Transcript to view the presentation.

Improving The
patient experience
Dr. Patrick J. Crocker, MS, DO, FACEP
Director of Best Practice Development
And your own experience too!
The Patient
Experience
This review contains:
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•
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Pre-Review Questions with answers and discussion
Executive Summary of key learning elements
Assembled EXAMPLE guidelines for your department
Risk Management Pitfalls
Additional Educational Resource links
Pre-Review Questions
Q. 1. HCAHPS is a new CMS tool that will:
A. Be just another temporary CMS headache
B. Encumber a physician’s decision making even further
and decrease job satisfaction
C. Drive hospital administrators and hospital staff toward
improving new quality measures
Pre-review questions
Q. 2. Human to Human communication is based on the
content of spoken words to what percent:
A. 90%
B. 75%
C. 50%
D. <15%
Pre-review questions
Q. 3. The patient simply cannot judge REAL
MEDICAL QUALITY. Improving their
experience/satisfaction will inevitably lead to a
decrease in the physician’s work life satisfaction.
TRUE or FALSE?
PRE-REVIEW QUESTIONS
Q. 4. “I've learned that people will forget what you said,
people will forget what you did, but people will never
forget how you made them feel”. Who issued this
poignant quote?
A. Thomas Jefferson
B. Monica Lewinski
C. Maya Angelou
D. Terris King, Deputy Director of CMS
Pre-review questions
Q. 5. AIDET is a simple and useful mnemonic for:
A. Stratification of pneumonia patients (similar to the
CURB score)
B. A concise guide to the patient experience
C. The newest novel anti-coagulant
D. A Meaningless Acronym, Dr. Crocker just made up
Pre-review questions
Q. 6. Butch Cassidy and the Sundance Kid likely
escaped and survived at the end of the final scene in the
original movie.
TRUE or FALSE?
Answers
Question 1 – Answer: C
HCAHPS and the CMS value based purchasing establish a
new playing field for CMS payments. The system is
structured to reward hospitals for improved performance
based on patient satisfaction. This makes imperative a good
understanding of just which factors build a positive patient
experience as hospitals (and ultimately the ED physician)
will have payment directly based on service and likely “at
risk” in the future. This system will drive administrators in
new ways toward achieving a positive patient experience.
Answers
Question 2 – Answer: D, <15%
On some level we have to find this amazing. Our words
themselves have <15% of the content of our intended
communication! More communication occurs through the
combination of vocal tone, vocal volume, body language
and other non-verbal cues than our words. You can give a
totally different message without changing a word! Try this
for yourself….say “You are one smart dude!” First as a
compliment, then as an insult. It is easy to accidentally send
a message different than you intend. We need to be mindful
of the “real message” we are sending when talking with
patients.
Answers
Question 3 – Answer: False
Improving the patient experience is simply good medicine
and can create more satisfying interactions for both the
patient and the physician. Using some very simple proven
communication techniques can be effective and improve
satisfaction scores on an individual/group basis. More
effective is the creation of a culture of improved patient
experiences. Every positive display action by a physician is
leadership by example and helps create a new culture. These
actions are now termed “positive deviance” and have been
shown to rapidly change cultures. You will read more on
this later.
Answers
Question 4 – Answer: C. Maya Angelou
This is a quotation that we should all keep top of mind
while treating patients as it places emphasis on how
successfully we have communicated with the patient. Good
communication can drive how the patient feels during and
at the end of their ED visit, and it is what they will
remember when it comes time to complete the HCAHPS
survey. The global perception of how they felt during the
hospital visit is what sticks in their memory and drives
completion of the surveys.
answers
Question 5 – Answer: B
AIDET is a simple mnemonic on the basics
• Acknowledge – greet the patient and family
• Introduce – Your name and role in their care
• Duration – Always give them an estimate of time
• Explanation – It is ALL about communication! Explain
your findings, lab and any x-rays. Then cover indications
to return to the ED if their condition worsens.
• Thank You – Thank the patient for choosing your
hospital ED for care. They do have choices!
Answers
Question 6
If you answered True you obviously have not seen the
movie, or are an incurable optimist. Butch and the Sundance
Kid ran out into a barrage of bullets delivered by half of the
Mexican Army. They died. For sure.
