Skip to content

Creating a Patient-Centered Mentality Through No Pass Zones

The Problem:
The McLeod Health system recognized that the size and complexity of their facilities had led their goal of being a patient-centered culture adrift.

The Goal:
To improve HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) scores by implementing an institution-wide program that affects a culture change in their facilities.

Method & Implementation:
Jennifer Rautenberg, the hospital’s Service Excellence Process Manager, decided to implement a No Pass Zone policy that empowered everyone, regardless of their relationship to clinical work, to respond patient call lights and other requests for assistance to whoever they passed.

“The idea was not to chase numbers, but chase the culture,” explains Rautenberg. “We should change the way our staff perceives their roles here.” This meant educating ancillary departments, like environmental services, engineering, IT and dietary, how to enter a patient’s room and properly identify yourself while offering help. Central to the operating theory behind this work is that improving the patient’s experience involves quickly and effectively responding to their needs rather than sticking to prescribed, preordained job responsibilities. “We wanted to put an emphasis on the fact that patients and visitors were not an interruption to our work, they were the reason for our work,” Rautenberg points out.

The program works based on a set of key principles, including the obligation to never pass a patient or visitor by, and a requirement to either provide what the patient was looking for or access to someone who can. Rautenberg provided training to the entire staff on the proper procedure, particularly for non-clinical staff, so that patient safety remained paramount. She also developed a handy mnemonic device using N-O P-A-S-S to drive home the proper procedure and ensure that the principles of patient-centered care carried through with the new program.

Another component of the program was to install “Yakker Trakkers” at nurses’ stations—this is a device that lets groups of staff member know when their volume is increasing and when it’s gone past a certain decibel level, which ensures the level of quiet needed for healing.

Challenges & Barriers:
Because of the ambition of achieving true culture change, Rautenberg ran into some unexpected hurdles in implementing this new process. While non-clinical staff were often quite enthusiastic about their new roles, patients would often be uncertain about nonclinical staff answering their call alerts. And non-clinical staff was often put into a bind when the room communication boards, which provided the necessary information when looking for support, were often out-of-date. This led to some additional apprehensiveness if the ad-hoc caregiver appeared confused or uncertain.

Despite some adversity, this new program proved to be a great success at the combined hospitals of McLeod Loris and Seacoast. When examining their HCAHP measures pre- and post-No Pass Zone was stark. Here are the HCAHP scores from the last quarter of 2016, before the program, and then the third quarter of 2017 after training was completed: Nursing Communication went from 85.06% to 90.42%; Responsiveness, 68.84% to 79.04%; and Environment, 74.96% to 81.91%.

These results led to dramatic percentile bumps, including rising above the median for responsiveness and entering the top quartile of hospitals for nursing communication and environment.

For more information about this story or to tell us about your own best practices, email us at