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This is a guest blog post by Andrew Gallan, PhD, a teacher, researcher,
and adviser to organizations on designing services to improve patient experience.
Now that over 50 healthcare organizations regularly publish patient evaluations of physicians on their public-facing websites (Ed Bennett Consulting 2017), transparency around physician ratings and reviews has become a growing focus in healthcare. University of Utah Health Care is a pioneering institution in today’s transparency movement.
While transparency around ratings can (understandably) be stressful for physicians, it can be very useful for patients
searching for the right physician for their own care (Patient Engagement HIT 2017). Transparency is about presenting digestible data to patients to help inform their purchasing decisions.
To that end, survey scores are converted into a five-star system; and all comments, positive and negative, are posted on a hospital’s website with redacted identifying or personal information.
Why are healthcare organizations adopting physician rating transparency?
It is now imperative for health care organizations and professionals to manage their online presence and reputation (PatientTrak2017). While Yelp and other third-party online sources capture attention, physician profiles on providers’ websites typically outrank other sources of information and provide more valid and reliable data (Mahoney 2016). CMS-mandated data, such as those collected from CAHPS surveys, are from verified patients of a specific provider, and the questions have been developed with good psychometric qualities.
When a healthcare organization transitions toward online physician transparency, they motivate physicians to improve performance, explains Vivian Lee, M.B.A., M.D., Ph.D. in a recent article for the New England Journal of Medicine. When physicians are compared to one another, very often they seek out counsel to improve the service they provide to patients. This can lead to improved patient-centered care and quality outcomes.
Then, the question for physicians and healthcare leaders becomes: If I’m being held accountable to certain standards, how can I improve my scores?
The answer to this question lies in patients’ comments. Patients might give high survey scores to physicians, but they describe their true care experiences in their comments. Physicians can learn from these first-person accounts about what patients need and expect of their care. It’s also true that people identify with stories over numbers, so a sample of patient comments that represent a specific trend out of aggregate qualitative data would resonate very well with physicians about the improvements they need to make.
How can healthcare organizations manage what is now transparent to potential patients?
As a result of physician transparency, it is more important now than ever to bring a scientific approach to understanding what patients are saying in their own words. Healthcare organizations need to make sense of both structured data (survey scores) and unstructured data (patient comments). By analyzing patient comments, providers can learn about patients’ experiences above and beyond CAHPS domains. Artificial Intelligence (AI) and Natural Language Processing (NLP) are methodologies that provide the capability to analyze and make sense of large amounts of text. When this analytical capability is coupled with intuitive visualizations on dashboards and easy-to-digest reports, such as those offered by NarrativeDx, it becomes so much easier for providers to learn from and build improvement actions on what patients are saying.
The goal of patient experience improvement is to gain a better understanding of what is important to patients.
Some examples that bring this issue to life include:
If patients complain about food, what are they saying? Are they commenting about taste, temperature, choice, or other issues?
If patients complain about noise, what are they hearing? Alarms, conversations, other patients, visitors?
If patients don’t understand discharge information, what do they recall? Do they remember the timing of when the information was given, the amount of information provided, instructions surrounding new medications, follow-up appointments, or other issues?
Patient experience professionals can now engage new techniques and tools to unearth additional insights from existing data that will help improve care experiences, and happy patients and families will in turn give much higher ratings to physicians.
Andrew Gallan, PhD specializes in researching, teaching, and advising organizations on designing and delivering patient-centered care. He has worked with organizations including Mayo Clinic (AZ), University of Chicago Medical Center, UPMC, and Advocate Health Care on their journey toward delivering world-class care. Andrew has engaged audiences as a keynote speaker, breakout presenter, and committee facilitator and advisor. His graduate class on Patient Experience, the first in the nation, is among the most highly rated classes at DePaul. He is a Beryl Institute speaker.
When home health providers think of the “patient experience,” high-quality care is likely what comes to mind first. In reality, physical care may just be one aspect of an outstanding patient experience.