• Now, the question of whether Shane of the movie of the same name
survived, is an open question. In the final scene, Shane is riding off
slumped over on his horse after being shot. He never looks back….is
that because he was dead or just shot? An open question. I happen to
think Shane lived.
• If you have not seen either movie take a break and watch them! Taking
time for fun and enjoyment will help you maintain a balanced lifestyle
and increase your own life/career satisfaction.
Executive summary
• The Patient Experience…a little new twist on previous
styles of attaining patient satisfaction. Instead of focusing
on “making them happy at all costs” the focus is more on
the process of care, communication, and patient inclusion
in the decision making process. This approach makes
sense.
• So, while some elements of old style “patient satisfaction”
are something we may find somewhere between droll and
nauseating, this new approach is both more reasonable and
simply good care.
• One often overlooked benefit is that YOUR DAY, YOUR
SATISFACTION, and YOUR MOOD will likely be
improved by embracing this approach.
Executive Summary
One of the first references relating to the concept of
routine positive patient experiences creating our own
job satisfaction, is found below:
“If our requirement for job satisfaction is a successful CPR or
trauma case, we will be disappointed on most days...so to obtain
job satisfaction on a daily basis, we must draw rewards from our
interactions with fellow human beings”. [Mike Mouw, writing
as The Armchair Philosopher, c. 1990]
Believe it or not, this was a new concept 25 years ago and not
how most physicians thought! It is, however, still true today.
Satisfying patient interactions will make YOUR day better.
The Patient
Experience
• We also now have HCAHPS (Hospital Consumer
Assessment of Healthcare Providers) to contend with. In a
nutshell, this program has been under development by CMS
for several years and is now implemented.
• As part of the new CMS approach to Value Based
Purchasing the patient’s assessment of care will be used to
determine hospital reimbursement under Medicare, and
hence indirectly YOUR pay, and our contract stability.
• The overall system goal is to redirect Medicare payments to
top performing hospitals and reduce them to under
performing sites.
The Patient
Experience
Three broad goals are encompassed under HCAHPS:
• 1. Implementation of a nationwide standardized survey
process that would allow objective comparisons between
hospitals.
• 2. Public reporting of the data to incentivize hospitals to
focus on and improve the quality of patient care.
• 3. Increase hospital accountability for quality care by
reducing payments to low performers and increasing
payments to top performers.
This program can swing a hospital’s net on CMS patients
by 2 - 4%.
hcaHPs
• The data will be randomly collected and based on a
standardized survey of just 300 patients per year per
licensed hospital.
• Hospitals may use a third party vendor to collect monthly
data throughout the year.
• This small number creates an imperative to improve care
and the quality of the patient experience for EVERY
PATIENT.
HcaHPs measures
• The ten HCAHPS measures will be reported on the
Hospital Compare Web site:
http://www.medicare.gov/hospitalcompare
• Six composite measures focus on how well doctors and
nurses communicate with patients, how responsive hospitals
are to patient needs, how well hospitals manage pain, how
well information on new medications prescribed is
transmitted to the patient, and whether key information is
transmitted to the patient at discharge.
The PHYSICIAN test
questions
• Did the doctor treat you with COURTESY AND
RESPECT?
• Did the doctor LISTEN CAREFULLY to you?
• Did the doctor EXPLAIN things?
PRETTY BASIC! And it is an OPEN BOOK TEST! You
know the questions before the test! What could be easier?
OTHER KEY QUESTIONS
• The survey has the same questions of nurse performance
MAKING THIS A TRUE TEAM ENDEAVOR (one bad
apple can spoil the results for everyone).
• Questions on the hospital environment – cleanliness and
noise levels are the focus points of this category.
• Questions on overall experience in the hospital – staff
helpfulness, pain control, and explanations are the focus
points. Pain control is a huge satisfier. Watch for the tip
“acknowledge and affirm” later in this review.
You can bet on it!
• Every hospital administrator, contract manager, and
physician service contract will rapidly evolve to be focused
on the HCAHPS survey and results.
• New contracts will likely include “at risk” payments to
service providers. Administrators are going to make every
effort to ensure that the entire “hospital team” is working
together. Hospitals working on already slim margins can’t
afford not to succeed.
• In a zero sum game, however, SOME HOSPITALS WILL
LOSE, as well as some physician groups. It is expected that
a number of low performing hospitals will be driven out of
business.
