Introduction to Improving the Patient Experience Part 1 – March 2, 2011

1. Introduction to Improving the Patient ExperiencePart 1 – March 2, 2011 Jill Steinbruegge, MD Diane Stewart, MBA

2. Agenda

3. PAS Five-year TrendSteady Small Gains in Statewide Average Performance +4.1 pts +1.6 pts +2.1 pts +2.5 pts Change in Cross-Sectional Mean Scores

4. An Evidence-based Approach to Improving the Patient Experience Jill Steinbruegge, MD

5. First, a definition Health Outcome + How Care is Delivered Patient Value = Price Paid + Non-monetary Costs The Patient Experience How care is delivered = interaction with patients and their families Price paid = out-of-pocket costs to patient (premium and co-pays) Non-monetary costs =impediments to obtaining care (e.g., delays, waits, hassles)

6. 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

7. 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

8. Key Drivers of the Patient Experience Effects of key drivers on overall measures of satisfaction are cumulative • 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

9. 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

10. 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

11. 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

12. FinancialOutcomes 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

13. 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

14. 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

15. 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

16. Leadership Actions • Visible leadership at all levels to set expectations and motivate staff • Leadership structure with clear accountability for improving service • Resources • Staffing • Analytic • Training • Reward and recognition

17. Leadership is Critical at All Levels • High performing teamshave high patient satisfaction, high morale and high quality measures • Leaders of these work units • Put patients at the center of all work • Motivate team members to improve team performance • Involve all team members in decision-making • Reward and recognize team members for their contributions Leadership creates a service culture

18. Improving the patient experience is not rocket science —

19. — it is harder than rocket science.

20. Changes to Improve the Patient Experience Diane Stewart, MBA

21. Outline • Effective tactics • Tools and resources • The evidence • How and where to start

22. 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

23. Need Both: Strategic and Tactical Changes Tactical Strategic • Practice: • Physician-patient communication • Care coordination • Access to care • Organization: • Communication training • Access training • Lab reporting system • Organization: • Leadership and culture • Systematic measurement and feedback • Communication • Improvement Infrastructure

24. Changes for Physician Practices Improving Physician-Patient Communication Refer to page 3 in the guide • Tips • Negotiate the agenda with the patient at the start of the visits • Make a personal connection and demonstrate empathy through eye contact and empathic statements • Provide closure by summarizing next steps and action plan • Resources • Sample concern (aka agenda setting) form • Script for Improving Doctor-Patient Communication • CQC’s Doctor-Patient Communication Teleconference Series (recorded sessions available on our website)

25. Changes for Physician Practices Refer to page 4 in the guide • What does “care coordination” mean to patients? • Tips • Notify patients of all test results • Review patient chart prior to the visit • Resources Improving Care Coordination

26. Changes for Physician Practices Refer to page 5 in the guide • Tips • Handle more than one medical problem during the visit and extend return visit intervals when appropriate • Open same-day appointment slots • Resources • Improved Access Tip Sheet Improving Access

27. Tactical Changes for Organizations Refer to pages 7-8 in the guide • Provide communication training to physicians and staff • Provide advanced access training to physician practices • Provide a systematic approach to reporting lab results to patients and physicians

28. Strategic Changes Refer to pages 9-11 in the guide • Provide direct and visible leadership at all levels of management throughout your organization • Provide routine feedback at the physician level and act on slippage • Communicate regularly and effectively across all levels of your organization • Provide technical support and training

29. 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)

30. Practice Level Results – cont’d Qualitative Results based on semi-structured interviews with 10 of 12 practices • 100% believe they can sustain changes • 80% believe staff satisfaction improved • 80% believe practice culture improved • 80% report improved personal job satisfaction • 72% report improved relationship with IPA • 71% reported that their practice is a “better place to work than 12 months ago” compared to 58% pre-intervention

31. CQC Collaborative Results Wave 1 = 4 groups, 410,000 pts Wave 2 = 7 groups, 610,000 pts State Avg = 225 groups, 10 million pts

32. Getting Started: “The short list” • Patient experience feedback at least quarterly (pg 10 of the CQC Guide) • Teleconference # 2 on March 9 will review options • $150/clinician/quarter • Training on patient communication techniques for clinicians (pg 7 of the CQC Guide) • $400/clinician for 8 hrs of training over 2 days

33. Where Do I Start? • Identify “gaps” • By Domain Use PAS Survey report • By Practice Use Clinician Survey (if available) • Choose your improvements based on gaps and organizational “energy” • Start Small, with a few Practices, then Scale up

34. Identifying Gaps By Domain You can find these tables on page 8 and 9 of your 2010 PAS report. Also, page 6 has your organization’s areas of weakest performance.

35. Identifying Gaps By Practice • 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

36. Start Small, then Scale Up 3 -10 Practices 6 – 8 months 6 – 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 Network Rollout Thanks to Chuck Kilo, MD

37. 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

38. Some Practices Need More TimePatient Ratings for 2 physicians receiving the same training Mission Viejo Family Physician Newport Beach OB/GYN

39. 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

40. 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