A Few Things I’ve Learned About What It Takes to Become a Patient-Centered Organization – Learning #4

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.

A Few Things I’ve Learned About What It Takes to Become a Patient-Centered Organization – Learning #3

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 Few Things I’ve Learned About What It Takes to Become a Patient-Centered Organization – Learning #2

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.

A Few Things I’ve Learned About What It Takes to Become a Patient-Centered Organization – Learning #1

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.

Patients’ Shared Decision Making Styles: Accommodating Various Approaches

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.

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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:

  1. Cultural factors: Some cultures are more comfortable listening than talking and concede power to providers.
  2. Generational factors: Older patients may have been raised to avoid questioning doctors, while many younger patients want to know everything before proceeding.
  3. Educational factors: Patients who are less health literate may avoid exposing themselves by remaining quiet.
  4. 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.