Assembled guidelines
There really are no algorithms for creating positive
patient encounters. It is a learned technique.
The next series of slides are some general guidelines governing
successful techniques for creating positive encounters.
• The first two are brief and to the point, while the third is the
more detailed evidence-based “nuts and bolts” of creating
positive interactions. When you first apply these to your
practice, use the brief guides, and then continue
improvement using the detailed guide. This is a learned skill
you must develop.
• All are very similar, as the basic techniques are well known
in the customer service industry.
Some basic tools
AIDET was developed as a simple patient experience
mnemonic.
A – Acknowledge. Greet the patient, say “hello”, or even SMILE (it doesn’t hurt!).
Use the patient’s name, it is on the chart.
I – Introduce yourself by name and your role. “I am Doctor X, and I will be
taking care of you today.”
D – Duration. Once you have taken a history and examined them, let them know
what is likely in store, time-wise.
E – Explanation. Explain what will happen, tests that are ordered, and review their
discharge medications and indications to return to the ED. If they are to be admitted,
let them know what to expect and what will happen next.
T – Thank you. Share your appreciation of them selecting your ED for care. A
simple “I am pleased to have had the opportunity to help you today, if you have
further questions let me know”. This goes a LONG WAY. Remember Maya
Angelou’s quote, “it is how you made them feel that is important, not simply what
you said to them.”
Crocker’s Rules
Crocker’s Rules of Engagement
A. Greet and introduce yourself to the patient and family. If
there is a wee-one involved, shake their hand too. It is actually
fun, a smiling child is a gift.
B. If there has been a long wait, a simple apology for the
delay goes a long way. Although it’s not your fault, you do
regret their wait, right?
C. Acknowledge you understand their problem, e.g., “I can
see you are uncomfortable, and will be ordering pain medication”; “I see
you are nauseated and I will order medication to take care of this”.
There is something about specifically defining the actions you will
take to treat their problem, that changes their perception in
positive ways. This step is called “acknowledge and affirm”. It
completes the communication cycle with the patient and is very
effective.
Crocker’s Rules
D. Explain what will happen next. It takes LESS than 60
seconds. “I will be ordering some lab, and some X-rays, and I will
be back to discuss with you as soon as they are completed”.
Simple. Straight forward. And it gives them a little sense of
establishing some control of their life on a bad day.
E. Go back to the room to discuss your exam findings and
the results of lab work. And let them know what happens next.
F. If they are an outpatient explain the medication,
reasons to return to the ED, and what follow up is
necessary. This is simply good care and reduces your risk and
their risk. They now know what to do.
The detailed nuts
and bolts
• Read what administrators are saying, regarding what their
high impact managed care providers are training on, in
order to improve the patient experience.
• These are detailed proven patient satisfaction techniques.
• Try not to get too bogged down in details, and remember
that a positive patient interaction also makes YOU feel
better.
• Start your change with the small AIDET step, and then
come back to this presentation and incorporate some of the
other proven tools in this section.
Nuts and bolts
Principles for creating a positive interaction:
Here's a selection from the customer relations pointers offered in the recent
workshop "Successful Strategies for Patient Satisfaction”.
•
Keep a professional appearance: For many patients, there is a relationship among
cleanliness, neatness and health.
•
Convey positive nonverbal messages. This is a key component in creating a positive
experience and a good communication skill. You must be aware of how you look and sound
from the other side of the mirror.
•
Greater patient satisfaction occurs not only with more touch but with more
nonverbal attention. This shows patients you want to establish a pleasant relationship or
bond with them.
•
Touching is a ritual that establishes your personal relationship with your
patients. Reach out and offer a handshake as you greet the patient, it shows you are a
caring person. But don’t touch an angry person!
•
Use eye contact. Look at patients as you listen or speak. Tapping your finger doesn’t
work!
•
Use an open body posture.
•
Use nonverbal encouragements such as nods and gestures.
Nuts and bolts
• Acknowledge the patient immediately.
1.
2.
3.
4.
Greet and comfort first, do paper work second. Don't let patients
wait, even if you are busy. Show that you will assist them shortly
and let them know you are aware of their presence.
Give your full attention to those patients who are present. If you
must answer the phone, do not hesitate to put the person on the
phone on hold, while you address the patient in your immediate
presence.