The real definition of patient experience can be beyond what providers and caregivers are used to, Joyce Boin, principal consultant at Strategic Health Care Solutions, explained to Home Health Care News.
“All patients assume as a home health provider you are sending a competent caregiver. The ‘wow factor’ comes in when you expand that idea even further than just great care,” Boin said. “The above and beyond comes from compassion and empathy.”
Patient Experience Project
In addition to caregivers showing compassion and empathy, another way home health providers should train caregivers to go above and beyond is by teaching how to engage patients in the care process, Andrew Gallan, an assistant professor at DePaul University who researches the patient experience, told HHCN.
This engagement could be as simple as asking the patient one or two extra questions to learn more about them, or explaining certain aspects of the patient’s recovery to keep them engaged in what’s happening.
Gallan has made the patient experience in health care his focus. He began his research in hospitals, but moved into the home care sector through a project with an Illinois home health provider, Advocate at Home, where he and Boin partnered together.
The project consisted of three phases that took just over two years. First, a survey was conducted among home health patients to see where caregivers stood in terms of quality of care. Then Gallan pinpointed the top drivers of the patient experience and created an index to track for those things. The items he tracked included communication with home health staff members, taking care of emotional needs and overall perception.
Second, Gallan did phone interviews with the patients to try to find out more details about the areas in phase one. In phase three, Gallan attended ride-alongs with home health staff to witness the caregiver/patient relationship firsthand. In total, Gallan made about 40 patient visits in the city of Chicago, the suburbs and rural areas of Illinois.
The results of the project found that patients overall had very good relationships with their home health providers, but they were reluctant to talk about their emotional state.
“Home health providers did a very good job of delivering the actual care, but the relationships formed could have been better,” Gallan explained. “The caregivers could have been better active listeners. Something as small as putting away computers or tablets and taking a few extra minutes to ask a few more questions could help create a clearer picture of the patients’ emotional state.”
Making goals very clear can also improve the overall patient experience, added Gallan.
“If patients can identify a goal, they can see a light at the end of the tunnel,” he said. “It’s a highly motivating thing. If caregivers can help them identify those goals, patients can make significant progress.”
Though the project is over now, Gallan continues to work with Advocate at Home to help implement the full patient experience and build upon the project’s findings.
Investing the Upfront Time
Caregivers can improve the patient experience is to work on building a strong relationship with the caregiver by encouraging patients to become engaged. Allowing caregivers to spend more time on visits sounds like it could be inefficient, but investing time upfront to build relationships and develop goals with patients actually has a positive impact on recovery times, according to Gallan.
“I know some of the pushback about being more engaging with patients is because it will take more time, but my response is that if it’s done well, it’s not going to be that much more time down the road,” he said. “And then, if the patient knows what’s expected of them from the beginning, once the nurse comes in they don’t have to reinvent the wheel.”
Building a strong relationship between caregiver and patient can also help put family members at ease.
“It’s a cause of concern and anxiety for some families when their loved ones are receiving in-home care,” said Boin. “The idea of having caregivers as somewhat of a support system is what value-based purchasing is really going to buy. If caregivers can deliver on that, the patients and caregivers will become more efficient.”
Written by Alana Stramowski
Two years ago my 89-year-old father had minor surgery on his leg to remove a cancerous growth. The dermatologist had to scrape so many layers before eliminating diseased tissue that he recommended my father visit the wound care center to speed healing. In this organization, wound care was part of the Physical Therapy department on the lower level. My father and I made our way down, and scheduled two appointments per week, Tuesday and Friday, for what would be a total of six weeks. Then we transitioned to only once per week as the wound healed.
My father would wait only a minute or two before being called back. Richard and Mark took turns applying topical anesthetic, debriding the wound, and wrapping up gradually diminishing wounds on my father’s leg. This took about 15 or 20 minutes, and I’d bide my time in the waiting room.
It didn’t take long for me to recognize the regulars. Despite my best efforts to pass the time checking e-mails, the stock market, and my never-ending Scrabble matches, I couldn’t help but to glance around whenever there was action in the reception area or waiting room. I made mental notes of the patients I saw most often.
