Transcript Slide 1

Introduction to Improving the
Patient Experience
Part 1 – March 2, 2011
Jill Steinbruegge, MD
Diane Stewart, MBA
Agenda
Time
Topic
Presenter/Facilitator
12:00 – 12:05pm
Welcome and Introductions
Giovanna Giuliani
12:05 – 12:30pm
An evidence-based approach to
improving the patient experience
Jill Steinbruegge
12:30 – 12:40pm
Q&A
All
12:40 – 1:05pm
Changes to improve the patient
experience
Diane Stewart
1:05 – 1:25pm
Q&A
All
1:25 – 1:30pm
Wrap-up
Giovanna Giuliani
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PAS Five-year Trend
Steady Small Gains in Statewide Average Performance
+1.6 pts
+2.1 pts
+2.5 pts
Change in Cross-Sectional Mean Scores
+4.1 pts
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An Evidence-based Approach
to Improving the Patient
Experience
Jill Steinbruegge, MD
First, a definition
Patient =
Value
Health Outcome + How Care is Delivered
Price Paid
+
Non-monetary Costs
The Patient Experience
How care is delivered = interaction with patients and their families
Price paid
= out-of-pocket costs to patient (premium and co-pays)
Non-monetary costs = impediments to obtaining care (e.g., delays, waits, hassles)
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Business Case for
Improving Service
• Research in service in other industries shows
– 40% of customers who switch to a competitor cite poor service as
the reason
– Increasing customer retention by only 5% produces a 30%-80%
increase in profitability in other industries
– Customers judge quality based on their experiences
– Value is always determined from the customer’s perspective
• KP found the same is true in health care
– Member retention reduces cost
– Improved access reduces cost
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Measuring Improvement in
the Patient Experience
• Moving CAHPS (health plan) scores
– CAHPS and PAS (physician group) scores
– Timing of improvements
• CAHPS and geography
– East vs West
– North vs South
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Key Drivers of the Patient
Experience
• Satisfaction with physician
• Ability to see primary care physician
• Access
– Appointment – days wait for an appointment
– Telephone – time on phone to schedule appointment
• Ease of seeing a specialist
• Helpful staff
Effects of key drivers on overall
measures of satisfaction are cumulative
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Satisfaction with Physician
• The physician-patient relationship is at the
heart of the patient experience
– All MD questions are highly correlated
• Satisfaction with PCP affects
– Health outcomes
– Satisfaction with specialist
• Improving satisfaction with physician
– Physician communication training
– Incentives tied to MD scores
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Satisfaction Outcomes
• Patient-centered care increases physician
satisfaction and retention
• Enhanced physician-patient communication is
highly correlated with patient satisfaction and
trust in the physician
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Health Outcomes
• Improved patient perception of overall health
status
• Increased adherence to physician
recommendations and better self-management
of chronic conditions
• Better physical functioning in daily activities
• Improved health outcomes: Diabetes, high
blood pressure
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Financial Outcomes
• Selecting a physician most highly influenced by
how well the physician communicates and
shows a caring attitude
• Doctor-patient communication and visit-based
continuity are key factors in patient retention
• Patient-centered communication results in fewer
diagnostic tests and referrals
• Good communication reduces malpractice risk
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Access – Primary Care
• Appointment and telephone access
(tend to be correlated)
• Access to primary care physician (as
defined by the patient)
– Seeing own PCP has a halo effect on other
PAS measures
– Loss of continuity increases utilization of ED and
hospital
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Access – Specialty Care
• Access to specialty care physician
• Total days wait for appointment (includes waits
for PCP, lab, radiology)
• Ease of referral
• Patient perception of “wait time”
– Impact on daily life
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Improving Access
• Advanced access – Capacity management
(supply-demand) system
− Know what you need, know what you have, act on
the gap
• Appointing system – Simple rules with adequate
appointment supply to PCP
• Leadership
• Constant focus
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Leadership Actions
• Visible leadership at all levels to set
expectations and motivate staff
• Leadership structure with clear accountability
for improving service
• Resources
– Staffing
– Analytic
– Training
• Reward and recognition
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Leadership is Critical at All Levels
• High performing teams have high patient
satisfaction, high morale and high quality
measures
• Leaders of these work units
–
–
–
–
Put patients at the center of all work
Motivate team members to improve team performance
Involve all team members in decision-making
Reward and recognize team members for their
contributions
Leadership creates a service culture
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Improving the patient
experience is not
rocket science —
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— it is harder
than rocket
science.
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Changes to Improve the
Patient Experience
Diane Stewart, MBA
Outline
• Effective tactics
– Tools and resources
• The evidence
• How and where to start
21
• Based on the
experiences of three
year-long efforts with 15
medical groups / IPAs
• High impact changes
with tools and resources
• Changes at the practice
and organization
• Strategic changes
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Need Both:
Strategic and Tactical Changes
Strategic
Organization:
1. Leadership and culture
2. Systematic
measurement and
feedback
3. Communication
4. Improvement
Infrastructure
Tactical
Practice:
1. Physician-patient
communication
2. Care coordination
3. Access to care
Organization:
1. Communication training
2. Access training
3. Lab reporting system
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Changes for Physician Practices
Improving Physician-Patient
Communication
Refer to
page 3 in
the guide
• Tips
– Negotiate the agenda with the patient at the start of the visits
– Make a personal connection and demonstrate empathy through
eye contact and empathic statements
– Provide closure by summarizing next steps and action plan
• Resources
– Sample concern (aka agenda setting) form
– Script for Improving Doctor-Patient Communication
– CQC’s Doctor-Patient Communication Teleconference Series
(recorded sessions available on our website)
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Changes for Physician Practices
Improving Care Coordination
Refer to
page 4 in
the guide
• What does “care coordination” mean to patients?
