Patient, Family Satisfaction Improve Outcomes

March-April 2013


The traditional approach to mental health services for children, adolescents and families was an authoritative, "I'm the expert and you're not," said Steve Lindquist, assistant vice president for behavioral health services at Avera McKennan Hospital & University Health Center in Sioux Falls, S.D. "Behavioral health professionals tended to be controlling, especially in the realm of child and adolescent care, and there was a tendency to blame the parents."

Eight years ago, Avera McKennan placed a new, system-wide emphasis on service excellence and improving patient satisfaction scores. Since then, the Avera Behavioral Health Center has broken new ground through a patient- and family-centered approach that not only garners high satisfaction ratings, but also positive patient outcomes.

"Research shows that patients get better faster when the family is happy with the services a patient is receiving, and so patient and family satisfaction becomes a very important key in treatment and recovery," Lindquist said.

Though it is a freestanding facility, the Avera Behavioral Health Center is considered a department of Avera McKennan Hospital & University Health Center, a 545-bed tertiary hospital. Formerly housed in the main hospital building, behavioral health services moved into their own, state-of-the-art inpatient facility in 2006. Concurrent with construction were plans to make behavioral health a "wow" experience from day one, said Thomas Otten, director of behavioral health inpatient services.

When the new Avera Behavioral Health Center opened, behavioral health leaders took it for granted that a new, beautiful building and a new approach to food service would boost patient satisfaction scores. "But after the first month in the new building, we had our worst scores ever. While a great facility is important, we knew right away it wasn't about the building," Otten said.

A patient satisfaction team specific to behavioral health was created with representatives from each of the center's adult, senior, child and adolescent units. "The first thing we needed to understand was if patient satisfaction impacted patient outcomes. If not, we may be perceived as just catering to patients, or trying to create a [hotel] experience," Otten said.

The team undertook a literature review specific to behavioral health and found study after study showing higher satisfaction led to better outcomes. "This became our platform," Otten said. "We not only wanted to provide good care — we wanted to change lives."

Caregivers with a "we know best" attitude create a power struggle, and patients push back by not following recommendations, Otten said, leading to poorer outcomes. "When caregivers create a good relationship with patients and families, patients tend to be more likely to get the recommended follow-up care and take their medications," he said.

With literature-based ideas in hand, the next step was to create a staff retreat made up of four sessions timed so that every staff member could attend. "We started with the concept of patient satisfaction, and drilled into where our scores were good and not so good and what we could do to improve," Otten said. A patient and family panel is a powerful part of the retreat, still held annually. "This is very moving and emotional as people share their stories related to behavioral health. It brings us together as a team and as a family of colleagues," Lindquist said.

Initially, some staff members resisted the new approach, maintaining it was not a good practice to "cater" to patients. "We realized that we needed to start hiring for attitude first and foremost, rather than what's on a resume," Otten said. "We can train someone with less experience, but it's very difficult to remove a chip on someone's shoulder."

A group reading of the book, Good to Great: Why Some Companies Make the Leap … and Others Don't, by James C. Collins, was eye-opening. "We realized we needed to have the right people in the right spots in the organization. It was like a lightning-bolt moment. Some people needed to move to different places on the bus, and some needed to get off the bus," Lindquist said.


The message to existing staff was very basic, Otten said: "Be kind; be polite." If someone's name was repeatedly brought up on patient comments as being rude or mean, leaders evaluated the reasons why. Some staff members with different philosophies left on their own accord, and a few had to be terminated. "Accountability was very important," Otten said.

Each of the five units developed a unit council that would examine patient satisfaction scores and comments and make needed changes in procedures — some drastic shifts, some small tweaks.

Listening to patients and their families became a priority, through informal comments and focus groups. "It's the moment-to-moment interactions that happen on the units that bring about good things for patients and their families," Lindquist said.

One effective change was to make daily family updates by phone. "Our staff calls every parent every day — answering questions and giving feedback," Otten said. Family meetings during a child's hospitalization also keep families informed and on the same page. Managers and supervisors contact parents, just to touch base and ask, "What can we do to make sure we are meeting your expectations?"

Scripting became an important piece. "Words are powerful, and scripting gives staff members the right words to say at the right time," Otten said.

The behavioral health center formed a family advisory council that holds meetings with staff and psychiatrists on a regular basis to encourage a team approach. "Patient- and family-centeredness took on a life of its own, and now, we no longer have to talk daily about this," Lindquist said. "It has become part of the fabric of our organization."