The young college-aged soccer player on crutches and her equally blonde mother who have permanent grins as if to convey the temporary nature of their predicament.
The knitter who waits with unwavering patience for her appointment time, only to abandon her knitting most willingly once she hears her name.
The burly older Polish man with the thick accent who brings plastic bags and the newspaper every time he visits. He sorts through the paper, separating the wanted from the unwanted, throwing away or sometimes leaving behind the inserts, ads, and undesirable sections. The staff knew to circle back after he left to check for trash.
The elderly gentleman with the walker, who without exception goes to the men’s room just before his therapist comes to call for him. And his wife who always rolls her eyes to the therapist, which is enough said.
The older couple who graduated from the university at which I teach, who one time engaged me in discussion about my affiliation based on my logoed sweatshirt. Since then, they haven’t even met my glance; perhaps time has diminished their recognition of me, particularly since I haven’t worn identifying clothing since then.
I’ve also observed the staff, both the ones who are affiliated with the department and those who pass through. I began to notice an almost metronomic tendency for actions to repeat themselves. The employees, who walk and talk through the waiting area as if there was no silence; who wait for the elevator as if no one will get off when the doors open; who whisk past and stare at the floor while listening to music through ear buds; who call everyone who checks in or out “sweetie” or “honey”; who listen to various iterations of almost scripted check-out conversation (“be gentle with the bill, I’m sore…”) and then feign interest and laughter. Initially annoying, it became familiarly amusing after a while.
Physical therapy and radiology share a common check-in desk, long enough to spread from one patient entry to the other. There are always more PT patients than radiology patients, so PT knows to check for their patients in waiting room chairs on both sides. And radiology knows not to question anyone wandering over to their circle of chairs that doesn’t look over. The PT patients are recognized and instantly checked in upon emerging from the elevator. On the other hand, for every eight or so PT patients, there is one radiology patient who pops out of the elevator, pauses to read the signs, and then nervously walks over to the receptionist.
Most of these patients are one-and-done; a simply x-ray or sonogram to eliminate something from the list of potential diagnoses. On a rare occasion there is a patient who walks in emitting stress and angst to suggest that she is in the midst of a life-changing event. The mother who pushes a stroller with a baby who wears a mask; the middle-aged woman who checks in for an MRI of her chest; the elderly woman and her daughter who are silent except for the simple word or two of direction from the daughter. These are the cases I noticed the most, for they are a brief glimpse into the potentially horrible world that is theirs alone to inhabit.
After all the trips, and time spent, and weather tolerated, I’m glad my father’s leg has healed. I’m also grateful that I don’t have to make the time to pick him up from his apartment at his independent living facility and drive him to and from the clinic. However, I’ll miss seeing him so frequently, even though I see him at least once a week. Surprisingly, I’ll also miss the observation, the regulars, (some of) the staff, and the routine. It seems that the wound care clinic transformed from a treatment facility to a Cheers-like venue where I expected the next man out of the elevator to be greeted with a chorus of “Norm!”.
Learning #4: Understanding the patient experience requires a strategic plan, the proper tools, and humility.
Frameworks and tools exist to help organizations better understand their processes from the patient’s perspective, designed to help organizations strategize around improvement, innovation, and redesign to enhance quality, safety, and productivity.
Implications: Understanding what your patients experience when they are in your facility requires humility. This may not be what you think it is; a recent article outlines major components of humility: “Recognition of what she owes to others, comparison with a reality that is greater than her, and finding something that has a high objective value that leads her to acknowledge her smallness.”1 It is a positive virtue that motivates an individual to be open to others, to listen carefully to others, and to assume an attitude of looking for guidance.
It is from this perspective that a leader creates a humble organization; one that has a desire to understand what patients and families go through to obtain care from and with your organization. Thus, putting yourself into the shoes of another, through Shadowing, is an important tool to understand care from the patient and family perspective. Shadowing is a cultural change agent, an orientation tool, and a reminder of your organization’s mission. What you see will go beyond your pre-conceived notions of what it is like to be a patient. It will connect you to other human beings, their vulnerability and goals, and bring out your sense of empathy.
