Accountability and Nursing Practice

TABLE TALK

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

A s health care providers, we rarely partici-

pate in discussions, watch interviews, or

read articles about our changing health

care system that do not concern patient engage-

ment. 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 syn-

onymous 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 re-

covery. One author captured the importance of

patient engagement with this statement: “If pa-

tient engagement were a [medication], it would

be the blockbuster [medication] of the century

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

http://dx.doi.org/10.1016/j.aorn.2014.02.007

� AORN, Inc, 2014 April 2014 Vol 99 No 4 � AORN Journal j 517

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 engage-

ment and advocacy is key to the care that we de-

liver 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 ground-

work 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 en-

ters the surgical suite with anxiety and looks to

the perioperative team for reassurances. He be-

lieves that inaccurate portrayals of surgery in the

media “contribute to patients’ perceptions of sur-

gery 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

goodbye to his partner before the procedure began,

which suggests that he perceived a lack of sup-

port 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 disci-

pline 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 engage-

ment and improved outcomes for periopera-

tive 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 accom-

plished without fully engaging patients in their own

care or without fully engaging their families. 7

According to a white paper on patient and family

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

518 j AORN Journal

April 2014 Vol 99 No 4 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 estab-

lish a model for engaging patients and should en-

sure 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 teach-

back (http://www.teachbacktraining.org) and Ask

Me 3 TM

(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 com-

munication and health outcomes. 9 By using inter-

active 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 infor-

mation 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 re-

lated 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. Part-

nership for Clear Health Communication developed

this technique with the intent of helping all patients

comprehend their particular health condition and

what they should do about it. There are three

questions 11

that patients are encouraged to ask

any health care provider:

n What is my main problem?

n What do I need to do?

n Why is it important for me to do this?

The use of these techniques adds structure to

patients’ interactions with their health care pro-

viders, 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 in-

depth 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 commu-

nication 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 re-

lationships 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 engage-

ment 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

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leaders sets an example for personnel but also

provides one more step in cementing the patient-

provider relationship that is so important to pa-

tient outcomes.

Helping personnel embrace “hardwire processes”

that are related to patient engagement is not sim-

ple, 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.

n 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

work these into the conversation. Use teach-

back 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 ac-

company 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.

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 System 13

documented sig-

nificant 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 es-

tablishing good physician-patient relationships and

must be addressed by the profession. Doing so is

especially critical as the health care industry fo-

cuses 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 out-

comes 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, educat-

ing 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

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 appro-

priate. 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 satisfac-

tion and will improve outcomes dramatically.

Yet, the world of health care becomes more

frenzied by the day, which has led to perioperative

520 j AORN Journal

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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 weak-

ens 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 suc-

cessfully 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

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 pa-

tients 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 set-

ting, 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, patient-

centered 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 per-

formed, 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. Further-

more, such a patient may be an unsuitable candi-

date for outpatient surgery.

As an example, a patient who is not motivated

to thoroughly administer his or her prescribed in-

testinal prep before a colonoscopy can adversely

affect the likelihood of an optimal procedure and is

at significant risk for cancellation entirely, there-

by 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 compli-

cations are crucial to a safe and timely recovery.

Although the relationship that perioperative

team members have with the patient is intuitive-

ly 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 self-

care 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 emo-

tionally charged time. Despite these difficulties, the

extent to which patient engagement can be lever-

aged during any given episode of care will almost

certainly enhance the outcome.

As definitive as I believe the relationship be-

tween patient engagement and outcomes is, the

relationship between patient engagement and pa-

tient satisfaction appears to be a bit less well es-

tablished 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 clar-

ifying 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 satisfac-

tion, 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 un-

charted. Clearly, this is a fertile area of exploration

because patients, especially those undergoing sur-

gical or other invasive procedures, will most defi-

nitely play an increasingly important role in the

responsibility for their own perioperative care.

Only through further exploration and evidence-

based research will the precise nature of the link

between patient engagement and outcomes be

more clearly elucidated. As a result of this fo-

cus 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, satisfac-

tion, 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 en-

gagement and patient satisfaction, therefore, are

an evolving and positive focus of health care, es-

pecially as we strive to improve the quality of

the perioperative services that we provide to our

patients. Surely, any efforts directed toward im-

provement on behalf of our patients are mission

critical for us as health care providers in the inpa-

tient 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. Mea-

suring patients’ perceptions of their care helps us,

their care providers, to understand their emotional

and spiritual health during all phases of periopera-

tive 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

creations who need to feel safe while also being

safe to thrive. Maslow’s hierarchy of needs de-

monstrated that, after an individual’s physical needs

are met, the individual ascends to more complex

needs to achieve self-actualization. 15

Understand-

ing the needs of our patients to thrive both physi-

cally and spiritually is critical to helping them

face whatever risks they encounter from disease

or injury.

