Caritas Certification Program Impact on Human Services Leadership Donna Montana-Rhodes ECU East Carolina University Docotor Of Nursing Paractice Program Dr. Bradley Sherrod July 17, 2022 Notes from Author To Dr. Julie Oehlert, Dr. Bradley Sherrod, Dr. Kathleen Sitzman, and Dr. Jean Watson, thank you for your unwavering interest, support, guidance and participation in my project. Your support was essential to the success of this project. Your passion for improving the experience of caring for teams and patients has molded my professional and personal growth. Your innovation and wisdom in improving healthcare and nursing through all barriers and celebrations creates an enduring change and is a beacon of light to all. To Johnnie Edwards my incomparable assistant, Kevin Hill for data expertise, Julio Maldonado, Jack Smith, Troy Sheppard, Ashley Demers, Amy Weber and Pete Puodziunas and the ES and FS teams your leadership, assistance, support, participation and implementation made it possible to reach this goal. To Dr. Christina Bowen, Dr. Amy Campbell, Lou Reida, MSN RN, and Dr Charlene Wilson these last two years have presented many challenges and your encouragement, prayers and support through all the trials and joy have made the difference many days. A very special thanks to my family (mere words are not enough): the love, support, sacrifices and absolute unwavering belief in this journey was the critical component of success. You all taught me to have and keep faith in God and His plan and to believe wholeheartedly this was a journey of discovery of my faith and my abilities to make a positive change in a career I love. I am proud to belong with such an incomparable group of individuals and hope I have made you proud. Abstract Health care organizations have a hidden treasure within their acute care settings that can expand the ability to improve the experiences of care by achieving improved team engagement of the second-largest workforce. On average, there is 10 minutes per patient per day that our Environmental (ES) and Food Service (FS) teams spend interacting with our patients and families. Applying Watson's Human Caring Theory and Caritas processes (Watson,2009) beginning at leadership levels in ES increased team engagement and improved patient experience. This hidden team benefited from understanding of caring in a professional framework and integration as a valued member of the care team as a partner in humanizing the care we offer. Addition of Watson Caritas Human Caring questions to the organizations’ team engagement and patient experience surveys provided data that demonstrated increased Caritas Processes adoption on self-rating scores and Caring leadership behaviors in four of five measures and improved team engagement in four of the five Watson Caritas Human Caring questions Keywords: Watson Human Caring, Watson Caritas Human Caring questions, team engagement, patient experience, Human Services teams, environmental services, food services Table of Contents Notes from the Author…………………………………………………………………………... 2 Abstract………………………………………………………………………………………….............. 3 Caritas Certification Program Impact on Human Services Leadership 7 Section I. Introduction 7 Background 7 Organizational Needs Statement 8 Problem Statement 13 Purpose Statement 13 Section II. Evidence & Literature Review 13 Methodology 13 Current State of Knowledge 15 ES & FS Impacts Related to Patient Experience 15 ES & FS Leadership Impacts 16 Current Approaches to Solving Population Problem 16 Customer Service & Hospitality Industry Influences 16 Impact on Team Engagement 18 Applicability of WHC to ES and FS 18 Evidence to Support the Intervention 19 National & International Support 19 WHC Application Beyond Nursing 20 Evidence-based Practice Framework 21 Theoretical Framework 21 Operational Framework 23 Ethical Consideration & Protection of Human Subjects 24 Section III. Project Design 25 Project Site and Population 25 Description of the Setting 26 Description of the Population 26 Project Team 27 Project Goals & Outcomes Measures 27 Description of the Methods and Measurements 27 Discussion of Data Collection Process 29 Implementation Plan 30 Timeline 32 Section IV. Results and Findings 32 Results 32 Findings 38 Section V. Interpretation and Implications 41 Section VI. Conclusion 48 References 53 Appendix A 62 Appendix B 63 Appendix C 71 Appendix D 72 Appendix E 73 Appendix F 74 Appendix G 75 Appendix H 76 Appendix I 77 Caritas Certification Program Impact on Human Services Leadership Patient experience and team engagement are claiming foundational positions in organizational strategic planning. Innovation in how nursing theory, processes, and leadership can influence the patient's experience is paramount to the success of any organization. Exploring non-traditional areas such as environmental services (ES) and food services (FS) impact on patient experience and the intersection with nursing theory to create and promote a caring environment was explored within the framework of Watson's Human Caring (WHC) Theory and Caritas Processes©. Section I. Introduction Background Improving patient experiences will not be accomplished without simultaneously creating exceptional care experiences and enhancing team engagement (Hofler & Kennedy Oehlert, 2020). Patient experience impacts the healthcare organizations' ability to receive maximal reimbursement in value-based purchasing, retain brand loyalty, hold market share, and support a positive culture. There are groups of team members, often unrecognized, that spend significant time with patients and families that have the opportunity to contribute to improved patient experience and team engagement. Those team members who spend their day disinfecting, sanitizing the patient care area, and assisting patients in ordering and delivering prescribed diets often are not recognized as being part of the patient care team. In the acute care inpatient setting, these non-clinical tasks can support healing and influence the patient experience (Mack et al., 2003; J. Watson, personal communication, April,2,2021). This vital population of team members spends 10 to 15 minutes every day with patients and families performing vital services (Ashton & Manthorpe, 2017). This time spent in direct contact with patients and families performing essential services allows for the opportunity to form therapeutic relationships with patients and families (Ashton & Manthorpe, 2017; Jors et al., 2016; Mack et al., 2003). A study in 2009 confirmed, "those health professionals who work in hospitals believe that clinical support services significantly impact satisfaction with the majority of segments studied ranging from 60% to 96% strongly agreeing support services have a big impact on clinical care" (Stanowski, 2009, p.58). Innovation, design thinking, and willingness to embrace disruptive change are imperatives in nursing leadership. Translating these behaviors into daily operations to deliver excellence in the experience offered to our teams, patients and families are required to meet the expectations of the quadruple aim where successful relationship development between those who seek care and receive bare must be beneficial to both (Bodenheimer & Sinsky, 2014, Jeffs, 2018). Creating high levels of team engagement by facilitating the integration of nursing caring theory components in environmental services and food services teams provides the opportunity to enhance authentic, caring, empathetic connections with patients. Organizational Needs Statement The identified organization is a non-profit rural 974- bed academic medical center with a mission "to improve the health and well-being of eastern North Carolina" through applying the values of integrity, education, safety, compassion, accountability, and teamwork (Health, n.d.). The organizational strategy is anchored in three imperatives: experience, quality, and finance. The organization places experience as a top priority. The Office of Experience (OX) sets strategic direction, goals, and philosophy for patient, family, and team experience, using Cultural Transformation Theory (CTT) and High-Reliability principles (Weick & Sutcliffe, 2001, Oehlert, 2021). Team engagement is recognized by the identified organization as a foundational metric by which other organizational outcomes are actualized, specifically but not limited to patient experience (Health Experience Committee, 2021). Currently, patient experience outcomes do not meet the desired performance for reimbursement under the Centers for Medicare and Medicaid Services (CMS) value-based purchasing (VBP) as measured by the Hospital Consumer Assessment of Healthcare Providers Survey (HCAHPS). As of April 30, 2021, the academic medical center inpatient overall rating percentile rank was rated in 35th percentile in the all-hospital database as measured by the Press Ganey company. The overall top box score for the overall rating (rated nine or ten by the patient) was 69.1 %, with a 2.9% gap in reaching achievement goals (Office of Experience, personal communication, April 30, 2021). In assessing HCAHPS composites that impact the overall rating, an opportunity was identified in cleanliness and quality of food experiences. For the fiscal year to date (FY/ FYTD), June 30, 2021, cleanliness had a percentile rank of 13% and an overall top box of 65.1%, with a 3.8% gap to the achievement goal. Quality of food for the FYTD as of June 30, 2021, had a percentile rank of 7% and an overall top box of 26.3%, with a gap to the achievement goal of 3% (Office of Experience, personal communication, June 30, 2021). Watson Caritas Human Caring (WCHC) questions were added to the organization's patient experience surveys in the FY 2020 and are reported monthly for the FY 2021(Brewer & Watson, 2015; Wei et al., 2020). Currently, the inpatient measures for these questions are underperforming from baseline inpatient reported levels achieved in the FY 2020 by three to five percent on each of the five questions. (Office of Experience, personal communication, April 30, 2021) The organizational definition of experience is stated as "how we experience each other is how our patients and families experience us and is called the Big E" (Hofler & Kennedy Oehlert, 2020, p. 41). In deliberate planning, three of the five WCHC questions were added to the team engagement survey for the calendar year to compare patient experience results to team engagement (Oehlert, 2021). Table 1 provides the WCHC caring questions added to the team engagement survey. The team engagement and culture of safety survey was rendered from June 6 to July 5, 2021. The final response rate by ES at 79% and FS at 82% for a total of 718 respondents out of 888 while providing rich discovery of engagement and experience correlations. (Human Resources (HR), personal communication, July 7, 2021). The national benchmark for response rates for health care is stated as 75% with the Press Ganey Company (Press Ganey Meeting, personal communication, June 29, 2021) Table 1 Team Engagement and Culture of Safety Survey Embedded WCHC Questions · The hospital / entity creates a helpful and trusting relationship. · My faith and personal beliefs are valued by this hospital /entity. · This hospital/entity promotes a caring