Once you have Shadowed patients, it is imperative to map the process using care experience flow maps, service blueprinting, or other tools to create a clear image of what is. Comparing what you have designed to what customers expect using the Gap Model of Service Quality will help you to reimagine what could and should be, and to redesign the process to best accommodate the patient. By using this methodology your department will also most likely save costs and improve safety.
Making a commitment to seeing your organization’s processes from your patients’ perspectives is not easy – it requires a high level of dedication from top leadership. A Servant Leadership model applies as well, where leaders put the needs of others before their own needs. After all, as humility research reminds us, “the humble leader is precisely the person who is best qualified to transform his firm into a profitable, successful, and respected organization.”
1 Argandona, Antonio (2015), “Humility in Management,” Journal of Business Ethics, 132 (1), 63-71.
Learning #3: Improving the patient and family experience cannot be distinguished from clinical care.
Patient experience, safety, and quality are categories of care constructed by organizations which often serve to separate rather than to integrate processes. They are inter-related; we cannot affect one without impacting the other two.
Implications: Watch what you say, and how you say it. Artificially dichotomizing “care” and “cure” does nothing to help your patients and their families in recovery. All it does is feed those in the organization who don’t want “patient satisfaction programs” to impact what they do. When you look at care experiences from the patient’s point of view, everything is everything. Patients want to feel safe and secure, to perceive that they are getting the best possible care, to be assured that they know what is happening and will happen, and to be heard.
How can any of these be pigeon-holed into safety, clinical quality, or experience alone? Doesn’t active listening directly impact shared decision making? And doesn’t timely and proper communication directly impact safety (falls, medication errors, etc.)? Doesn’t discharge planning, discussions about home and social support systems, and clear instructions on new medications and follow-up visits directly impact readmissions? So why should one aspect be distinguished from the others?
For example, many organizations will show a near-100% compliance providing discharge instructions to patients and families. However, patient surveys such as HCAHPS reveal a significantly lower percentage of patients recall this information. Some organizations interpret this disparity as the patient’s fault: “We checked the item, so it must have happened. It’s not our fault that the patient can’t remember.” If an organization receives 70% top-box scores for discharge information, 30% of patients don’t recall critical information designed to improve safety, outcome, compliance, and to reduce no-show appointments and readmissions. Instead of attributing the source of blame, an organization would do well to assess why 30% of their discharged patients can’t recall discharge information. Are there language issues? Is the discharge process confusing or too technical for some patients to recall? Can your organization better involve family members and other caregivers in the discharge process?
The best organizations discuss all aspects of care together – for instance, the impact on quality and patient experience when safety protocols are redesigned, the impact of new quality guidelines on safety, costs, and patient perceptions of care, etc. You may consider appointing one person in every meeting to provide feedback on every strategic initiative from the patient’s point of view. This way, the patient’s voice is continually infused into planning and tactics.
A couple weeks ago, I covered why healthcare organizations shouldn’t make patient satisfaction their main goal. This week, I’d like to focus on my second key point for becoming a Patient-Centered Organization:
Learning #2: Caregivers should recognize that instead of having “difficult patients” they are treating patients in a difficult situation.
At least that should be the default. A fresh perspective changes the conversation:
Producing value for → Producing value with
Potentially adversarial → Potentially partnering
A burden or obligation → An opportunity or gift
Implications: When patients are labeled as “difficult,” the relationship with them immediately turns adversarial. When a patient is understood to be in a difficult situation, the relationship can be a partnership. Caregivers who assume that patients are [perhaps even inappropriately] expressing difficulty in dealing with a situation should empathize with patients, try to identify sources of pain, dissatisfaction, and discomfort, and work to address the situation that has developed. Tactics start with eye-level communication, a comforting tone of voice, and enacting a service recovery plan. Indeed, a service recovery plan should emanate from the realization that patients are vulnerable, and at a disadvantage, in your facility.