If you are talking with another staff member, excuse yourself
immediately and address the patient. All staff must recognize that
the patient comes first.
End all personal conversations on the telephone immediately upon
the approach of a patient.
Nuts and bolts
• Introduce yourself. You too, are a person with an identity to which
the patient can relate. Give the patient your first name and describe in
simple terms what you will be doing.
• Greet the patient by name, it’s simply polite. Using the
patient's name helps personalize the service you provide. Open
conversations with patients with a friendly greeting. For example,
"Good morning, Mr. Smith." (Smile.) "I am Dr. C. I need some
information for your record. It will not take long." (Smile.)
• Use a natural conversational tone. Speak with a calm, firm,
caring and confident tone. Do not raise your voice in anger. Speak clearly
and distinctly.
• Pay attention to details. Little things are important and send
signals to patients about who you are.
Nuts and bolts
• Give the patient your full attention. Staff members should not
interrupt when you are with a patient except in emergencies.
• Use appropriate language. Use language the patient will
understand. Don't talk about irrelevant subjects. Use the time to explain
procedures and routine tasks.
• Tell the patient what you can do. Do not begin your comments
with statements about what you cannot do. Provide choices or alternatives
that you can offer the patient.
• Inform, instruct and explain.
1.
2.
Provide as much information as the patient is interested in knowing,
such as basic and elaborate instructions, explanations and directions.
People respond better when they are informed about what is going to
happen to them. Uncertainty causes fear, worry, confusion
Nuts and bolts
• Inform, instruct and explain (Cont’d)
3. Explain delays and changes truthfully.
4. Explain why you are performing certain tasks The informed patient is
likely to be more cooperative.
• Build a partnership with the patient. Partnership-building goes
beyond informing and soothing the patient. It is involving the patient in a
participatory relationship by enlisting patient input.
• Show appreciation. Show and tell patients how much you value
them.
• Be discreet. Respect the patient's privacy.
• Make the last impression count. Use a positive manner to wrap
up the interaction. Don't end the interaction on a hostile note
Creating your own
job satisfaction
• As the practice of medicine and expectations change,
an increasing number of physicians are questioning
their personal job satisfaction. A few tips from various
sources, Mind Tools, among them.
• Maintain a balanced lifestyle. Many doctors don’t.
When work seems to take over your life, you lose your
sense of perspective and negativity can cloud all
aspects of your life. Make time to relax, for fun and
family, vacations, start a hobby, or read some books
just for fun.
Job and Life
Satisfaction
• A positive attitude will take you a LONG way! Your
own attitude plays a huge role in job satisfaction.
Accept the fact that while we cannot change the
circumstances life throws at us, we can decide how
we respond to the challenges.
• Stop negative thoughts from entering your brain by
reframing circumstances to positive thoughts.
• Put the actual event that are dissatisfying into their proper
perspective. Will this really matter to me in two weeks?
Most likely not. Put another way, “Don’t sweat the small
stuff. It is all small stuff ”.
Satisfaction
• If you are working 15 shifts or more, you are spending
more waking hours of your life at work than you do at
home with family or friends. To find a balanced lifestyle
that is fulfilling, you must have a satisfying work life.
Choose to create more positive interactions and experiences
with patients, and you will find you will enjoy it and feel
better at work and after.
• Even when the patient didn’t really need to be in the ED,
ending the encounter with a smile and a handshake will
make you feel good; it is infectious and they will feel
good too. HCAHPS may actually prove to be a very
positive change on a personal level.
Speculation?
• And if I have you have still been wondering about final
scenes of movies….
• TONY SOPRANO IS ALSO DEAD. That final scene
told it all!
Risk management
pitfalls
Here are a few tips on how to handle some recurring
patient-physician situations of dissatisfaction.
• FIRST, never bring up “negatives” with the patient
before establishing rapport. Commenting on the fact that
“they don’t need to be there, their child is obviously not ill”, or that
their “back pain is obviously secondary to their obesity,” are clear
losers.
• Starting off a conversation regarding the patient’s
complaints before you examine them, will usually provoke
anger. Deal with such issues after your history and exam;
you have absolutely no credibility until you do.
Risk Management
pitfalls
• The Long Wait
We all hate to wait, patients included. The ED may be busy
or understaffed that day and that is clearly not your fault.