environment. Note. Questions listed above are the WCHC embedded in the 2021 team member engagement survey and patient experience surveys administered by Press Ganey. (Health Experience Committee, 2021) Literature reviewed shows the ES team members describe their daily work as having a positive impact on patients' experience in technical cleaning and daily conversations with the patient and helps them provide better care (Jors et al., 2016; Shrestha & Abbott, 2018). Jors et al. (2016) revealed that when patients share about their illness, its effects on their personal life, and even about death, the ES team often feels unprepared to respond. Additional review revealed that ES and FS team members value patient contact (Jors et al., 2016). These professionals would benefit from a program focused on team engagement and a framework based on caring science to effectively manage their conversations and interactions to support the patient experience. The Institute for Healthcare Improvement (IHI) introduced the Triple Aim in 2008 to "improve population health, improve patient experience, and reduce the cost of healthcare" (Berwick et al., 2008, p.759). This ideal has permeated the healthcare industry. The quadruple aim revealed that a relationship develops between providers and those who seek care, and to be successful, it had to benefit both parties (Bodenheimer & Sinsky, 2014). The triple/quadruple aim has further developed the link with interprofessionality of healthcare teams providing an integrated approach to the experience of patients having their needs met which has been a focal point since the Institute of Medicine report To Err is Human (Bachynsky, 2019; Bodenheimer & Sinsky, 2014). The IHI further develops the concept that achieving exceptional experience requires leadership focus on hearts, minds, and respectful interprofessional partnerships (Balik et al., 2011). Encased in the process are components identified that ES and FS teams can integrate and support. Processes include comfort, cleanliness, safety in physical surroundings, relational components of empathy, emotional support, dignity and respect, human interaction and touch, nutritional and nurturing aspects of food, and spirituality as identifiable experiences for patients and families. Leaders at all levels view experience as core organizational work "from how care is provided to housekeeping, finance, parking services, and environmental design. Everyone is a caregiver" (Balik et al., 2011, p. 9). Clearly articulated is that the team must feel supported by leaders and engaged in demonstrating respect, empathy, and compassion. This translates into the quality of all interactions and recognition that everyone in the inpatient setting is a caregiver (Balik et al., 2011). The advent of the Hospital Value Based Purchasing (VBP) program through the Patient Protection and Affordable Care Act (ACA) has a rewards and risk payment framework. Value-based purchasing integrates experience domains from the CMS and HCAHPS surveys and through reporting is intended to improve the quality and experience of inpatients because they are attached to financial incentives. The domain of Person and Community engagement measures the expereince of care from the patient's perspective. The experience domain carries a 30% weight on the overall score (Kocakulah et al., 2019; Revere et al., 2021). The domains capture patients' perception ratings from HCAHPS on the areas of cleanliness and quietness of the hospital environment, the responsiveness of staff, and overall rating, which are areas the ES and FS teams’ impact daily. The organization's academic medical center remains 1.74 % below the threshold in responsiveness, above the achievement threshold by 0.39% in cleanliness, and above the achievement threshold for the overall rating by 3.20%. These ratings total a potential penalty impact (see Appendix A) of $455,200 for FY 2021(Office of Quality, personal communication, March 18, 2021). The CMS Star rankings influence consumer decisions on where to obtain patient care as they are publicly reported; patient experience has ten measures where cleanliness, the responsiveness of staff, and overall rating are below the national mean scores (Office of Quality and Office of Experience, personal communication, March 18, 2021). The Beryl Institute, the international leader in the patient experience movement, in its published annual state of patient experience survey results, found that team engagement was believed by 90% of respondents to affect the patient experience. In addition, 89% identified culture and leadership, and 64% identified environment and hospitality as critical influencers of patient experience outcomes (The Beryl Institute, 2021). When reporting on organizational priority items to achieve a top-rated patient experience, the focus was reported to be on having high team engagement and team development and training. Respondents show a 27% growth of ES and FS moving into the operational scope of the office of experience (The Beryl Institute, 2021). Problem Statement Improving staff engagement of the second-largest workforce supports achievement in strategic outcomes, including improving organizational inpatient experience. Applying Watson's Human Caring Theory, Caritas processes, and WCHC questions to all leadership levels in ES and FS will increase team engagement based on WCHC questions, improve overall inpatient experience based on WCHC questions and improve HCHAPS domains on cleanliness and quality of food, reducing the associated $88,600 penalty in the VBP projections. Purpose Statement This evidence-based project aims to improve team engagement and improve patient experience within ES and FS to align with national benchmark data. This project supports, empowers, and respects all team members involved in creating the environment of inpatient care and influencing organizational outcomes in team engagement. This project educates ES and FS leaders in using Watson's Theory of Caring and applying the 10 Caritas (heart-centered human to human practices) processes. This project was collaborative in design and implementation with Watson Caring Science Institute (WCSI). Section II. Evidence & Literature Review Methodology The application and impact of WHC theory on patient experience outside the nursing profession guided the research strategy to determine the role of ES and FS team members' influence on interactions with patients, the application of WHC on patient experience, and the application of the theory of caring outside the nursing profession. The overarching goal of the literature search was to identify the efficacy of applying WHC and Caritas processes for impact on both team and patient experience in ES and FS. Pub Med, Google Scholar, Cumulative Index to Nursing and Allied Health (CINHAL), and a general Joyner Library search were the databases utilized. References in articles, textbooks, and Jean Watson Curriculum Vitae were reviewed for additional resources. Search terms used included housekeeping impacts on patient care and experience, food service impacts on patient care and experience, WHC theory with the builders AND/ OR to join search terms of education and implementation further divided into nursing and other professions. The search identified 148 articles imported into RefWorks, and in total, 45 articles and three textbooks were used in the review. Criteria for inclusion were too narrow around ES and FS. The filter for years was removed to find substantial studies related to ES and FS impacts on patient care and their personal and professional experiences with patient interactions resulting in five qualitative studies conducted in the United Kingdom National Health system. Searches for WHC implementation and leadership impact on nursing and other professions required a more comprehensive range of years. The more exhaustive search revealed one article of the theory explicitly applied outside the nursing profession and several that spoke of how all teams in organizations that implemented WHC received some training with the main concentration on nursing. The literature search also revealed one systematic review of current intervention studies based on WHC between January 2005 to February 2018. Exclusion criteria were narrow due to the lack of substantive returns surrounding ES and FS teams. Out of the original 148 articles reviewed for the identified concepts, 38 articles were kept for inclusion. The 38 articles are included in an attached literature matrix (see Appendix B). Current State of Knowledge ES & FS Impacts Related to Patient Experience The studies associated with nursing scholarship that identified ES and FS interactions and impacts on patient experience were limited. Most of the studies conducted in the United Kingdom focused on the National Health Service (UK NHS) with no supporting theories to drive the research. In addition, there were no articles found discussing how training was provided to ES and FS or how the theory was implemented. Only one article identified the impact of FS team members on patient experience. Therefore, the majority of thematic learning concentrated on ES. The common themes surrounding the experience of ES teams working with patients included: daily work routine, communication and interactions with patients, experience and the burden of death and dying in context to their work, coping strategies and possibilities of support, witnessing patients suffer, and positive interactions and impacts. (Ashton & Manthorpe, 2017; Jors et al., 2016; Kaasalainen et al., 2017; Mack et al., 2003) All identified the absence of recognition of these teams and their potential impact on patient experience. Lack of recognition led to decreased team involvement and engagement. There was clear evidence that patients and ES teams communicate daily with an average of 10 minutes in each patient's room assigned to the ES team member (Jors et al., 2016; Kaasalainen et al., 2017). Qualitative research found that ES teams felt uncomfortable and ill-prepared to deal with death and dying, cancer, dementia, and managing general conversation though ES teams also reported: "loving patient contact'" (Ashton & Manthorpe, 2017, p. 1130; Mack et al., 2003). Themes surrounding valuing patient contact and impact on creating a clean and safe environment as supportive of patient care are documented. ES and FS teams saw their positive contribution to the patient's care (Ashton & Manthorpe, 2017). They recognized the need for training to demonstrate patience in communication with patients and attending to their well-being (Jors et al., 2016; Kaasalainen et al., 2017; Mack et al., 2003). Many conversations with patients ranged from the weather, illness, suffering, and personal life to death and dying (Ashton & Manthorpe, 2017; Jors et al., 2016; Kaasalainen et al., 2017; Mack et al., 2003; Shrestha & Abbott, 2018; Sorrell, 2010). ES & FS Leadership Impacts Leadership support of the ES team's experience with patients and families was identified as crucial. ES workers described their feelings of anger with leadership when there was a lack of insight into the impacts of interactions with patients and families. One participant is quoted in the literature stating, "I get angry with our bosses because they don't see the