• Tips
– Notify patients of all test results
– Review patient chart prior to the visit
• Resources
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Changes for Physician Practices
Improving Access
Refer to
page 5 in
the guide
• Tips
– Handle more than one medical problem during the visit and extend
return visit intervals when appropriate
– Open same-day appointment slots
• Resources
– Improved Access Tip Sheet
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Tactical Changes for
Organizations
Refer to
pages 7-8 in
the guide
• Provide communication training to physicians
and staff
• Provide advanced access training to physician
practices
• Provide a systematic approach to reporting lab
results to patients and physicians
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Strategic Changes
Refer to
pages 9-11
in the guide
• Provide direct and visible leadership at all levels
of management throughout your organization
• Provide routine feedback at the physician level
and act on slippage
• Communicate regularly and effectively across
all levels of your organization
• Provide technical support and training
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Evidence These Practice
Changes Work
Study Design: Matched control physicians within same IPA
• Greater improvements in all communication and care
coordination measures compared to controls (2-3 points)
• Changes sustained over time (re-survey 6 months postintervention)
• Physicians with Largest Gains:
– Started with lower scores at baseline
– Demonstrated greater engagement as compared to
controls (6 point gain)
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Practice Level Results – cont’d
Qualitative Results based on semi-structured
interviews with 10 of 12 practices
• 100% believe they can sustain changes
• 80% believe staff satisfaction improved
• 80% believe practice culture improved
• 80% report improved personal job satisfaction
• 72% report improved relationship with IPA
• 71% reported that their practice is a “better place to work
than 12 months ago” compared to 58% pre-intervention
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CQC Collaborative Results
Wave 1 = 4 groups, 410,000 pts
Wave 2 = 7 groups, 610,000 pts
State Avg = 225 groups, 10 million pts
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Getting Started: “The short list”
1. Patient experience feedback at least
quarterly (pg 10 of the CQC Guide)
• Teleconference # 2 on March 9 will review options
• $150/clinician/quarter
2. Training on patient communication
techniques for clinicians (pg 7 of the CQC
Guide)
• $400/clinician for 8 hrs of training over 2 days
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Where Do I Start?
1. Identify “gaps”
a) By Domain
Use PAS Survey report
b) By Practice
Use Clinician Survey (if available)
2. Choose your improvements based on gaps and
organizational “energy”
3. Start Small, with a few Practices, then Scale up
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Identifying Gaps By Domain
You can find these tables on page 8 and 9 of your 2010 PAS report.
Also, page 6 has your organization’s areas of weakest performance.
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Identifying Gaps
By Practice
Ratings for selected Domain(s)
Clinician IDUnique # Pts Site Location
Specialty
Doctor 8
Doctor 4
Doctor 7
Doctor 5
Family/General Practice
Family/General Practice
Family/General Practice
Internal Medicine
2932
2200
2110
1298
Practice Site 5
Practice Site 3
Practice Site 5
Practice Site 4
Domain 1:
Interactn
83.5
87.0
88.0
88.2
Domain 2:
Access
75.8
86.6
59.4
79.3
Domain 3: Overall
Office Staff Rating
86.8
87.3
88.1
86.9
78.5
82.6
83.0
83.2
Look for:
• Practices with lots of your patients
• Average, or just below average, scores
• When you are just getting started, find some potential
“champions” to engage early
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Start Small, then Scale Up
3 -10
Practices
6 – 8 months
• Learn about getting results
at your practices
• Develop physician and
staff champions
• Understand what it takes
from the group to support
practice changes
6 – 12
months
Design systems and
tools to support changes
across many sites
Network
Rollout
Thanks to Chuck Kilo, MD
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Some Notes on Engaging
Clinicians...
• To start, one-on-one face-to-face
conversations
– To start, medical director with manager and patient
reports
• Offer assistance, invite participation
• Anticipate stages of reacting to date
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Some Practices Need More Time
Patient Ratings for 2 physicians receiving the same training
Overall Rating of Care
Respect
During your most recent visit, did this doctor or other health providers show respect for what you
had to say?
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100%
80%
Percent
Rating (0-10)
10
6
4
60%
40%
20%
0%
2
0
Baseline
M1
M2
Complet ed Responses
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12
17
Overall Rat ing of Care
7.4
9.4
9.1
Progress
M3
M4
M5
29
18
15
14
9.2
8.7
9.1
9
Report *
Progress
M6
M7
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15
14
8.9
9.3
9.4
Report ^
Baseline
M1
M2
Progress
Report*
M3
M4
M5
Progress
Report^
M6
M7
Yes, Definitely
73.0%
80.0%
80.0%
82.9%
70.6%
82.6%
73.3%
76.4%
86.7%
100.0%
Yes, Somewhat
24.3%
6.7%
20.0%
11.4%
23.5%
13.0%
20.0%
18.2%
13.3%
0.0%
No, Definitely Not
2.7%
13.3%
0.0%
5.7%
5.9%
4.4%
6.7%
5.5%
0.0%
0.0%
Goal
Data Collection Period
Data Collection Period
Mission Viejo Family Physician
Newport Beach OB/GYN
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Final thoughts...
• Improving the patient experience benefits
physicians, patients and the organization
• Improving physician-patient communication
is key to improving the patient experience
• Measurement and training are the
foundation to improving physicianpatient communication
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Available resources:
• CQC Guide to Improving the Patient Experience
• Practices of High Performers Webinar on March 30 http://calquality.org/programs/patientexp/perform/index.html
• CHCF paper on the patient experience in ambulatory care in
California - http://www.chcf.org/publications/2010/12/patientexperience-in-california-ambulatory-care
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