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An Action Plan to Increase Patient Engagement

Nicole Toohey

Delaware Technical Community College

NUR 420 2W1

September 30, 2018


An Action Plan to Increase Patient Engagement

If you were to stop ten strangers on the street and ask them about healthcare in the United

States, you might get ten different responses but deep-rooted in those answers would be a

common theme: the system is broken. How then do we go about fixing the system? Healthcare

costs rise every year; insurance deductibles and out-of-pocket expenses for the patients seem to

be at an all-time high. It feels as though we are fighting an uphill battle. Does the answer lie

with the doctors, with the nurses, or with the patients themselves? I believe we are all

responsible for the needed change: doctors, nurses, and patients alike, and the key phrase is

patient engagement.

The Affordable Care Act (ACA) defines patient engagement as, “the active participation

of patients and their families in the process of making medical decisions” (Mason, Gardner,

Outlaw, & O’Grady, 2016, p. 209). However, that definition does not encompass the true

meaning of patient engagement. An engaged patient is a person who understands their own

health, the steps the doctors and nurses are taking to better that health, AND someone who is

involved in those decisions. In essence, an engaged patient is a fully informed patient. How

then do we go about properly informing our patients?

A study performed in 2010 by the Agency for Healthcare Research and Quality found

that hospital readmissions lead to 41.3 billion dollars in additional hospital costs (Shinkman,

2014). There are numerous factors that must be considered when looking at readmissions. Jess

White noted in her article “Closer Look at what Causes Readmissions,” (2015) that Beth Israel

Deaconess Hospital in Boston, MA, found that one of those factors in readmissions was, “people

who didn’t have a high level of health literacy, which made it difficult for them to understand

what they needed to do to maintain their health after discharge” (para. 10). If a patient has


trouble understanding their own complex health issues, how can we expect them to be engaged

in their own healthcare decisions? I believe the answer lies directly with education. A patient

who has been educated by nurses and doctors about their health issues, is a patient who can make

more informed decisions about their healthcare and who will, in turn, become more engaged and

more compliant with physicians’ orders and lifestyle change suggestions. So where do we start?

As a former bedside nurse, I have been in the front line of healthcare. I have seen the

patients who are referred to as “frequent flyers” because they are admitted to the hospital so

often. I have also seen many patients deemed “non-compliant” because they were not following

their fluid restriction at home or they did not take their medication as it was prescribed. I always

found myself wondering, what we (the healthcare team), could have done to better prepare the

patient for a discharge to home. Did I spend enough time educating the patients on their illness?

Did the patient understand just how important their medication was to keep their chronic

condition at bay? More often than not, I realized the education was falling short, but why?

As a society we have understood for a very long time that everyone learns differently,

and we need to use that understanding to better teach our patients about their acute and chronic

conditions. Kaiser Permanente Panorama City Hospital (KPPCH) in California began using a

TeleHealth Service called TIGR in 2008 (Interactive Patient, 2012). This service helps to

personalize patient education during hospitalization with the goal for the patient to become more

engaged in their health. KPPCH found that within two years of implementing TIGR the

readmission rates for CHF and pneumonia were lowered by six percent. It also found that

patient satisfaction, or patients who felt they understood their condition went from 70% to over

90% and the overall hospital satisfaction for patients went from 80% to 90%. So, just by


implementing a different type of education format for their patients, KPPCH was able to improve

patient understanding of their health conditions by 20%. Those number are astonishing.

Another key factor to educating my patients was the amount of time I spent with them.

There were nights that I only had three or four patients, all of whom were stable, and I was able

to spend ample time with all my patients. I was able to take the time to explain the current

measures we were taking to improve their health and what actions they could take to also better

their health. I was also able to take the time to sit and listen to my patients about their needs at

home and what services may benefit them once they were discharged. That quality time with my

patients was key. However, there were many nights that I had five critically ill patients that

required most of my attention and very little time was able to be spent educating my patients or

their families. Prior to leaving bedside nursing, there were more shifts that I had five patients

under my care than there were not. The education ball was being dropped and I knew it. If a

better educated patient leads to better health outcomes and fewer 30-day readmissions, than I

was adding to the problem and I was in turn costing the hospital I was working for to lose money

in the long run.