other side" (Ashton & Manthorpe, 2017, p. 1136). There is an identified need for their emotions to be recognized. The difficulty of losing a patient may be positively impacted when managers offer an opportunity to talk about the experience (Ashton & Manthorpe, 2017). Remarkably, feedback to ES teams was mainly considered absent unless corrective and clear delineation existed between what immediate supervisors understood versus the managers. ES and FS workers also indicate a lack of recognition of the impact their work has in connection to relationships with families and caregiver colleagues "Managers don't understand our contribution or how demanding it can be (participant 6 D)" (Ashton & Manthorpe, 2017, p. 1138). The synthesis indicates perceived distance in relationship and understanding from patient-facing teams and leadership. Current Approaches to Solving Population Problem Customer Service & Hospitality Industry Influences In the United States, ES and FS professional organizations are aware of the ability of these teams to have a significant impact on patient experience. The models' used focus on tactics and customer service versus hospitality and caring behaviors (Miller, 2016). The Association for the Health Care Environment (AHE) publications defines customer service as the "degree to which recipients of a service are satisfied with its level and quality" (Mattice, 2015, para. first). Professional blogs identify providing customer service as necessary for ES & FS leaders to implement and monitor key performance indicators. Tasks identified include scripting, escorting patients, reporting comments and concerns, performing professional duties such as greeting by name, asking permission to enter, and engaging in meaningful conversations. Leaders discussed building frameworks that create bonds and the "wow" experience (Merlino & Kutteh, 2017). The ES leadership identifies the patient as a guest, not someone who could have a caring relationship with the ES or FS team. Publications reviewed identify the ES or FS workers becoming more comfortable communicating as they develop a relationship with the patient. The need to integrate hospitality into the patient experience framework was noted (Barnes, 2019; Bujisic et al., 2018). The AHE partnered with the Department of Human Sciences College in the College of Education and Human Ecology (EHE) at Ohio State University to develop an undergraduate certificate program in health care, environmental, and hospitality services in 2017 (Bujisic et al., 2018). Research shows a need to overlap hospitality with current focuses on customer service and experience to increase HCAHPS results (Barnes, 2019; Bujisic et al., 2018). Identification of the need to demonstrate compassion for patients and create a genuine connection and positive memory is reported. Connections are accomplished through a customer service model without defining how caring is framed within a theory of caring for patients. In addition, studies found a need for high morale among the team and leader rounding, but do not describe a theory of creating interpersonal team relationships of caring or patient caring framework; it is still business based on hotel and customer service models (Barnes, 2019; Bujisic et al., 2018) Impact on Team Engagement Clinical support services such as ES and FS have a significant impact on team engagement and the patient's experience. A study revealed that 92% of the respondents of 700 health care professionals divided into five segments in random telephone interviews strongly agreed that support services have a significant impact on clinical care ranging from 96% to 35% agreement (Stanowski, 2009). ES and FS can significantly impact nursing perceptions when they perform duties as partners to return time to the nurse to perform other care functions, help avoid unnecessary delays, follow tasks through to completion, and communicate clearly if there are expected delays. One quote supports the impact of these teams and their leaders, "they are the backbone of what keeps things running smoothly- operating room nurse" (Stanowski, 2009, p. 59). This review connects the need to train ES and FS members on the concept of empathy, using "right words" and to be seen as an extension of providers' and nurses' bedside manner to connect and decrease patient anxiety (Stanowski, 2009). Applicability of WHC to ES and FS WHC has been an accepted theory to support caring focused primarily in the nursing profession. As the theory has evolved, caring has been identified as a critical concept in nursing and healthcare as a whole and is transcending nursing. The perceived lack of human caring in health systems has allowed nursing's ontological and praxis focus on caring to acquire relevance to other human service teams in adopting the caring science model across all disciplines involved in acute healthcare settings, including housekeeping. Human caring is now seen as an essential resource to reimagine artificial "hospitality" environments into authentic environments of healing that can be measured in patient experience surveys (Clarke et al., 2009; Watson, 2006; 2009). Evidence to Support the Intervention National & International Support As identified by the IHI in 2011, exemplar organizations view everyone as caregivers and identify that patient-centered care cannot be mandated. Everyone must feel supported to genuinely feel empathy, show compassion, and foster care teams that communicate with one another and convey transpersonal caring moments to patients. Supportive team environments create healing and have relationships based on mutual respect. Compassionate communicators and teamwork are essential. From the executive level to supervisors on the units, leaders must share the commitment and apply it to all supporting roles. To achieve this, everyone should identify as a caregiver (Balik et al., 2011). The triple aim evolved into the quadruple aim and identifies the challenges of a national complex healthcare labor environment and the need for have high value, improvement in population health, and patient experience. Staff well-being must be attended to in order to achieve any of the three previous three (Berwick et al., 2008; Grant et al., 2020). Watson's (2008) first Caritas process, "practicing loving-kindness and equanimity within the context of caring consciousness" (p. xvii, 47), highlights this call to action with a focus on demonstrating respect for self and others, listening, treating each other with kindness, honoring human dignity, and being open to connectedness (Sitzman & Watson, 2018). The Beryl Institute (2021) identified that focusing on the human, community, and workforce experience brings healthcare to the heart of the patient experience. Interactions, culture, and perceptions influence patient experience. It is people caring for people, and the health care business is seeing the need to continue its experiences efforts, with 66% of organizations surveyed having a formal mandate for patient experience. It also notes a widening recognition that ES and FS are part of the experience structure (The Beryl Institute, 2021). WHC Application Beyond Nursing WHC application of Caritas processes has been utilized in areas such as law enforcement to reduce conflict in inter-professional relationships. The application of WHC allowed probation officers' interactions with probationers to support an ethic of caring, understanding, and a commitment to human dignity, allowing equanimity to surface for the parole officers in their interactions with parolees (Giovannoni et al., 2015). The utilization of WHC theory did not preclude the ability to hold individuals responsible for their actions. The focus on the first of the ten-Caritas process; practicing loving-kindness and equanimity within a context of caring consciousness, was found to reduce the stress levels of the probation officers, allowing them to have increased authentic presence and improve their positive regard towards their clients and parolees (Giovannoni et al., 2015; Sitzman & Watson, 2018, Chapter 5). WHC has also been used in interdisciplinary learning for nursing and social work students. This interprofessional education (IPE) model an identified framework when two or more professions learn from each other to improve collaborative relationships and positively impact the quality of care. The Institute of Medicine (IOM, 2001), seminal publication Quality of Health Care in America: Crossing the Quality Chasm, identified the need for professionals in health care to share expertise and perspectives with a common goal of improving patient outcomes and sharing resources. The World Health Organization (WHO) identifies IPE benefits that shift how healthcare workers interact with one another, improving the working experience of all staff and benefitting the patient and community as a whole (Burton et al., 2010). Watson identifies caring as a human science that embraces interdisciplinary collaboration, allowing for a framework to understand caring and identify intentions' impact in transpersonal caring moments. Social work and nursing students learned in cross-disciplinary exchanges how their unique professional values and beliefs impacted decision making and the meaning of the experiences of older people and their families (Chan et al., 2009). Evidence-based Practice Framework Theoretical Framework WHC is descriptive, ever-evolving qualitative, naturalistic, and phenomenological research versus the traditional scientific methodologies. A mixed-method of qualitative-quantitative review is expected to deliver rich results. Watson's work has been labeled a conceptual model, a framework, a theory, a philosophy, an ethic, and a paradigm (Alligood & Tomey, 2006, Chapter 6; Tomey & Alligood, 2006, Chapter 7). The core concepts of the theory encompass relational caring for self and others, transpersonal caring relationships, caring occasions/moments, multiple ways of knowing, reflective/ meditative approaches, caring as inclusive, circular, and expansive, and caring as a catalyst for changing self, others, and the culture of groups or environments (Sitzman & Watson, 2018, Chapter 2; Watson, 2008). The application of Caritas Processes© supports the core concepts of humanistic values such as kindness, empathy, concern, and love that are consciously and intentionally chosen when interacting with patients (Drenkard, 2008). The Caritas Processes© encompass a universal language, allowing clear communication of human caring (Sitzman & Watson, 2018). In WHC, the patient is a valued partner with the entire health care team to optimize well-being physically, emotionally, and spiritually. Watson labels the mind, body, spirit connection by creating an intentional environment within the interactions with patients (Cara, 2003). It is not necessary to have the team recite or memorize the Caritas Processes©; however, understanding the core principles of the theory woven into the work of the processes helps internalize understanding. For example, the first Caritas Process©, loving-kindness, makes connections between core task such as sanitizing room, ordering meals, assisting with room set up, or meal setup with meaningful connection and conversations that is empathetic and compassionate. This