The only surefire way to transcend issues that block the ability of a patient (and providers) to move forward is to identify patient goals. What is important to her? What is unknown by the patient that inhibits her from reformulating plans for future? Does the patient have unreasonable demands and expectations that can be moderated through discussion of her current state? What steps, resources, and timelines are necessary for the patient to see progress toward her goals? Starting with good questions about expectations and goals is a great way to initiate the process of converting a difficult patient to a patient in a difficult situation who now sees a way out.
Donna Ladd, BSBA, Director, Patient Relations at Eastern Main Medical Center recently shared the following with The Beryl Institute: “With psychiatric patients whose behavior can at times be challenging, I think to myself – “how hard is their life?” – and that helps me remember that I am blessed with friends, support and the ability to communicate in a way that people can understand.” To live up to this ideal, healthcare organizations need to hire employees with empathy and ensure that their culture and incentives don’t discourage empathetic behaviors.
In October of last year, I had the honor of delivering a keynote address for the 2015 PFCC VisionQuest in Pittsburgh, PA. I structured my talk around four key points that I’ve learned over the years as I’ve engaged with healthcare organizations regarding Patient Experience and culture change.
Since I delivered my talk, I’ve come to realize that providing learnings is not enough. Those in attendance may have found inspiration from my talk, but I could have done more to provide them with sufficient detail to do something differently!
Over the next 6 weeks, I’d like to follow up on my talk with reminders of the four points I made, coupled with behaviors and tactics that naturally follow from these learnings. This week’s takeaway focuses on patient satisfaction.
Learning #1: Patient satisfaction should not be the goal of a healthcare organization.
The objects and measures of success for a healthcare organization should extend past patient satisfaction and should include patient activation, patient engagement, and patient loyalty. Patient satisfaction may be fleeting and an insufficient driver of lasting effects.
Implications: Engage patients and their families in shared decision making. This may take the form of providing decision aids; involving a variety of personnel to spend time with patients discussing their condition, prognosis, and options; and, using evolving technologies to continue discussions outside of clinical appointment times. Caregiver-patient interactions should focus on identifying patients’ goals, not lecturing patients about the goals identified by guidelines. What is realistic for a given patient? What is attainable? What is unacceptable from a clinical perspective? How can a patient goal (e.g., wanting to attend a loved one’s wedding or graduation) provide inspiration and continued motivation for attaining clinically meaningful goals? Caregivers should document patient goals, distribute them among members of the organization, and ensure that subsequent communication refocuses activities on achieving them.
Reframing discussions of patient satisfaction to patient engagement and understanding what patients and their families experience while under you care helps to move away from objections and stalemates. We’ve all heard “We’ve tried this and that,” “We have a long history of patient satisfaction programs,” and “I’m here to save their ass, now I have to kiss their ass too?” Some organizations have too long of an organizational memory, such that it inhibits the ability to move forward and to effect lasting change. Thus, move the discussion away from patient satisfaction, which has fleeting associations with behavioral changes, to engagement and activation. These are the terms that will connect patient experience initiatives to safety, clinical outcomes, costs, and other metrics to align your efforts with others in your organization.
Dr. Michael J. Barry’s recent blog post makes an outstanding case for the positive impact of shared decision making and a powerful argument against many myths about it. My thoughts here are complementary and supportive. I am not a clinician. Rather, my perspective is from the vantage point of patients and their families.
My efforts have been to provide health care organizations with the voice of the patient and my research has been to learn more about patient experiences in health care. I’d like to share some of what I’ve learned about patient approaches and preferences related to shared decision making.
Why is Shared Decision Making Important?
A caregiver-patient encounter is the “moment of truth” when care is directly delivered (this does not have to be face-to-face). However, in order for health care organizations to create value with patients, interactions require the resolution of dual-sided information asymmetry (a condition when neither side has all the information necessary to design an optimal plan of care). When a provider (physician) contributes technical (clinical) knowledge and a patient shares personal knowledge, each side obtains the knowledge necessary to work together effectively. Thus, shared decision making exists when a provider and a patient engage in learning with the aim of working together to attain realistic goals for improved health and well-being.