The state of California, in 2004, became the first state to implement minimum nurse-to-

patient ratios (Impact, 2011). In 2008 the ratios were revisited, and changes were made. A step-

down unit (like the type of unit I came from) in 2004 had a ratio of 1:4, or one nurse to four

patients, but by 2008 it was decided that better outcomes occurred with a 1:3 ratio. Dr. Linda

Aiken, PhD, RN and her colleagues, looked at the effectiveness of the mandated ratios in

California and performed a study comparing CA with two other states, New Jersey and

Pennsylvania (Impact, 2011) and her conclusion was astounding. “Hospital nurse staffing ratios

mandated in California are associated with lower mortality and nurse outcomes predictive of


better nurse retention in California and in other states where they occur. Thus, the minimum

nurse-to-patient staffing ratios mandated in California have great potential to improve patient

outcomes and nurse retention (Impact, 2011, para. 13).

If the type of education a patient receives is important, as evidenced by the KPPCH

study, and the amount of time a nurse spends with a patient can aid in better patient outcomes

then where do we go from here? We lobby for change of course.

At the local level I will start with the organization I work for. Bayhealth, where I am

employed, is a two-hospital system in the state of Delaware. The organization has multiple

councils that a nurse can become involved to help enact change. The Patient Care Services

(PCS) Council provides a forum for discussion of policies, procedures, and processes that affect

patient care. It also provides a forum for reporting analysis, action plans, and opportunities for

improvement. The co-chairs of the council are Jenn Fields and Jessica Taylor. A sub-council to

the PCS council is the Nursing Open Forum. The open forum allows nurses to come and discuss

solutions to evolve an environment that supports nursing excellence. The co-chairs for this

council are Connie Ajah-Young and Lisa Blake. A third council that I feel would be beneficial is

the Professional Practice Council. The objectives of this council are to coordinate activities to

promote clinical practice and enhance patient outcomes, as well as make recommendations and

support decisions related to nursing practice at Bayhealth. The chairperson of this council is

Karen Merson. Finally, the Research Council, chaired by Teresita Raymundo, has a top

objective of supporting and mentoring Bayhealth staff in nursing research. Nursing councils

may be the first, best step to confronting the enormous issue of patient engagement.

A few points to bring up at the council meetings would be: a standardization of nurse-to-

patient ratios throughout the Bayhealth organization, different types of education material for


patients and how to can go about obtaining them, and the patient portal MyChart and assisting

patients in accessing the MyChart website while in the hospital so that they can better understand

how to look at the information once they have been discharged. Besides the nursing councils, a

great person to contact would be Brenda Blain, the new senior vice president and chief nurse

executive at Bayhealth. A few of Blain’s responsibilities are patient care services, education,

and service excellence. A news briefing about the hiring of Blaine in 2017 stated that she looks

forward to “improve the knowledge of outcomes” and “create action plans and goals for all

units” (Brenda, 2017, para. 5).

At the state level I will approach the representatives and senators that are members of

committees that are directly involved in healthcare. In the Delaware State House of

Representatives there is a committee named Health and Human Development. The chair of this

committee is David Bentz, a Democrat from district RD18. The Delaware State Senate has a

similar committee. The Health, Children, and Social Services committee is chaired by Bryan

Townsend, a Democrat from district SD11. David Bentz can be reached at 302-744-4351 and

Bryan Townsend may be reached at 302-744-4165. Mason, et. al., state, “Identifying the

appropriate sponsor to introduce a bill is critical to its success” (2016, p. 378), that is why Mr.