transforms the tone of daily interactions into transpersonal caring moments where two individuals interact, and each is positively affected (Norman et al., 2016). In the framework of a transpersonal caring encounter, both caregiver and receiver have a deep, authentic connection where both have a positive effect when processing words and feelings (Dudkiewicz, 2014; Norman et al., 2016). In applying Watson's theory and Caritas Processes©, the focus is not only on the tasks to be completed for and with the patients, but intentionally creating a healing and caring environment (Norman et al., 2016). Team members such as ES and FS may not fully grasp their impact on a patient or family's overall discernment of being cared for. Every interaction by these team members contributes to the patients' experience with care. Literature supports the implementation of a caring based model that improves team member engagement and recognition of the vital importance of their role in overall care, which meets the experience definition of how we experience each other is how our patients experience us (Dudkiewicz, 2014; Hofler & Kennedy Oehlert, 2020; Norman et al., 2016; Stanowski, 2009). Using Watson's theoretical framework that focuses on transpersonal caring moments, Caritas Process©, and the caring moment among the team, including leadership and the patient, provides the necessary concepts to drive improvement in team engagement, meaning in work, leadership relationships, and patient experience (Brewer & Watson, 2015; Bujisic et al., 2018; Drenkard, 2008; Dudkiewicz, 2014; Wei & Watson, 2019). The expansive model of caring science and philosophy serves as a philosophical and ethical guide for all that provide healthcare (Brewer & Watson, 2015; Dudkiewicz, 2014; Wei & Watson, 2019). The improvement in caring science awareness and application also improves the domain of quality and finance as both are measured objectively and subject to the qualitative experience of the patient and family (Berwick et al., 2008; Drenkard, 2008; Grant et al., 2020). Human caring and the response of all team members across all departmental boundaries that interact with the patient and family are influential attributes of the patient experience. Operational Framework To operationalize WHC using CTT and incorporating human-centered design complements the premise of Watson's concepts of transpersonal caring relationships and Caritas processes. CTT describes and defines relationships on a continuum from domination and “power over” to partnership and "power with". In this continuum, the goal is to reach a cultural objective where relationships are trust-based, equalitarian, and designed to be flexible hierarchies of actualization, with mentorship being a cornerstone of success (Eisler, 2013; Eisler & Potter, 2014; Hofler & Kennedy Oehlert, 2020; Kennedy Oehlert, 2015). These operational frameworks complement Watson's theory in transpersonal caring among the team and leadership and patients and families. Utilizing design thinking allows for an empathetic lens for the team to ensure that the education and enculturation of Watson Caring Science and Caritas processes create an emotional connection to the participants' transpersonal relationships and the strategy of the Caritas processes. Design thinking is a framework for complex problem-solving. The framework allows for continuous innovation cycles of trials and incorporates the following steps: empathize, define, ideate, build, and beta test. In the first step, which is empathy, the goal is to understand the audience that is being designed for, and this step is commonly called empathizing with and for the end-user (Altman et al., 2018; Hofler & Kennedy Oehlert, 2020; McLaughlin et al., 2019; Razzouk & Shute, 2012). The second step of design thinking is defining, a process by which an organization agrees on the definition of the lexicon used in the design thinking process (Altman et al., 2018; McLaughlin et al., 2019; Razzouk & Shute, 2012). Ideation is the step where idea brainstorming is done with the team to identify as many creative solutions as possible (Altman et al., 2018; McLaughlin et al., 2019; Razzouk & Shute, 2012). The build step is experimentation with potential solutions to manipulate and find gaps in design (Altman et al., 2018; Hofler & Kennedy Oehlert, 2020; McLaughlin et al., 2019; Razzouk & Shute, 2012). The beta test includes sharing the prototype with target users obtaining feedback, and allowing for modifications to be based on what the audience provided for feedback during the empathy step. (Altman et al., 2018; Bazzano et al., 2017; Hofler & Kennedy Oehlert, 2020; McLaughlin et al., 2019; Razzouk & Shute, 2012) (see Appendix D). Design thinking allows for the needs of the team and leaders to have bidirectional movement and iterative exploration, and continual refinement for increased understanding and application of Watson's core concepts and application of Caritas processes. Design thinking process creates open-mindedness, suspension of judgment, and a call to action valuing the diversity of the team and valued collaboration supporting creating transpersonal caring relationships even as improvement cycles are designed and implemented (Altman et al., 2018; McLaughlin et al., 2019; Razzouk & Shute, 2012). Ethical Consideration & Protection of Human Subjects Preparation for the formal approval process included completing the Collaborative Institutional Training Initiative (CITI), which includes social, behavioral, and educational sciences. In preparation for the Internal Review Board (IRB) with the project facility, the facility's approved project assessment tool was completed outlining the project's development, implementation, and evaluation. The project site's formal IRB was relied upon and shared with the university with the designation of a Quality Improvement Project (QI). The IRB review was submitted to the established department for Nursing Research and Grants at the organizational site on November 1, 2021. Approval was granted through this body on November 3, 2021, and shared with the educational institution. The approval letter was received on November 3, 2021, via digital media and is in the supporting documents (see Appendix E). All leaders from ES and FS that participated in this learning and application of WHC concepts are part of a larger design implemented for all ES and FS team members in a predetermined sequence. For this project, the concentration of education and application centered on leadership and their participation in education was designed from a massive online open course designed by WCSI and expert in WHC theory and Caritas Processes© delivered in facilitated remote and in-person learning. One additional option of self-guided experiential learning utilizing prerecorded videos of each Caritas Process© by Dr. Jean Watson and accessed through the WCSI completed the educational process. At completion, the leaders were awarded WCSI Caritas Service Partner designations. The cohort of leaders was determined by the professional job role spanning from supervisor to general manager. Participation was equitable to all leaders in ES and FS. There was no potential for harm to any participant and no conflict of interest. The identified learning outcomes designed in partnership with WCSI are noted in the appendix (see Appendix F). Section III. Project Design Project Site and Population The project was completed at a non-profit rural 974-bed academic medical center. The evaluated population included all ES and FS leadership with the title of a supervisor up to the general manager with direct leadership of teams that interact with patients daily. Barriers to implementation of the QI project included technology related to virtual education, the IRB process, limitations imposed by COVID-19 gathering restrictions, the educational level of the participating leaders, and time constraints. Facilitators included using medical centers' framework of design thinking to improve delivery and connection of educational material, the WCSI preconstructed educational offerings, and accessibility and flexibility of local WHC theory and Caritas expert to partner in facilitating educational offerings and support of internal data analytics team. Description of the Setting The setting for implementation was a non-profit rural 974-bed academic medical center with a mission "to improve the health and well-being of eastern North Carolina" through applying the values of integrity, education, safety, compassion, accountability, and teamwork (Health, n.d.). The organizational strategy is anchored in three imperatives: experience, quality, and finance. The organization places experience as a top strategic priority. The OX sets strategic direction, goals, and philosophy for patient, family, and team experience, using CTT and High-Reliability Frameworks (Oehlert, 2021). Description of the Population The number one driver noted by the organization to affect patient experience and team member engagement is found in the organizational definition of experience "how we experience each other is how our patients and families experience us” and is called the Big E (Hofler & Kennedy Oehlert, 2020, p. 41). The population audited included all ES and FS leaders with job positions of supervisor up to general managers responsible for leading teams that provide direct care at the inpatient patient's bedside. The population demographics included twenty (20) Females, twenty-one (21) Males, twenty-five (25) African Americans, fourteen (14) Caucasians, and two (2) Latino. Education levels ranged from General Educational Development (GED) to Master's degrees. The QI project evaluated the leaders understanding pre and post of WHC, Caritas Processes©, and the resulting impact on team engagement and WCHC collected on both the patient experience survey and team engagement survey administered by Press Ganey Company. Project Team The project team included two faculty members, a certified Caritas Coach and expert in WHC, a project leader (DNP student), a Site Champion, the Office of Experience data analytics team, the WCSI, and Dr. Jean Watson. The site Champion provided oversight of the development and implementation of the project. The project leader focused on developing and implementing the QI project based on current evidence and identified gaps leading to the innovation of applying WHC education and the Caritas process to those outside of nursing working in ES and FS, impacting direct inpatient care. Project Goals & Outcomes Measures Description of the Methods and Measurements An IRB review was completed prior to project implementation. The site had a formal IRB process and provided written confirmation to the university. After IRB approval, project implementation was initiated. Prior to intervention, baseline data were collected that included results of WCHC in both team engagement survey and IP patient results. Data was collected from HCAHPS composites regarding the cleanliness and quality of food composites as of June 30, 2021. The VBP projected potential penalty impact was assessed for FY 2021 (see Appendix A). The team engagement and culture of safety survey was rendered from June 6 to July 5, 2021. The final response rate by ES at 79% and FS at 82% for