family_Engagement_2013.pdf. Accessed January 13, 2014. 8. Shoshanna S, Schumann MJ. Fostering Successful Patient and Family Engagement: Nursing’s Critical Role [white paper]. Silver Spring, MD: Nursing Alliance for Quality Care; 2013. http://www.naqc.org/Main/Resources/ Publications/March2013-FosteringSuccessfulPatientFami lyEngagement.pdf. Accessed February 10, 2014. 9. Schillinger D, Piette J, Grumback K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003; 163(1):83-90. 10. Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001. http://psnet .ahrq.gov/resource.aspx?resourceID¼1599. Accessed January 13, 2014. 11. Ask Me 3. National Patient Safety Foundation. http:// www.npsf.org/for-healthcare-professionals/programs/ ask-me-3/. Accessed January 13, 2014. 12. Pelletier LR, Stichler JF. Action brief: patient engagement and activation: a health reform imperative and improvement opportunity for nursing. Nurs Outlook. 2013;61(1):51-54. 13. Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 14. Coulter A. Patient engagementdwhat works? J Ambul Care Manage. 2012;35(2):80-89.

TABLE TALK 15. McLeod S. Maslow’s hierarchy of needs. SimplePsychology. 2007. http://www.simplypsychology.org/ maslow.html. Accessed January 13, 2014. 16. Duffy WJ. The value of our practice. AORN J. 2004; 79(6):1125-1127. 17. Brendle TA. Surgical care improvement project and the perioperative nurse’s role. AORN J. 2007;86(1):94-101. 18. Costa MJ. The lived perioperative experience of ambulatory surgery patients. AORN J. 2001;74(6):874-881. 19. Establishment of Center for Medicare and Medicaid Innovation within CMS. Patient Protection and Affordable Care Act (Pub. L. 111e148) x 3021(2010). http:// www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW -111publ148.pdf. Accessed February 6, 2014. 20. ANA Policy & Provisions of Health Reform Law. Silver Spring, MD: American Nurses Association; 2010. http:// www.nursingworld.org/MainMenuCategories/PolicyAdvocacy/HealthSystemReform/Policy-and-Health-ReformLaw.pdf. Accessed February 6, 2014. 21. Health care transformation: the Affordable Care Act and more. American Nurses Association. http://nursingworld .org/MainMenuCategories/Policy-Advocacy/HealthSystem Reform/AffordableCareAct.pdf. Published March 23, 2012. Accessed February 6, 2014. 22. The CMS Innovation Center. Centers for Medicare & Medicaid Services. http://innovations.cms.gov/. Accessed February 6, 2014. 23. About the Partnership for Patients. CMS.gov. http://partner shipforpatients.cms.gov/about-the-partnership/aboutthe partnershipforpatients.html. Accessed February 6, 2014. 24. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014. 25. Guiding principles for patient engagement. In: The Nursing Alliance for Quality Care National Consensus Conference program. Nursing Alliance for Quality Care. http://www.naqc.org/Main/Resources/Publications/2012 -NursesContributionsFosteringSuccessfulPatientEngage ment.pdf. Accessed February 10, 2014.

The authors of this article have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

The AORN Journal is seeking contributors for the Table Talk column. Interested authors can contact Charlotte Guglielmi, column coordinator, by sending topic ideas to [email protected].

528 j AORN Journal

The growing role of patient engagement: relationship-based care in a changing health care system.

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