Bentz and Mr. Townsend would be the two people to contact about enacting legislation on nurse-

to-patient ratios.

At the national level, the US House of Representatives and Senate have both introduced

bills to change legislation directly related to nurse-to-patient ratios. S. 1063, also known as,

Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2017, was

introduced by Senator Sherrod Brown, a democrat from Ohio. This bill was then referred to the

Health, Education, Labor and Pension committee of the Senate and that is where the bill


currently sits. HR. 2392, also titled Nurse Staffing Standards for Hospital Patient Safety and

Quality Care Act of 2017 was introduced by Representative Janice D. Schakowsky, a democrat

from Illinois. The bill was put in front of the House Energy and Commerce; Ways and Means

committee and then it was referred to the subcommittee on Health which is where it currently


I believe the best way to keep the ball rolling on these two bills, is by contacting US State

Senator Chris Coons or US House of Representatives member John Carney. It will be important

to gather a group of other nurses who can aid in contacting both congressmen so that they

understand how important this issue is to Delaware and for Delawarean nurses.

Increased patient engagement has proven to lower healthcare costs. Better educated

patients are patients who have a clearer understanding of their complex health issues and who

more closely follow instructions provided to them by their healthcare team. Adherence to

medication and other lifestyle changes may be key in lowering healthcare costs by lowering

hospital readmissions. A small step in getting patients more engaged is creating a hospital

environment that allows the nurses ample time to properly educate their patients. Another small

step is providing nurses with more diverse education material that they can provide to their


Over the next 90 days I will begin taking steps towards creating change at the local,

state, and national levels. I will contact the chairs of each Bayhealth nurse council meeting

mentioned above, so that I have a better understanding of which council can assist this action

plan. If a research study is needed to show the importance of proper staffing ratios, then I will

approach the research council with the study idea. I would also like to have a meeting with

Brenda Blain and inquire about the steps Bayhealth is taking to become better at engaging their


patients in their own healthcare. I will also ask questions directly related to education material

provided by Bayhealth, for their patients. Are there other types of education material that we

have at our disposal that we are possibly unaware of? Information is key here.

The next step will be to gather a group of nurses who feel strongly about staffing ratios,

patient education, and patient engagement. This group of nurses will then begin contacting

congressmen Chris Coons and John Carney, so that these gentlemen understand that their

constituents support the senate and house bills related to staffing ratios. The nurses that I gather

will also begin a correspondence with Mr. Bentz and Mr. Townsend to see if we can gather

support of a congressmen to get a bill started in Delaware that relates to staffing ratios. If the

national bills just sit in committee, it is possible we can get state bills to be written, sponsored,

and passed.

Ultimately, I would like to see change happen at a national level so that nurses in every

state can spend more time with their patients, which will then lead to more time allotted to

educate those patients. However, if change can not happen nationally, it is possible we can

create change at a state or local level. The only way to create change is to begin taking active

steps towards that change. The nurses in California banded together to fight for change and I

believe Delaware is filled with plenty of nurses who wish to have a voice and this action plan can

be the first step in getting those voices heard.



Brenda Blain Welcomed as New Chief Nurse Executive. (2017, October 23). Retrieved

September 30, 2018, from


Impact of Nurse-to-Patient Ratios: Implications of the California Nurse Staffing Mandate for

Other States. (2011, May). Retrieved from



Interactive Patient Education Reduces Readmissions, Increases Satisfaction: Kaiser Permanente

Panorama Hospital Case Study. (2012, August 31). Retrieved from



Mason, D. J., Gardner, D. B., Outlaw, F. H., & O'Grady, E. T. (2016). Policy & Politics in

Nursing and Health Care (Seventh ed.). St. Louis, MO: Elsevier.

Shinkman, R. (2014, April 20). Readmissions lead to $41.3B in additional hospital costs.

Retrieved from


White, J. (2015, June 16). Closer look at what causes readmissions. Retrieved from