a total of 718 respondents out of 888 while providing rich discovery of engagement and experience correlations. (Health Human Resources (HR), personal communication, July 7, 2021). The national benchmark for response rates for health care is 75% with the Press Ganey Company (Press Ganey Meeting, personal communication, June 29, 2021). Measures for leadership included pre and post-Watson Caritas Leader Self Rating Score© (WCLSRS©)that inventories on a 7- point Likert scale from never, being one, to always, being seven, treating others with loving-kindness, modeling appropriate self-care, having helping and trusting relationships, creating a caring environment supporting others personal and professional growth, valuing personal beliefs and faith of others allowing for their success, and one open-ended qualitative data source of notable caring and uncaring moments experienced while working as a leader (see Appendix G). This data collection was deidentified per participant. Measurement for team members included pre and post-WCHC questions stating ‘this hospital/entity promotes a caring environment that helps me heal’ placed on the baseline team engagement survey in June of 2021 and pulsed survey for post data completed May 2022 based on scale and scope of questions administered by Press Ganey Company. This question was identified in baseline data as a high-performing key driver in analyses of organizational results by Press Ganey Company in the team engagement survey conducted in June 2021. (Office of Experience Board Committee report. Personal communication, 09/21/2021). Measurements for patients included pre baseline data of twelve weeks duration from December 2021 to February 2022 previous to the training of WCHC question ‘creating a caring environment that helps me heal’ for IP acute care patient experience surveys. Post data collection was for twelve weeks post-education for patients admitted to IP care March 2022 to May 2022.Post data collection utilized the same WCHC question ‘creating a caring environment that helps me heal.’ Measurements for patients also included baseline data of HCAHPS question regarding the cleanliness of the hospital environment that impacts the VBP penalty and post-intervention collection. Analyzing the VBP penalty results was performed by data analytics support based on the published formula from CMS (see Appendix A). The question on the IP patient experience surveys administered by Press Ganey Company for FS changed beginning October 2021 and limited the ability to complete post comparison. The FS question changed to; "how would you rate the courtesy of the person who served your food?" With an associated Likert scale of very poor, poor, good, and very good. Recording of de-identified post-education session discussions was collected for subsequent research post-completion of the project. These discussions were transcribed to guide the further advancement of new knowledge in this area. This project was a portion of multiple stages of advancing WHC within the organization's human services departments. Discussion of Data Collection Process Data was collected initially, i.e., baseline, to determine the WCLSRS©, team engagement score for WCHC question utilizing the three embedded questions as administered by Press Ganey team engagement survey from the ES and FS participants in the WHC and Caritas educational program. The participants were identified by the job title of supervisor to general manager and invited to participate by written, verbal, and posted educational information. Post-data collection included the WCLSRS© immediately post education and sixty days later. The same questions utilized from the pre-engagement survey from Press Ganey were collected sixty days post-education from the participants to compare increased recognition of leadership behaviors incorporating Caritas processes. Baseline IP patient experience surveys administered by Press Ganey company asking WCHC question ‘creates a caring environment that helps me heal’. Post-intervention data were collected from February 2022 to May 2022 to compare an increase in reported yes responses to questions by admitted inpatients to the organization. In addition, indicators were tracked pre-and post-intervention for specific HCAHPS questions surrounding cleanliness of hospital environment top box scores. The analytics team assessed the post-intervention scores in the OX for impact on VBP penalty explicitly related to the cleanliness question. Implementation Plan The implementation plan was designed to introduce human service personnel, specifically ES and FS leaders in the first phase, to WHC and Caritas Processes© as a foundation for their work over four weeks. Utilizing dynamic inquiry and exploration, the participants learned about WHC and Caritas practices transforming work-life by reflecting on the purpose, dignity, and actual value of their service to each other, patients, and the organization. The participants completed a specifically designed facilitated course based upon the operational framework of design thinking. This course was offered at two different times on January 25, 2022, to accommodate leaders on all shifts for attendance. A mixed digital, online, and in-classroom learning method was used for the one-and-a-half-hour sessions. The project leader, in preparation, received a one-hour planning session with the WHC and Caritas process expert. In partnership with an expert in WHC and Caritas processes, the project leader provided education through lectures, video demonstrations, and visual aids of Caritas processes. Design thinking and specific elements were woven into the course to support meditations and visual examples included in the learning. The design of the learning environment was set to reinforce principles of caring in Watson's theory specifically. Part of the design for each learner included an orange and bottle of water along with a keepsake stone engraved with the words "I choose" to reinforce the pebble in a pond model and core and trim model used to illustrate concepts of the Caritas processes. Each participant was also provided a badge buddy with a quote from Dr. Jean Watson on the caring moment and reminders to be authentically present. They also received touchstone cards with reminders on setting intentionality and consciousness for caring and healing and the ten Caritas process. This session included an introduction to WHC theory, transpersonal caring moments, and Caritas processes. The participants completed the pre- and post- WCLSRS© data collection tool prior to the educational offering, upon completion and 60 days post education (see Appendix G). Participants also completed pre and sixty-day post team engagement data collection. Participants' identification was redacted in the pre-and post-survey. The participants also completed a recorded reflective discussion with the project leader in post-education sessions capturing qualitative data surrounding notable caring and uncaring moments experienced while working as a leader focused on the Caritas process. Participants' identification was not included in the recorded data collected. The leadership team then completed a self-guided digital learning option with videos providing definitions with explanations of the application of each Caritas process narrated by Dr. Jean Watson. The Watson Caring Science institute provided access to the published videos. The videos were utilized over the next four weeks to complete the designed educational process and identify the participants as WCSI Caritas Partners. Each participant provided self-attestation of completion of the video series. The video series was also used in leadership huddles and meetings to review and apply each Caritas process in daily leadership activities. The learning outcomes were developed in partnership with the WCSI (see Appendix F). A celebratory event was designed and implemented for the participants that completed both phases, where they received certification as WCSI Caritas partners along with a designed pin to be worn on their badge identifying them as WCSI Caritas partners. Timeline The implementation phase of the educational section of the project occurred over four weeks with dedicated facilitation of the learning plan and classroom support, data collection, participant interviews, and collaboration with the WCSI Caritas coach on gaining certification for participants. Data collection and analysis began at the end of the first week of education. They were completed in June 2022 to capture patient experience results in the 45-day window post-discharge utilized by the Press Ganey Company. Team engagement results were collected pre, immediately, post, and sixty days post from engagement survey questions contained in the Press Ganey Team engagement survey. Continual application of the design model operational framework for the learning plan occurred after each session on January 25, 2022, assessing learners' needs and comprehension of WHC and Caritas processes and achievement of learning outcomes (see Appendix C, D, and F[BS3] ). Section IV. Results and Findings Results In current publications from The Beryl Institute related to consumer perspectives in the United States, the data presented highlights the critical importance for health care of a fundamental commitment to the human experience, with 94% of those consumers surveyed saying a good experience is very or extremely important (The Beryl Institute, 2021). The consumer expectation of being treated with respect, correlated good patient experiences contributing to healing and to good health care outcomes. Also being addressed as a person is ranked in the top 5 reasons (The Beryl Institute, 2021). Recognizing that all team members are involved in creating the caring healing environment of inpatient care and influencing organizational outcomes in team engagement, the purpose included improved team engagement for ES and FS leaders and improved patient experience within ES and FS to align with national HCAHPS and VBP benchmark data. Education was provided for leaders in ES and FS on using WHC theory and applying the 10 Caritas (heart-centered human to human practices) processes. This was the first step in the multi-layered adoption of a caring theoretical framework for ES and FS team members and was the focus of this project. Intervention A total of 32 leaders from ES and FS completed the initial education day, with 31 of participants completing data collection tools; session one had 23 participants, and session two had nine participants. In post-data collection, 30 participants completed data collection tools. The teams completed a pre-engagement and a 60-day post-survey, matched to the engagement survey administered by Press Ganey in 2021, focusing on the WCHC questions. Participants completed the Watson Caritas Leader Score© (WCLS©) measuring the overall consistency of human to human caring experienced while working with your leader for a primary single data point post-education to help inform one up leaders of the demonstration of Caritas behaviors as perceived from their leadership teams once knowledge was acquired. Additionally, participants completed the WCLSRS©, which measures the overall consistency of human-to-human caring for others experienced