Nevertheless, you would have liked to provide better service,
right? Of course you would. Also, remember patients who
feel they were treated well are less prone to litigate or
complain.
• A simple “I am sorry for your delay today. The ED has been
very busy but I am here to help you now. What can I help you
with today?” will help the tension of a dissatisfied patient
melt away. You have started service recovery and have set
the experience clock back to zero. Now build a good one.
Risk management
pitfalls
• “Doc, I need pain pills”.
One of our least favorite encounters. First and foremost, do
not discount that the patient may indeed have a real
emergency condition. Assure them there will be options for
managing their pain but you must first conduct your history
and physical. If after the exam it is clear that there is some
drug seeking behavior, explain first that treating chronic
pain with narcotics is now known to possibly be both
ineffective and harmful, and that chronic narcotic use for
pain control requires a pain specialist, which you are not.
Offer non-narcotic medications or medications for chronic
neuropathic pain, such as gabapentin.
Risk management
pitfalls
• When in doubt, consult the state prescribing database.
It takes a few minutes, but can add some important
information. Make a brief note that you did so.
• If the prior narcotic seeker does have an identifiable
acute injury, moderated routine management is likely
in order. For example, an acute fracture might still
require 72 hours of narcotic pain relief. If you choose
this option, explain that there will be no refills.
Risk management
pitfalls
• “I bumped my head and I need a CAT scan”.
Fortunately, this conversation has become easier. Explain
that a CAT scan is generally a good choice when the doctor
feels it is necessary, but that it does entail some significant
radiation exposure. Explain that this raises their risk of
cancer later in life and that you want to help them reduce
that risk; that right now their neurologic exam is normal,
and it is unlikely that they will benefit from the test. Open
the door for them to return if symptoms continue or
worsen. Most patients are satisfied with your decision when
approached this way.
Risk management
pitfalls
• “I want antibiotics for my cold”.
Although a frustrating recurrent encounter, do not respond
in a negative way. REMEMBER, it is not your words, it is
the delivery. Express understanding; do a little explaining,
and leave the door open for the patient to return.
i.e. “I understand you want to get well as soon as possible.
However right now this appears to be a virus, and unfortunately
antibiotics won’t help. Using antibiotics to “prevent” an infection
will only insure that the infection will be resistant to the antibiotic,
and we are losing effective antibiotics this way. Please return if you
worsen or fever >72hrs as sometimes a secondary infection will
surface and we would like the opportunity to treat that for you.”
Risk management
pitfalls
• “You have a weight problem”.
Well, they may indeed, and it may be the proximate cause
of their acute health concern. However, you must approach
this one very carefully or you will immediately lose rapport
with your patient.
No rapport = No positive action on the patient’s part to
address their problem.
A more casual reference to how their weight may contribute
to their back pain should come at the end of a brief
explanation of mechanical back pain. “And as you know,
carrying extra weight will make your pain worse, so considering
losing a few pounds would be a positive move. Talk to your clinic
doctor about techniques and about being more active.” Try using
something non-threatening of a similar nature.
SO FAR WE’ve
LEARNED…
• HCAHPS is here, and it will change hospital and provider focus on
the “patient experience”.
• These changes will affect us all, raising a new mandate for creating
the best possible patient experience. Our future income and contract
stability depends upon it.
• KEY POINT – Better interactions and communication with patients
will MAKE YOUR WORK LIFE EXPERIENCE BETTER. Smiling
and saying “thank you” are a much more satisfying way to practice.
Make a little extra effort and give it a try, and see how you feel.
• When patients trust their physician, they are more likely to adhere to
your care plan and follow your advice. Communication builds trust,
and of course our goal is to help them get back to health.
• Effective listening may help you uncover a patient’s real needs, goals,
or subtle diagnosis.
HCAHPS CHECKLIST
• HCAHPS Physician Questions:
1.
2.
3.
Did the doctor treat you with courtesy and respect?
Did the doctor listen to you carefully?
Did the doctor explain things?
It’s not a high bar! It’s just good practice from every
perspective. Creating a positive patient experience is really
not that difficult.
CULTURAL CHANGE
It’s all about LEADERSHIP.
Leadership by example at every level is how we will create a culture of
positive patient experiences. This includes the Medical Directors, “Old-timers”,
Mid-Level Providers and “Newbie” docs. Everyone must participate.
