Introduction to Improving the Patient Experience

Part 1 – March 2, 2011

Jill Steinbruegge, MD

Diane Stewart, MBA

Agenda

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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

PAS Five-year TrendSteady Small Gains in Statewide Average Performance

Change in Cross-Sectional Mean Scores

+1.6 pts +2.5 pts +4.1 pts+2.1 pts

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An Evidence-based Approach to Improving the Patient

Experience

Jill Steinbruegge, MD

First, a definition

+

+=

Health Outcome How Care is Delivered

Price Paid Non-monetary Costs

The Patient Experience

How care is delivered = interaction with patients and their familiesPrice paid = out-of-pocket costs to patient (premium and co-pays)Non-monetary costs = impediments to obtaining care (e.g., delays, waits, hassles)

Patient Value

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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

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Effects of key drivers on overall measures of satisfaction are cumulative

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 recognition16

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 culture17

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Improving the patient experience is not rocket science —

— it is harder than rocket

science.

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Changes to Improve the Patient Experience

Diane Stewart, MBA

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Outline

• Effective tactics– Tools and resources

• The evidence

• How and where to start

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• 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 Tactical

Organization:

1. Leadership and culture

2. Systematic measurement and feedback

3. Communication

4. Improvement Infrastructure

Practice:

1. Physician-patient communication

2. Care coordination

3. Access to care

Organization:

1. Communication training

2. Access training

3. Lab reporting system

Refer to page 3 in the guide

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Changes for Physician Practices

• 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)

Improving Physician-Patient Communication

Refer to page 4 in the guide

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Changes for Physician Practices

• What does “care coordination” mean to patients?

• Tips– Notify patients of all test results– Review patient chart prior to the visit

• Resources

Improving Care Coordination

Refer to page 5 in the guide

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Changes for Physician Practices

• 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

Improving Access

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Tactical Changes for Organizations

• 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

Refer to pages 7-8 in the guide

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Strategic Changes

• 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

Refer to pages 9-11 in the guide

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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 post-intervention)

• 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’dQualitative 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

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

Identifying Gaps By Domain

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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.

Identifying Gaps By Practice

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Domain 1: Interactn

Domain 2: Access

Domain 3: Office Staff

Overall Rating

Doctor 8 2932 Practice Site 5 Family/General Practice 83.5 75.8 86.8 78.5Doctor 4 2200 Practice Site 3 Family/General Practice 87.0 86.6 87.3 82.6Doctor 7 2110 Practice Site 5 Family/General Practice 88.0 59.4 88.1 83.0Doctor 5 1298 Practice Site 4 Internal Medicine 88.2 79.3 86.9 83.2

Ratings for selected Domain(s)

SpecialtyClinician IDUnique # Pts Site Location

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 months6 – 12

months

• Learn about getting results at your practices

• Develop physician and staff champions

• Understand what it takes from the group to support practice changes

Design systems and tools to support changes across many sites

Thanks to Chuck Kilo, MD

NetworkRollout

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 TimePatient Ratings for 2 physicians receiving the same training

Overall Rating of Care

0

2

4

6

8

10

Data Collection Period

Ratin

g (0

-10)

Completed Responses 22 12 17 29 18 15 14 47 15 14

Overall Rating of Care 7.4 9.4 9.1 9.2 8.7 9.1 9 8.9 9.3 9.4

Baseline M1 M2Progress

Report*M3 M4 M5

Progress

Report^M6 M7

RespectDuring your most recent visit, did this doctor or other health providers show respect for what you

had to say?

0%

20%

40%

60%

80%

100%

Data Collection Period

Perc

ent

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

Baseline M1 M2P rogress Report*

M3 M4 M5P rogress Report^

M6 M7

Mission Viejo Family Physician Newport Beach OB/GYN

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 physician-patient 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/patient-experience-in-california-ambulatory-care

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