Improving The patient experience

1. Improving The patient experience Dr. Patrick J. Crocker, MS, DO, FACEP Director of Best Practice Development And your own experience too!

2. The Patient Experience This review contains: • 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

3. 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

4. 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%

5. 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?

6. 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

7. 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

8. 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?

9. 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.

10. 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.

11. 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.

12. 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.

13. 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!

14. 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.

15. 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.

16. 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.

17. 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.

18. 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%.

19. 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.

20. 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.

21. 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?

22. 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.

23. 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.

24. 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.

25. 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.”

26. 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.

27. 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 controlof 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.

28. 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.

29. 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.

30. Nuts and bolts • Acknowledge the patient immediately. • 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.

31. 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.

32. 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. • 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

33. 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

34. 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.

35. 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”.

36. 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.

37. 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!

38. 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.

39. Risk Management pitfalls • The Long WaitWe 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.

40. 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.

41. 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.

42. 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.

43. 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.”

44. 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.

45. 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.

46. HCAHPS CHECKLIST • HCAHPS Physician Questions: • 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.

47. 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 ChangeThere 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: • Positive Deviance [perhaps THE MOST CRITICAL!] • Positive Images • Positive Practice • Positive Reflection

48. Creating cultural change • Positive DevianceDefining 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.

49. Creating cultural change • Positive ImagesMotivating 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.

50. Creating cultural change • Positive PracticePositive 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.