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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 symp-

toms 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 de-

livery 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 inexperi-

ence 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

cannot be solved if we do not involve the patients in

their care. As McGowan stated in his article, a pa-

tient who is made to feel valued and part of the care

process is a patient who has a better chance to ex-

perience 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 valu-

ables, 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

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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.

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 ambu-

latory setting is a bit unique because of my pro-

fessional background. For the past 42 years, I have

worked for a major surgical organization and have

witnessed the development of statements, guide-

lines, 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 mis-

sion 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 previ-

ously comprised only representatives from profes-

sional societies.

I have been a surgical outpatient on three occa-

sions: 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 sur-

geon’s office. In all three instances, I was impressed

with the level of preoperative and postoperative

care that personnel provided. During these experi-

ences, I was encouraged to ask questions about the

surgical procedure and was given written informa-

tion as well. I felt a part of the process and was

treated as a unique individual and not as an anon-

ymous patient or just another procedure.

I believe that patients must be their own advo-

cates 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. Un-

like 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 experi-

ence, patient education is instrumental to preoper-

ative planning and postoperative recovery. As stated

earlier, the written and verbal explanations were

very helpful and spoken in terms that were under-

standable to me as the patient. My questions were

encouraged and willingly answered, and I felt val-

ued 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 dis-

charge very helpful. The nursing team made sure

that I understood and was following the postoper-

ative instructions. At-home care regimens can in-

clude, 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

524 j AORN Journal

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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, particu-

larly the perioperative team, should be prepared

and ready to guide and understand the patient’s

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 pro-

vided 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

3021 19 of the Affordable Care Act,

20,21 a statute the

Centers for Medicare & Medicaid Services Inno-

vation 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 read-

missions, 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 con-

ditions 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 re-

duced 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 patient-

centered goal of perioperative nursing practice,

which is to assist patients and their family members

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with achieving a level of wellness equal to or

greater than the level of wellness that the pa-

tients 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 assess-

ment, developing expected outcomes of care, in-

cluding 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 postpro-

cedure evaluation process. The perioperative RN

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 act-

ing 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 periop-

erative nursingerelated topics. In particular,

several position statements convey and support

the importance of the

relationship among peri-

operative nurses, patients,

and their family members

during the perioperative

period. A number of AORN

tool kits also provide re-

sources for engaging pa-

tients and their family

members. These resources

include the following:

n AORN Position

Statements

n Care of the Older Pa-

tient in Perioperative

Settings (https://

www.aorn.org/Wo

rkArea/DownloadAsse

t.aspx?id¼21926) n Creating a Practice

Environment of Safety

(http://www.aorn.org/

WorkArea/Download

Asset.aspx?id¼21919) n Patient Safety (http://

www.aorn.org/Work

Area/DownloadAsse

t.aspx?id¼21930)

Resources: Partnership for Patient Affinity Groups

Information shared via the Partnership for Patients hospital

engagement networks often comes from Affinity Groups with

clinical focuses, such as health careeassociated infections, medi-

cation safety and pharmacist engagement, patient and family

member engagement, and product safety and resource manage-

ment. AORN, the American College of Surgeons, the American

Society of Anesthesiologists, and the American Association of

Nurse Anesthetists collaborated with the Partnership to create the

Procedural Harm Affinity Group, 1 which endorses successful

practices related to surgical safety, such as use of the World Health

Organization’s Surgical Safety Checklist. 2 Members of the Part-

nership 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 pro-

fessionals have direct access to resources that can be used in

providing optimal preoperative, intraoperative, and postoperative

care to the surgical patient.

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.

526 j AORN Journal

April 2014 Vol 99 No 4 TABLE TALK

n 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) 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:

n guiding principles 25

to support nurses’ efforts

in fostering patient engagement and

n the Fostering Successful Patient and Family

Engagement white paper 8 to propose a strategic

plan that both encourages nurses’ support of

patient engagement and identifies how organi-

zations and individual nurses can be active in

implementing the plan.

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

M. Steelman, PhD, RN, CNOR, FAAN, has em-

braced the concept of patient engagement by ap-

pointing 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 trade- mark 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.

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

AORN Journal j 527

TABLE TALK www.aornjournal.org

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 litera- ture. 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 Engage-

ment Strategies. Chicago, IL: Health Research & Educa-

tional Trust; 2013. http://www.hpoe.org/Reports-HPOE/

Patient_Family_Engagement_2013.pdf. Accessed

January 13, 2014.

8. Shoshanna S, Schumann MJ. Fostering Successful Pa-

tient 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 engage-

ment 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.

15. McLeod S. Maslow’s hierarchy of needs. Simple-

Psychology. 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 ambu-

latory surgery patients. AORN J. 2001;74(6):874-881.

19. Establishment of Center for Medicare and Medicaid

Innovation within CMS. Patient Protection and Afford-

able 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/Policy-

Advocacy/HealthSystemReform/Policy-and-Health-Reform-

Law.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

April 2014 Vol 99 No 4 TABLE TALK

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