The result of such tactics as selecting staff based on attitude, plus training, retreats, recognition and unit councils, is an exceptional, empowered staff. "Our staff love what they are doing and are highly motivated," said Matthew Stanley, D.O., medical director for Avera Behavioral Health Services. "They have ample educational opportunities and, of course, experience itself is a wonderful teacher. All these factors make our staff unequaled at other facilities in the Midwest and even across the nation."

With only a few exceptions, Avera McKennan's patient satisfaction scores for behavioral health have remained above the 90th percentile every month for the past six years.

"From day one of hospitalization, we make decisions based upon what is right for the patient and family. We believe that all the other priorities will follow, for example, our financial goals, quality of care and positive outcomes," Otten said.

Patients may come to be admitted by physician referral, or they may contact the Avera Behavioral Health Center through a 24-hour assessment, intake and call center, staffed by master's-degree-level counselors and social workers. In a region where behavioral health units specific to children's care are very rare, young children come from a wide geographical area of about 300 miles. Adolescents come from a 180-mile radius.

For both children and adolescents, the top reason for admission is always risk of harm — usually to themselves, but also to others, Stanley said. Another key reason is failure to improve in outpatient treatment for a diagnosis such as attention deficit disorder.

Child admissions often center on unmanageable behaviors. "Yet a concerning trend is the number of younger kids who have depression, and suicidal thoughts or actions," Lindquist said.

Problems such as gang activity and copycat suicide attempts or suicide pacts have resulted in admissions from nearby Native American reservations.

The most common reason for adolescent admission is depression with some serious attempt or thoughts of suicide. "We occasionally see adolescents in the beginning of a chronic mental illness, such as bipolar disorder or schizophrenia," Lindquist said. Another alarming reason for adolescent admissions is drug use and its effects, particularly "designer" or homemade drugs involving hallucinogens. "It's difficult to determine how a child will react," said Otten. "A child can use a drug one time, and it results in a psychotic episode."

About half of children and adolescents are covered by their parents' health insurance, and most of the rest are Medicaid patients. Based on Avera's mission of health ministry, no patient is turned away based on inability to pay.

The Avera Behavioral Health Center handles 8,000 assessment calls a year, as well as 5,000 face-to-face visits. The goal is to refer the patient and/or family to the appropriate level of care. "We refer a significant number of the calls we receive to other resources," Lindquist said. "We take a very patient-friendly approach of helping people find the right level of care."

The 14-bed child unit cares for children ages 5-12, and the 26-bed adolescent unit cares for youth ages 12-18. Average length of stay is approximately one week, although that varies with different patients and diagnoses.

Family involvement before, during and after hospitalization is considered to be essential. "We give parents a very clear picture, not only of what we have diagnosed, but also the plan of care during and following the hospitalization. We gain their feedback and provide an opportunity for them to ask questions," Stanley said.

A comprehensive evaluation includes psychological and behavioral testing, a chemical dependency evaluation and more. "Parents know that we are taking a very comprehensive look at what's going on with their child," Stanley said.

Along with evidence-based service excellence principles, psychiatrists and staff stress evidence-based behavioral health approaches.

Behavior modification is foundational to the child program. "This is based on a positive rewards system," Stanley said. "We catch them being good, and ignore as much negative behavior as we can," Otten added. For example, if one child is under the table throwing a temper tantrum, caregivers award those children who are on task with a token that is good for additional recess or computer time. "Pretty soon, that child realizes his [tantrum] is not having its desired effect," Otten added.

The cornerstone of adolescent care is cognitive behavior therapy. "We teach them how to think differently. Are their behaviors serving them well? They learn that it is not the events that happen to them that cause their anxiety or depression — it's their beliefs about those events," Otten said. "The child's peer group is important, so we do a lot of group processing," Stanley said.

Depending on their individual needs, patients in the units will participate in recreation therapy, art and music therapy and therapy groups. "Our daily schedule is very busy. A child admitted to our program is doing anything but sitting and staring at the four walls," Stanley said. "It is a very active and involved program."

So the children don't fall behind, on-staff educators contact school personnel to discuss class work, and they spend a couple of hours each day working one-on-one with each patient on school assignments.