In health care, patients may provide perspective on issues such as tolerance for risk, likelihood to change, knowledge of disease state and possible treatments and preference for treatment. Physician communication with patients conveys critical clinical information, views on treatment alternatives and additional resources for the patient. A continuum of provider-patient interactions is useful to assess the (im)balance of power between provider and customer.
Paternalism, a condition when the physician takes control of the encounter, is quite common in health care. This condition is often provider- or productivity-focused. Paternalism should be tempered with benevolence, to avoid violations of ethical standards. The risk in this type of interaction is that patients may not become fully empowered or engaged to take increasing control of their health and well-being because they are not included in co-designing a plan of action.
Consumerism, a condition when the patient has most control over the encounter, is not the most fertile ground for shared decision making, as it represents a state that may be focused on unrealistic customer demands rather than the patient’s health and well-being. Examples of this include when patients are drug-seeking, are resolute about knowledge obtained from an unreliable source of information or ask for a specific medication seen on TV – situations that may be misaligned with patient goals. Moreover, consumerism in health care can have destructive effects through excessive resource utilization and lack of cost control.
Finally, Mutualism, the condition when patient control is balanced with physician control, presents a state where value co-creation is most likely to be fully realized. When providers acknowledge the contributions of the patient and when patients fully enact their role (e.g., ask questions, clarify issues, and contribute their emotional resources), fertile ground exists for shared decision making to flourish. Mutualism is respectful and transformational. It resolves dual-sided knowledge asymmetry and is tied to optimization of processes, plans, and outcomes. Empirical work has shown that respectful, balanced discourse between physicians and patients results in improved health and well-being, including improved mental health (Kawachi and Berkman 2001), decreased mortality and morbidity (Stewart 1995), increased compliance/adherence (DiMatteo et al. 2002), and cost reductions (Carman et al. 2013).
What Influences where Patients Land on the Spectrum?
Some of the factors that may push providers and patients to either end of the continuum include:
- Cultural factors: Some cultures are more comfortable listening than talking and concede power to providers.
- Generational factors: Older patients may have been raised to avoid questioning doctors, while many younger patients want to know everything before proceeding.
- Educational factors: Patients who are less health literate may avoid exposing themselves by remaining quiet.
- Vulnerability: Patients who feel vulnerable or exposed to a system they don’t understand may react by holding back.
Build a Care Circle
To mitigate these factors, it may be helpful to engage a variety of people within a patient’s family and social network, include translators or other patient advocates in discussions, ask “safe” questions that don’t put patients on the spot and check-in with the patient for understanding on a regular basis.
Finally, the figure lists some strategies that health care providers can consider to move interactions toward the “sweet spot” of shared decision making. These are couched as provider strategies since health care organizations are hosts to visiting patients and as such should endeavor to welcome all who enter.
In general, these strategies include:
- Being focused on the present moment as a sacred opportunity
- Listening to what patients and families are saying not what providers think they will say
- Asking situational questions that help open up patients to additional considerations
- Providing information when and where it is needed.
Patients who prefer consumerism or paternalism aren’t “wrong” – they are simply defaulting to a position based on complex factors. Providers should work to understand motivational factors to help patients manage and reset expectations
Create a Shared Set of Goals
The most important issues for patients are their health and well-being GOALS. Often, patients are in the process of (re)defining these, of understanding a new meaning of health and well-being and coming to terms as to what it will take. I have often heard physicians advise patients to [choose one: lose weight, exercise more, eat better, etc.], only to have the patient share with me outside the exam room that they won’t/can’t follow orders. What a shame! If only the conversation between provider and patient mitigated dual-sided information asymmetry and a common, realistic and scientifically-justified goal was crafted by both sides, there would be a real chance of improved health and well-being.