while working with others as a Caritas leader. The leader self-rating tool was administered pre-education and immediately post-education to capture the application of learnings to leadership practices and sixty days later to gauge the internalization of the Caritas leadership framework. The Leader Self-Rating Tool reliability has a Cronbach's alpha of 0.82. Engagement Scores The pre- and post-team engagement scores showed improvement in the three specific WCHC questions. Press Ganey designed the survey as a five-point Likert scale from strongly disagree to strongly agree. The first questions ‘hospital /entity creates helpful and trusting relationships’ for FS initially rated a 3.65 and improved to 3.86; for ES, this initially rated a 3.79 and improved to 4.00, showing strong movement from neutral to agree. ‘My faith and personal beliefs are valued by this hospital/entity’ for FS initially rated 3.65 and improved to 3.79, for ES initially rated 3.86 and improved to 4.00. The third WCHC ‘this hospital /entity promotes a caring environment’ for FS initially rated 3.71 and declined to 3.69, for ES initially rated 3.86 and improved to 4.06. Cartias Processes Internalization The WCLSRS© was collected pre-education, directly post-education (same day), and 60 days post-education to recognize and internalize the Caritas process and WHC theory. This survey is based on a 7-point Likert scale from never to always. The data was collected with only the indicator of FS or ES. The Office of Expereince analytics team completed the data calculations. The data for FS seen in Table 2 showed an increase in all five questions in immediate post data and only a sustained increase in two of the five questions at 60-day post data collection from pre-data levels. The immediate post data seen in Table 3 for ES showed a flat score in two of the five questions and slight decreases in the other three. However, at the 60- day post-data collection point, four of the five questions increased, and one remained flat at all three data points. Table 2 Watson Caritas Leader Self Rating Score-FS Watson Caritas Leader Self Rating Score Scale: Never/Always Pre education Total N=17 Post Education Total N =17 (Same day) Post Education Total N=14 (60 days) Treats others with loving kindness 6.35 6.53 6.15 Model appropriate self -caring as a means for meeting basic needs of self and others with dignity 6.18 6.35 5.93 Have helping and trusting realtionships with others 5.82 6.41 6.07 Create a caring environment that supports others personal and professional growth 6.41 6.41 6.23 Values the personal beliefs and faith of others, allowing expected and unexpected success in their roles 6.41 6.65 6.43 Note. Questions listed above are the Watson Caritas Leader Self Rating Scoring© on a 7-point Likert scale from never to always. This table contains averaged responses from food service leadership supervisor to client executive with an n=17 to identify consistency of human caring other have experienced while working with you (Watson & Brewer, 2011). Table 3 Watson Caritas Leader Self Rating Score- ES Watson Caritas Leader Self Rating Score Scale: Never/Always Pre Education N=14 Post Education N=14 (Same day) Post Education N=16 (60 days post) Treats others with loving kindness 6.50 6.29 6.63 Model appropriate self -caring as a means for meeting basic needs of self and others with dignity 6.36 6.36 6.31 Have helping and trusting realtionships with others 6.36 6.36 6.44 Create a caring environment that supports others personal and professional growth 6.64 6.36 6.50 Values the personal beliefs and faith of others, allowing expected and unexpected success in their roles 6.57 6.50 6.56 Note. Questions listed above are the Watson Caritas Leader Self Rating Scoring© on a 7-point Likert scale from never to always. This table contains averaged responses from environmental service leadership supervisor to client executive with an n=16. (Watson & Brewer, 2011). Patient Experience & VBP Impact Additional data points that correlate to increased leader integration of WHC theory and Caritas processes included pre and post HCAHPS data collected from baseline IP patient experience surveys administered by Press Ganey company asking the WCHC question this hospital /entity creates a caring environment that helps me heal. Post-intervention data were collected from February 2022 to May 2022 to compare an increase in top box responses to questions by admitted inpatients to the organization. In comparative period of December 2021 to February 2022 results for creating a caring environment to help mem heal was at 64.5% top box and post intervention was at 66.6% top box. While the whole of this increase cannot be completely attributed to this one intervention it mirrors the increase, we saw in the HCAHPS specific question for cleanliness rendered in the same surveys. A frequency analysis tracked additional indicators via Press Ganey database pre-and post-intervention for specific HCAHPS questions surrounding cleanliness of the hospital environment and the courtesy of the person who served your food top box scores. For the FS team, this data was a point of interest as the HCHAPS IP survey question was changed mid-way through the project, so pre and post data reflects on the changed question only. The question asked about the courtesy of the person who served your food on a five-point Likert scale ranging from very poor to very good. Post education, our FS teams saw a decrease in very poor and poor ratings, a two percent increase in good, and remained flat in very good. Our ES teams for the cleanliness of the hospital environment saw on a scale of never to always a 2.3 % decrease for never,1.2% increase for sometimes, 1.2% decrease in usually, and 2.2% increase in always. Overall, the HCAHPS question related to the cleanliness of the hospital environment for IP increased to a top box of 63.7% from base line data of 60.9% top box. The analytics team assessed the post-intervention scores in the Office of Experience for impact on VBP penalty explicitly related to the cleanliness question. Achievement threshold for Hospital cleanliness is 66% and at the end of the study period had risen to 63% from 59% with trends indicating continued increases. At completion of this project the organization was only 3% from achieving threshold to avoid penalty status. Expectation is that by the end of the FY there will be continued trends to achieve threshold. (See Appendix A) Findings Gaps were identified in the expected integration of WHC theory and the Caritas process for our FS teams. Based on the immediate post-data collection using the WCLSRS©, there were significant increases in four of the five data points, with as much as 0.20 increases in the averages. This trend was not sustained, and at the 60-day check-in, two of the five data points remained above pre-data values. The frequency analysis of the HCAHPS question related to the courtesy of the person serving your food also saw no improvement in very good ratings, 2% increase in good rating, and slight decreases in very poor and fair. This was coupled with lower pre- and post-team engagement scores than their ES colleagues. It indicated the potential of unengaged leadership and a lack of understanding of integrating the Caritas process. These results returned the team to our fundamental experience definition of how we experience each other is how our patients and families experience us. This also led to a renewed cycle of design thinking for the needs of this team. While higher in frequency with patient interactions they are not the same duration per interaction as our ES teams. There remain gaps in the literature for the FS teams in acute care hospitals, and it requires further study to understand the implications fully. The outcomes for ES followed the expected trends and evidence from the literature once the introduction and integration of WHC and Caritas processes began. Compassion must be treated as a collective responsibility with a well-defined framework throughout all roles (Balik et al., 2011; Bivins et al., 2017). The ten Caritas processes provide definitive actions undertaken by those providing a caring interaction with the patient (Morrow & Watson, 2021). It is not necessary to have the team recite the Caritas Processes©; however, understanding the core principles of the theory woven into the work of the processes helps internalize understanding. For example, the first Caritas Process©, loving-kindness, makes connections between core task such as sanitizing room, ordering meals, assisting with room set up, or meal setup with meaningful connection and conversations that is empathetic and compassionate. These tasks give the opportunity for two individuals to interact and each is positively affected creating a transpersonal caring moment (Norman et al., 2016). Themes surrounding valuing patient contact and impact on creating a clean and safe environment as supportive of patient care are documented. ES and FS teams saw their positive contribution to the patient's care (Ashton & Manthorpe, 2017). The teams recognized the need for training to demonstrate patience in communication with patients and attending to their well-being (Jors et al., 2016; Kaasalainen et al., 2017; Mack et al., 2003). The ES team had sustained improvement 60 days post data collection and had integrated the Caritas process into their action plans for team engagement and patient experience plans. They had integration of WHC theory and the Caritas process into their lexicon in team meetings and interactions. In addition, their one-time data collection for their one-up leader Watson Caritas Leader Score captured in Table 4 measures the overall consistency of human to human caring you experienced while working with your leader, top box scores averaged 0.10 to 0.23 points higher than their FS colleagues. The evidence stated feedback to ES teams was mainly considered absent unless corrective and clear delineation existed between what immediate supervisors understood versus the managers. Furthermore, ES and FS workers indicate a lack of recognition of the impact their work has in connection to relationships with families and caregiver colleagues "Managers don't understand our contribution or how demanding it can be (participant 6 D)" (Ashton & Manthorpe, 2017, p. 1138). The average results of this data point indicate top box performance for both ES and FS. Table 4 Watson Caritas Leader Score- One Up Leader Watson Caritas Leader Score – One up leader Scale: Never/ Always FS N=17 Top box of 6/7 ES N=14 Top box of 6/7 Treat others with loving kindness 6.18 6.29 Model appropriate self-caring as a means for meeting basic needs of self and others with dignity 6.06 6.29 Have helping and trusting realtionships with others 6.18 6.36 Create a caring environment that supports other’s personal and professional growth 6.12 6.29 Value the personal beliefs and faith of others, allowing for expected and unexpected successes in their roles 6.24 6.36 Note. Questions listed above are the Watson Caritas Leader Score© on a 7-point Likert scale from never to always. This table contains averaged responses from environmental service (ES) N = 14 and food service (FS) N =17 leadership supervisor to client executive of human to human caring