The "Arts in Healing" program is a favorite among patients and staff alike. "The arts in healing goes back to Biblical times, when King Saul asked David to play the harp for him, and it calmed him," Otten said. "Any art expression can be very powerful for kids."

Puppet shows and drama involving the children are fun and have a powerful impact. Staff created a "stage" with a wall painted as a curtain background in the adolescent/child area for performances. Also, Christian performers in town for concerts sponsored by the national LifeLight organization make frequent stops at the Avera Behavioral Health Center, as do national performers visiting the city.

Planning for hospital discharge begins as soon as a patient is admitted. "The social work staff immediately begin to identify resources that may be important for the patient and family," Otten said.  

During the stay, family meetings are held to work with the family as an entire unit to better understand the concerns and determine how to move forward as a family.  "Just prior to discharge, we have the final family meeting where we work with parents to let them know what things we have found successful while at the hospital and then make recommendations to both the family and school on ways to help the child be successful," Otten said.

Post-discharge resources always include follow-up with mental health professionals such as a psychiatrist, psychologist or counselor for individual or family counseling. Follow-up may also be recommended with a family practitioner if a physical issue needs to be addressed. "Our goal is that each patient have a follow-up appointment within a week," Otten said. In rural areas where mental health resources are not as plentiful, telemedicine visits are an option through Avera's eConsult service.

The post-discharge plan may include other services including NAMI (National Alliance on Mental Illness) Family-to-Family training, social service resources or a wide range of other family supports. 

"Treatment doesn't end when patients leave the hospital; nor is the problem completely resolved," Stanley said. "It's an ongoing plan."

In addition to medical and behavioral health specialists, parents play a key role. "No one would argue that environment is so impactful for a child," Stanley said. This does not assess blame for the child's condition, because children from very positive home environments have been known to develop behavioral health problems. "Yet environment is part of the solution. While peer group is important, parents are still the most powerful force in their children's lives," Stanley said.

DONNA FARRIS is writer/editor for Avera McKennan Hospital & University Health Center, Sioux Falls, S.D.


Although Avera Behavioral Health Center's leaders discovered that successful behavioral health care is "not about the building," the state-of-the-art, 110-bed facility completed in April 2006, has numerous benefits.

"We truly created this as a world-class facility," said Thomas Otten, director of behavioral health inpatient services at Avera McKennan Hospital & University Health Center in Sioux Falls, S.D. "It has a high-end feel that treats patients as if behavioral health is a very important health care delivery piece."

Steve Lindquist, assistant vice president for behavioral health services, said, "We place a great emphasis on the body, mind and spirit, and our design reflects that with our use of space, light and colors." An indoor waterfall adds sound to visual cues and artwork promoting serenity, notably 27 pieces of commissioned artwork, all based in some way on Psalm 139: 9-10: "If I rise on the wings of the dawn, if I settle on the far side of the sea, even there your hand will guide me, your right hand will hold me fast."

All the artwork incorporates this theme in some way, through doves, kites or butterflies. "It's a message of hope to our patients," Otten said.

Mental health units have often been relegated to an out-of-the-way area of a hospital as an afterthought. "This organization made a very deliberate decision to say we're not going to approach behavioral health issues that way," Lindquist said. "These are medical conditions and we should be treating folks here the same way we are treating them for heart disease or cancer."

The patient environment is designed for peace and calmness, as well as privacy and confidentiality. Visitor hallways are separate from the main foyer, and inpatient areas are separated further by doors requiring a security badge for entrance. Even supply closets are restocked from the visitor hallway for as little disruption to patient areas as possible. Most rooms are private, accessed from pie-shaped common areas as opposed to long, narrow hallways. The gathering area of each unit is the central focus. Units can be full, yet still feel calm and relaxed as opposed to chaotic and noisy.

"That's very important to the recovery process," Lindquist said. While art cannot be hung on the walls of patient rooms for safety reasons, staff members have used calligraphy to paint uplifting sayings and words of encouragement, such as "Love one another," and "Jesus loves you."

The vast majority of patients are thrilled with the hospital's food service allowing them to order meals room-service style. For children, a kid-friendly menu features such choices as pizza, hamburgers and chicken strips.

Serving meals made to order "costs a little more to provide, but it eliminates waste," Otten said. "If a child doesn't like green beans, that portion of the meal will stay on the tray and be thrown away."


Copyright © 2013 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Patient Family Satisfaction Improve Outcomes

Copyright © 2013 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.