Spotlight Case February 2007

1. Spotlight Case February 2007 The ‘Customer’ Is Always Right

2. Source and Credits • This presentation is based on the February 2007 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available through the Web site • Commentary by: Niraj L. Sehgal, MD, MPH, UCSF School of Medicine • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Understand the importance of identifying a patient’s agenda • Appreciate the factors that contribute to unmet patient expectations • Define the concept of patient-centered care • Understand the relationship between patient-centered care and safety, quality, and patient satisfaction

4. Case: The ‘Customer’ Is Always Right An 18-month-old female was brought to the family medicine clinic with a chief complaint of “rash and diarrhea.” Five days earlier, the patient’s mom noted a rash on her daughter for which she was advised to administer diphenhydramine (Benadryl) as needed. While the rash improved, the child developed diarrhea and low-grade fever. The mother also revealed that her daughter had fallen from a 1.5 foot high bed earlier and appeared unsteady. She expressed concern that her child might have a fracture and requested an x-ray.

5. Case: The ‘Customer’ Is Always Right Physical exam revealed a fussy child with normal vital signs and no evidence of ecchymosis, edema, or localized tenderness in the extremities. The child was somewhat unsteady when placed on the floor to stand and was uncooperative with an attempt to demonstrate her gait. The resident physician’s diagnosis was “viral syndrome” causing the diarrhea and low grade fever. He attributed the child’s unsteadiness to the Benadryl, perhaps exacerbated by the viral infection.

6. Case: The ‘Customer’ Is Always Right The resident advised the mom that a fracture was unlikely based on the exam findings. He discussed his findings with the attending physician, though he did not specifically mention the mother’s request for an x-ray.

7. Identifying the Patient’s Agenda • History taking skills include linear, focused questions based on a succinct chief complaint • Providers quickly focus in on the problem rather than identifying the broader agenda • In practice, only one-third of clinical encounters begin with open-ended questions Marvel MK, et al. JAMA. 1999;281:283-287. Dyche L, Swiderski D. J Gen Intern Med. 2005;20:267-270.

8. The Open-Ended Question • Only 59% concordance rate between physicians and patients when no open-ended solicitation occurs • 85% concordance when patients given opportunity to express complete agenda Dyche L, Swiderski D. J Gen Intern Med. 2005;20:267-270.

9. The Open-Ended Question • “What brings you into the clinic today?” • “What concerns do you have today?” • “How can I help you?” • “Anything else?”

10. Identifying the Patient’s Agenda • Providers tend to interrupt patient’s opening statements after 18-23 seconds • Without interruption, it takes a mere 6 additional seconds for patient to completely share agenda Marvel MK, et al. JAMA. 1999;281:283-287.Beckman HR, Frankel RM. Ann Intern Med. 1984;101:692-696.

11. Unmet Expectations • Nearly 10%-15% of office-based visits are associated with an unmet expectation • Usually the result of physician omissions in history taking, physical examination, or diagnostic testing Kravitz RL, et al. Ann Intern Med. 1996;125:730-737.Bell RA, et al. J Gen Intern Med. 2002;17:817-824.Peltenburg M, et al. Ann Fam Med. 2004;2:534-540.

12. Patient Satisfaction • Assessed via surveys of time spent with providers, the quality of the interaction, and the perceived quality of care received • The direct relationship between meeting patients’ expectations and their level of satisfaction is obvious, though whether this relationship improves the quality and safety of care is a more complex question

13. Case (cont.): The ‘Customer’ Is Always Right Later that evening, the mother went to the emergency department to request an x-ray because of her daughter’s inability to bear weight. An x-ray was performed, which showed a non-displaced fracture of the tibia, requiring placement of a cast. Frustrated with the sequence of events, the mother felt that her concerns at the first visit were not heard.

14. How Would You Feel as a Parent? • Angry: “The incompetent doctor should have listened to me.” • Guilty: “I should have pushed harder for the x-rays knowing something was wrong.” • Righteous: “I knew it! I know my kid better than anyone.” • Worried: “Will it heal correctly now?”

15. Patient-Centered Care • “Health care that establishes a partnership among practitioners, patients, and their families to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.” Committee on Quality of Health Care in America, Institute of Medicine. 2001.

16. Picker Institute’s 7 Prime Aspects of Patient-Centered Care • Respect for the patient’s values, preferences, and expressed needs • Coordination and integration of care • Information, communication and education • Physical comfort • Emotional support • Involvement of family and friends • Transition and continuity The Institute for Alternative Futures on behalf of The Picker Institute; July 2004.

17. Current System: Provider-Centered Care • Many current systems seem designed to meet needs of providers rather than patients, supported by varying adoption of patient-centered practices in a recent survey Audet AM, et al. Arch Intern Med. 2006;166:754-759.

18. Patient-Centered Care Initiatives • Transforming Care at the Bedside effort • Joint publication from the American Academy of Pediatrics and the American College of Emergency Physicians See Notes for complete references

19. Take-Home Points • Using open-ended questions and eliciting a patient’s full agenda requires little additional time when done well. This skill should be taught, practiced, and evaluated • Focusing on patient satisfaction independent of quality, safety, and efficiency creates an inherent tension that is important to understand • Patient-centered care is a necessary commitment, which may contribute to improved patient satisfaction and higher quality and safety in care