experienced while working with your one up leader (Watson & Brewer, 2011). Section V. Interpretation and Implications Costs and Resource Management The major expenses for this project included affiliation agreements, honorariums, collateral/supplies for facilitated learnings, team recognition, and conference attendance fees to present findings. Supply expenses included all collateral needed to aid in facilitated learning and having touchstones of learning for each participant for reference in daily work. The affiliation agreement was the most significant expense. It was funded by the contracting company that provides ES and FS leadership for the health system. The ES and FS management company would directly benefit from improvement in engagement and experience scores that are incentivized portions of the contractual agreement. The honorarium dollars and conference dollars were acquired from dedicated contingency funds in the Office of Experience (OX) budget. All time components were considered normal work operations based on strategic goals at organizational and departmental levels. The development of the pilot program content and integration of the Caritas process into developed facilitated learning will make replication possible with the utilization of a free massive open online course (MOOC) that is taught twice a year, reducing the $5000 honorarium during the course of the project. However, contingent funds were identified in the OX budget going forward. The program's total cost was $15,850 (see Appendix I). The organization will continue to partner with the contractual leadership group to maintain WCSI affiliation reducing costs by another $10,000, leaving a total; sustainability cost of $600 that will be absorbed by the OX and the ES and FS service lines. COVID-19 surge of Omicron did hamper ease of rollout. Additional facilitated learning taught through OX resources allowed flexibility and decreased impact on normal or abnormal operational surges. Moreover, this also allowed more accessible access to late-night shift leadership and teams for saturation of culture change into WHC and Caritas processes. Reduction in turnover, which can be considered an indicator of engagement, ran as high as 30% and was reduced to 22% among these teams. The reasons for turnover are multifactorial. However, team engagement and leader connections captured on the WCHC team surveys was considered a leading factor for reduction of turnover Qualitative conversations with executive nursing leadership with the project manager indicated they had observed a distinct change in the engagement of the teams’ comfort with nurse and patient interactions. Increased use of appreciation portal notes, which is per to peer on line recognition program, surrounding the ES and FS teams from colleagues, including the Chief Medical Officer and Chief Well Being Officer of the project site, was identified. Future research exploring the development of stronger interprofessional partnerships has been considered. Dedicated ES teams were developed for the top ten inpatient impact units based on volume and experience ratings in HCAHPS data. Leaders whom completed the project and supported these team members as the first group of bedside teams to complete facilitated learning from WHC and Caritas processes resulted a positive trajectory for achieving threshold goals in experience and engagement by the end of the FY. These early findings will be the subject of additional research and publication beyond this project. The Chief Experience Officer (CXO) and President of the project site approved all expenses for the budget, and our contractual management group continued to support additional costs and integrated learning for the leadership teams. Implications of the Findings Positive feedback from the ES leadership teams has led to innovations in their leadership styles. ES leaders used reflective/inspirational Caritas quotes in meetings and developed engagement boards where team members practice loving kindness by pulling a quote and using it as a touchstone throughout the day. They are asked to share the quote with another team member throughout their shift or give it to a colleague, visitor, or patient. In open discussion after facilitated learnings, one team member shared the following, "I now have a name and framework for what I have been looking for to help improve how I care for my patients and team" (L. Montana Rhodes, personal communication/ unofficial transcripts, January 2022). One follow-up question was given to leaders after 60 days that asked would you recommend our hospital to someone you love. Total responding (n= 32) with a response rate of 97% (n =28) responding “yes” and the rest responding with “no” or “no answer”. The ES teams have sustained improvement in integrating the Caritas process, engagement, and experience. The ES teams have more extended periods of sustained interaction with patients. With the development of integrated teams on high-impact units,' the development of interprofessional partnerships and relationships with families has improved. The ES leaders are embedded with their teams, and rounding is part of the daily activity with the team and unit leadership. There are anticipated barriers for the FS team, this includes sustainability, changes in leadership and stability of the team. The FS teams will need to reenter the design framework. It is recognized that the FS teams have more touchpoints with the patient throughout the day but less time per touchpoint. The IP HCHAPS survey question surrounding diet was changed. Previously the question asked about the understanding of diet and now has moved to a relationship-focused question asking about the courtesy of the person serving the food. This change impacted planned data collection for the project. However, there was improvement from patient responses in pre- and post-data collected but not integrated into results for this project. Implications for Patients Based on information from the HCAHPS surveys, patient experience nationally has declined over the past two years of the COVID-19 pandemic. The likelihood of recommending the hospital saw a reduction of 4.5%, and the overall rating of hospitals on a zero to ten scale noted a 4% decline (Press Ganey Associates LLC., 2021). Watson's theory based on human interactions and the development of the WCHC questions as part of patient experience surveys allows for a quantitative collection of data on what is seen as subjective experiences. There is a connection between the Caritas processes and patient and team responses that evidence caring outcomes (Morrow & Watson, 2021). Research shows, practicing compassion requires a culture based on relationships supported by CTT and has norms of trust, concern, and empathy (Dutton et al., 2006; Hofler & Kennedy Oehlert, 2020). Caring must be treated as a collective responsibility with a well-defined framework throughout all roles (Balik et al., 2011; Bivins et al., 2017). The ten Caritas processes provided definitive actions undertaken by those providing a caring interaction with the patient (Morrow & Watson, 2021). Consumer expectations of being treated with respect, correlating good patient experiences as contributing to healing and good health care outcomes, and being addressed as a person are ranked in the top five reasons in consumer surveys (The Beryl Institute, 2021). The Beryl Institute (2021) found that consumer perspectives in the United States highlighted the critical importance of a fundamental commitment to the human experience, with 94% of those surveyed saying a good experience is very or extremely important. Improving the experience of patients and families by creating a team that is trained in human caring, expanded beyond traditional roles of nursing and providers, supports the call for the fundamental commitment to human experience expected by 94% of the surveyed consumers. Implications for Nursing Practice Inclusion of all team members in ES and FS that have direct contact with the patient and family consistently supported the reduction of the majority of the burden being placed on nursing and increased the interprofessional partnership that is the hallmark of power with culture. Caring and compassionate care are often seen as a cost-neutral easy fix with binding responsibility on nurses versus a collective responsibility, rooted in well-defined practice across the whole range of staff roles (Bivins et al., 2017). Stanowski (2009) confirmed, "those health professionals who work in hospitals believe that clinical support services significantly impact satisfaction with the majority of segments studied ranging from 60% to 96% strongly agreeing support services have a big impact on clinical care" (p.58). Impact for Healthcare System(s) A culture that supports caring as a core component of everyone's roles can positively drive change on key indicators around patient experience, team engagement, sustainability, or even market share growth. When patient comments and the patient's voices free of structured surveys are reviewed, the themes of fostering relationships that are warm, personal, and driven by empathy rise to the top (Cochrane et al., 2019). Value-based purchasing becomes a competitive edge in complex markets as there are restricted free or accessible resources leading to a concentration on reducing variation to acquire needed resources (Spaulding et al., 2018). In a recent study, the greater the disproportionate share of the hospital, the lower they tend to score in patient experience domains. Some markets cannot fully implement all the VBP domains because of restrictions related to the realities of their markets (Spaulding et al., 2018). There is also the scoring system itself. The whole score is significant, but also if reviewed annually could identify certain domains to strategize improvement, to achieve a measured increase in resource allocation (Spaulding et al., 2018). Recognition of the contributions of a typically unseen resource of ES and FS teams with a guiding theoretical caring framework can improve patient experience. This project provides new knowledge that a nursing caring theory can help improve VBP domains and improve overall patient experience and team engagement. Sustainability ES and FS teams desired to reduce discomfort in demonstrating caring and wanted to communicate with patients leading to positive interactions and impacts (Ashton & Manthorpe, 2017). Leadership development in WHC and Caritas processes removed identified barriers in the literature of leaders not recognizing the critical role of insight into the teams' interactions with patients and families (Ashton & Manthorpe, 2017). It also encouraged reward and recognition of the demand this placed on the team and reduced the distance in leadership's relationships with the team and each other regarding the caring contribution to the patient (Ashton & Manthorpe, 2017). Integration into onboarding and current offerings to drive the sustainable use of Caritas processes was created by highlighting the correlation in a Caritas process crosswalk to each of the facilitated learning the teams completed hospital level hearts and minds offerings such as Empathy, Hospitality, Brand Recognition, Brand You (your personal brand), heartfelt