The New Science of Cultural Change
There have been some research breakthroughs in the understanding
of organizational and individual learning that have revolutionized
leaders' abilities to change organizational culture. This science has
led to the development of a simple change methodology based on
the Four Positives. These have been used effectively for culture
change in many other industries, as well as in hospital emergency
departments:
1.
2.
3.
4.
Positive Deviance [perhaps THE MOST CRITICAL!]
Positive Images
Positive Practice
Positive Reflection
Creating cultural
change
• Positive Deviance
Defining a clear, compelling image of the desired attitudes
and behaviors, is critical to cultural change. This is
“leadership by example” at its core.
Positive deviants, those few people in a hospital who best
exemplify the patient-centric culture, have the expertise and
style to lead an entire department toward patient
satisfaction and operational excellence.
Being a leader, positive deviance is a good thing! Public
praise and recognition by YOU will help drive the creation
of new deviants.
Creating cultural
change
• Positive Images
Motivating people to embrace the positive deviant attitudes
and behaviors as their own, is the next step in changing a
culture. The neuroscience of positive images shows that
people working in groups who read and discuss the positive
deviant’s compelling purpose and work, release
neurotransmitters that promote increased openness to new
ideas and speed learning of new attitudes and behaviors. In
addition, if the participants write down their ideas during
this discussion, neural resources are shifted from portions of
the brain associated with fear and resistance, to those
associated with a sense of empowerment and control.
Creating cultural
change
• Positive Practice
Positive practice is performing a function with a conscious effort
to do so, as defined by the positive deviants. Hence, “leadership by
example”.
Every function of the job is practiced frequently, in the right
way, each time it is performed.
Cultural change involves specific changes to behaviors and
business processes that are learned by practicing a desired
function correctly.
The positive deviant definition of operational excellence
describes how to perform the function for the most positive
results, and in ways that align with the desired new culture.
Creating cultural
change
• Positive Reflection
Cultures change one person at a time, and the most
important driver of this type of change is personal reflection.
The neuroscience of learning indicates that time spent
thinking about performing a function is as important as
trying the new attitudes and behaviors.
This positive practice can produce rich experiences that can
be a great source of reflection about the new culture.
Again, leadership by example.
Creating cultural
change
• The Power of the Four Positives
Regardless of the medical community's range of
perspectives on the appropriateness or value of “Rate-theDoctor” social media, or the Medicare “Pay-forPerformance” policy, both forces will put significant
pressure on hospitals for the foreseeable future.
The Four Positives can change hospital cultures quickly and
effectively to improve patient satisfaction.
1. Positive Deviance
2. Positive Images
3. Positive Practice
4. Positive Reflection
Cultural change is a
must do!
To read a little more on the “new science” of cultural
change go to the link below, or copy and paste it into
your browser:
http://www.hhnmag.com/display/HHN-newsarticle.dhtml?dcrPath=/templatedata/HF_Common/Ne
wsArticle/data/HHN/Daily/2013/Mar/seidman03071
3-3110007162
Next steps
• Discuss the importance of HCAHPS at your next meeting.
Review a few of the simple techniques.
• Adopt 4 or 5 key techniques and implement them. Every
physician on the team needs to participate.
Get started….HCAHPS data is already being collected.
Let go of past beliefs around creating a positive encounter…it
does NOT take antibiotics and hydrocodone to build a positive
experience.
• See how implementing these techniques goes, and if you
notice the satisfaction of more positive encounters with
your patients. I think you will.
Next steps
• Take the next step and implement the “Nuts and Bolts”
strategies.
• Behind every expanding and thriving business, there is a
core group of individuals PASSIONATE about creating
change to facilitate further success. These are the positive
deviants. Through example, they set a new bar and create a
new culture. Choose to be a leader by example, and help
create the new culture that will further differentiate us from
the rest of the pack! It is critical to our continued success
and growth.
• Believe the Armchair Philosopher! Your day will be a better
one, fueled by interacting in more positive patient
experiences.
Some other
resources
• ACEP Clinical & Practice Management Patient
Satisfaction http://www.acep.org/patientsatisfaction/
• Dell Children’s Medical Center Good-To-Great project
[The DCMC project – has led to over two years of
averaging above the 95th percentile for satisfaction!]
The Image Below Has An Active Video Link: DCMC’s “Good to Great Project”