apology, restoring relationships and narrating care (see Appendix J). The Caritas process was integrated into competency-based orientation programs, team meetings, and evaluations. The system sets team share goals and is based on creating a caring environment and positive sentiments received from patients and families. The facilitated learning program will extend to all FS and ES team members and hospitals within the system. A visual impact and crosswalk design was developed by the project leader and shared with all leaders in ES and FS to help the integration of the Caritas process in all facilitated learnings (see Appendix J) and offered a focal point to help all team members as WHC theory and Caritas processes were disseminated throughout the systems ES and FS teams. Dissemination Plan Project dissemination occurred at all levels of the organization with board presentations and submission for board quality award recognition. It was shared at executive leadership meetings for the academic medical center with periodic updates and final results for leaders. It was also discussed in a one-to-one meeting with the academic medical center president and nursing leadership. This created continued support for the project and integration into strategic planning to improve patient experience and team engagement. The project was also disseminated to the contractual company that provides leadership for ES and FS within the organization with planned publication of the results in a shared white paper. Initial early results were shared in a poster presentation on local collaborative nurse research day. The project was submitted to the International Association of Human Caring and received podium presentation status. Additional dissemination included a presentation to the nursing college and submission for ECU scholarship publication. WCSI invited the project leader to present project work in general sessions and private collaborative meetings of WCSI affiliates with planned updates from continued research and posting on the WCSI webpage. This project demonstrated a substantial impact on engagement and experience. It was submitted for consideration to Press Ganey and the Beryl Institute for national conference topic selection in both poster and podium formats. Other sites that could benefit from the dissemination of the project include the Association for Healthcare Environment professional trade publication. Section VI. Conclusion Limitations and Facilitators Limitations for this project centered on ongoing COVID-19 surges causing a delay in identified start date. Initial education was rescheduled within 48 hours of start as in-person meeting safety concerns and hospital census took precedence. Rescheduling created IT limitations in redesigning a combination of in-room and virtual facilitation in a large enough space to accommodate all safety protocols for the in-person dependent portions. Rescheduling also impacted the number of participants able to participate as patient care demand increased, and leaders were redeployed to provide direct operational support for patient throughput. It was also a distraction as the surge, while decreasing, was still creating abnormally high census demands on the rescheduled date and stress on leaders to manage a high volume of team members placed out of work due to positive COVID screenings. Delay in collecting data on lagging indicators also affects the ability for a quick turnaround in data showing a positive impact on the organization. Facilitators included the project site champion and our educational center which redeployed technology and room usage to accommodate safety needs. The support of the WHC and Caritas coach and professor was an integral facilitator to the success of this project and the ability to adapt to the rapidly changing environment of the team. The data analytics team embedded in the project leader's service area allowed for seamless processing of raw data sources that would have been bulky and time-consuming to correlate, and allowed for richer support of reliable data with structural integrity to drive outcomes for the project. Other facilitators included our marketing and communications team, which completed a photo documentary of the initial facilitated educational day and the graduation of participants at the end of the project. The WCSI and Dr. Jean Watson were essential facilitators supporting the pilot program's design and co-development, providing additional resources for facilitated learning, and supporting recognition for the team as Watson Caring Science Caritas Partners. Recommendations for Others The project concept can be utilized for other acute care facilities with consistent ES and FS compliments. However, continued research of these programmatic elements in smaller rural hospitals would be beneficial for continuity in facilitating learning and integration design. There is limited research available that focuses on ES and FS impact on patient experience and team engagement in the literature requiring the generation of continued new knowledge. Applying WHC and Caritas processes outside of nursing is scarce in the literature, with only one documented study showing efficacy, and it was limited in scope to the first Caritas process. Organizational expectations of 30,60,90,120-day rapid cycle program development, implementation and recommendations, and connection with the timeline for the DNP course of study presented some challenges in this project. There was limited knowledge on the topic and development of the project in alignment with the university cycle causing some disconnect with the rapid cycle change framework used by leadership at the project location. The changing policy landscape of health care requires innovation with a quick turnaround of program impacts with a successful implementation that demonstrates sustainability (Skillman et al., 2018). There has to be a balance between project identification, analysis, and demands of rapid cycle evaluation. Using a mixed-method of qualitative and quantitative data is considered optimal for allowing a flexible process for data preparation (Skillman et al., 2018). There is some concern that relying on deductive analysis with quantitative data can set the stage for bias and hamper creativity (Skillman et al., 2018). The literature indicated that rapid-cycle feedback has the potential for decisions to be made based on early results without a complete understanding of the intervention and its impact, leading to integrity issues (Skillman et al., 2018). This can be mitigated by sharing what is known right now and the following steps to continue to have organizational support without diluting the design and outcomes of the study. Design thinking and a culture is defined by relationships identified as CTT and a "power with" with focus required us to un-silo the activities around patient experience and team engagement allowing for "Big E strategies" to unfold by designing internally using the health care team as the experts focusing through a lens of love to have the assurance that all educational offerings, theory, and process deployments have an emotional connection to relationships, culture, and strategy to ensure holistic design, support, and integration of the project by the organizations' teams (Hofler & Kennedy Oehlert, 2020). Strong partnership with content experts and original sources brings added validity and direction to developing a project that is generating new knowledge to fill gaps in the literature. Partnership and development of pilot programmatic components allowed the explicit connection between caring, loving, and humanity for the transformation of self and system with faculty associates that teach about the caring moment (Turkel, 2014). Recommendations Further Study The impact of WHC and Caritas processes needs further study and additional focused studies as this is new knowledge for the US. The literature review demonstrated most articles centered in the UK with no specific caring theory framework addressed towards human services teams. WHC and Caritas processes specifically applied outside of nursing were found in only one study with no relationship to health care. This study indicates a positive impact of applying the WHC and Caritas process to team engagement and patient experience focused through the lens of ES and FS leaders in an academic hospital setting. Further studies with translation science frameworks in rural hospitals, nursing homes, and other care facilities would generate a broader range of findings specific to human services impacts. This project will be applied in rural hospitals within the system that the academic medical center is part of as a continuation of research and solutions to improve patient experience and team engagement. Partnerships with companies that provide contractual management to ES and FS would benefit from supporting additional research. They are held accountable for key performance indicators in team engagement, patient experience, and VBP impacts in the experience domains. Final Thoughts The IHI in achieving exceptional experience requires leadership focused on hearts, minds, and respectful interprofessional partnerships with leaders viewing experience work as core organizational work that includes ES and FS and identifies everyone as a caregiver (Balik et al., 2011). Turkel (2014) specifically stated that we have an ethical responsibility to integrate caring and humanity into our dialogue as nurse leaders. With the IHI focus on everyone as a caregiver, this applies to all teams, not just nursing. Watson identifies connections among caring, love, and humanity as integral for transforming self, the healthcare system, and humanity at large (Watson, 2003). Being intentionally present is an expression of compassion that never leaves one unaffected, it is the human-to-human act of caring (Watson, 2003). ES teams specifically see value from their work impacting patient experience. ES and FS also make strong connections to leadership's understanding and perception of engagement and understanding of the value they bring to interactions with patients. What is not identified beyond customer service focus is a caring theory that provides a framework and processes to support their contributions to the caring culture. However, they have direct responsibility for HCHAPS domains and VBP impacts for organizations. This EBP was designed to improve team engagement and patient experience by utilizing WHC and the 10 Caritas processes (heart-centered human to human practices) for Human Services leaders in ES and FS in partnership with the WCSI, as evidenced by results in team engagement surveys, HCAHPS surveys and improved VBP outcomes. The results supported sustained applicability to ES teams and integration to established facilitated learnings with improvement in all data points identified, specifically, engagement and patient experience, and require further innovative design and research to support sustainable integration for FS teams. References Alligood, M. R., & Tomey, A. M. (2006). Nursing theory utilization and application (3rd ed.). Mosby Elsevier. Altman, M., Huang, T. T., & Breland, J. Y. (2018). Design thinking in health care. 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