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CHAPTER 1
The Heat Is On: A Case Study
In healthcare, conversations like these are becoming common:
Among physician leaders of a private practice: "Our group should be able to do better than 20th percentile satisfaction scores from our patients. We can't play the blame game here. It's on us. And it's embarrassing."
A hospital administrator to his contracted emergency medicine (EM) group: "We need higher patient satisfaction scores from our physicians. I'd prefer it to be with you guys, but I'm willing to switch groups if I need to."
A medical director to a confidant: "Dr. Smith's colleagues seem to respect his clinical skills, but he sure seems to rub his patients the wrong way. He's only been here six months, and he leads the place in patient complaints."
A hospitalist to a colleague: "My patient satisfaction scores are lower than most of my partners'. I'm more than a little self-conscious about it. What do they know that I don't?"
These doctors and leaders are concerned for good reason. Satisfying patients is a key to good patient care, provider satisfaction, and business success. As I expanded my consulting practice to help doctors better engage with their patients, I also started helping practice leaders and hospital administrators create environments that simultaneously support and require better physician–patient interactions.
I have looked on as some of my client-doctors flawlessly handled difficult situations, often under tight time constraints. These interactions are a thing of beauty. I've also helped open doctors' eyes to changes that immediately resonated with their patients. I've seen individual doctors and whole groups raise their patient satisfaction scores from mediocre to the 99th percentile. The personal satisfaction and professional pride they gain from this transformation is unmatched. It's gratifying to know that, over the careers of these physicians, those new behaviors will positively affect thousands of patients.
But early on, I noted that some of my clients couldn't seem to make changes and improve their scores, though they understood what they needed to do to get better and seemed motivated to improve. When I got tired of feeling irritated and disappointed in these instances, I went to work to figure out why some doctors didn't improve when others did — and how to bridge that disconnect.
I talked with my clients and researched change theory from psychology and business. I also borrowed a few insights from my experience as a Baldrige Performance Excellence examiner and from my tenure as a leader at a Malcolm Baldrige National Quality Award–recipient hospital.
In short, I became a student of the ideal physician–patient interaction and the path to get there. Over time, it became clear that successful interactions — and unsuccessful ones — have fundamental commonalities.
No, engaging patients is not rocket science. But there's a lot more to being appreciated by the patient than most people consider. Their appreciation is earned when doctors are mindful of and master specific behaviors. And I've noted again and again that physicians are most successful when their organizations create an environment that requires, supports, and recognizes high performance.
What I learned changed the way I approach my work. And my clients' success rates improved further as a result. Now I use the insights outlined in this book to help those who lead physicians make and sustain changes that their patients notice and appreciate.
No quick fix exists for turning around patient satisfaction scores from mediocre to exemplary, but the case study that follows offers proof that it doesn't have to take all that long, either, when transformation becomes a priority.
TO 99TH PERCENTILE IN PATIENT SATISFACTION: ONE GROUP'S STORY
Patient satisfaction scores can improve rapidly — not just for individual doctors but for whole groups of doctors. Take the experience of a client of mine, an emergency medicine (EM) group that made incredible progress in just one year — and has sustained it since.
The Practice
First Physician Corporation (FPC) is a privately owned physician group. It employs 11 EM physicians and 17 mid-level providers who see patients exclusively at Charlton Memorial Hospital in Fall River, Massachusetts.
Fall River is a coastal community located near the Rhode Island state line. It is predominately blue collar with a large Portuguese-speaking population. As a two-hospital town, Fall River is also served by Saint Anne's Hospital, part of the Steward Health Care System.
More than 70,000 patient visits occur each year in the Charlton Memorial emergency department (ED), with about 40 percent of those served through a fast-track urgent care model staffed by the mid-level providers — physician assistants and nurse practitioners.
FPC has always been proud of its stability and the quality of its providers. Many have been with the group for a decade or more.
FPC's Patient Satisfaction Results, Before
For years, the group focused on providing good care, efficiently delivered. It tracked the performance indicators common for EM providers: patients seen per hour, patients returning to the ED within 72 hours, admission rates, rates of mortality or transfer to the intensive care unit within 24 hours, and adherence to Centers for Medicare & Medicaid Services quality measures.
The group didn't pay much attention to patient satisfaction scores, which weren't great. That changed in 2010 when Charlton Memorial's competitor, Saint Anne's, was acquired by a new owner that soon announced a capital infusion into significant facility upgrades in the Saint Anne's ED and a strategic focus on increasing ED market share.
In no position to match the facility upgrades at Saint Anne's, the leaders at Charlton Memorial quickly zeroed in on the poor patient satisfaction scores in their ED. What had been a non-issue suddenly came into sharp focus as both a problem and an opportunity.
Charlton Memorial's senior leadership asked FPC to improve its patient satisfaction scores as a part of the broader effort to improve the scores for the ED as a whole. Much discussion ensued, both between the group and the hospital and among FPC doctors. The physicians knew they had to embrace the hospital's challenge; because the group gets paid for each patient it treats, their livelihoods were at stake.
Brian Tsang, MD, FPC president (personal communication, November 5, 2014), recalls:
My personal patient satisfaction scores were among the lowest in the group, and that helped me convince the group to accept this shift in priorities, because anything I asked them to do, I was going to have to do, too.
On this and other efforts, Dr. Tsang has worked in partnership with Lissa B. Singer, NP, MBA, CPC-I, the group's chief quality officer (personal communication, November 13, 2014). She notes:
It was important for us to show the hospital that we were in the game, committed, and serious about improvement. Patient satisfaction is just one of our improvement initiatives, but once things start moving in a positive direction, it became really hard to not want that continued success.
Tsang made one key request of Charlton Memorial's leaders: The hospital had to invest in obtaining a larger sampling of ED patients for its patient satisfaction survey. With a larger sampling, each provider could obtain a more convincing, and more statistically reliable, number of patient surveys each quarter, adding to the credibility and reproducibility of individual scores.
Making Decisions and Gaining Momentum
Through the spring and summer of 2012, FPC decided how to proceed. It took a while, and that patience was key to the success of the effort. Tsang says:
We're very democratic. That means things take a little more time, but the final decisions have more buy-in. And I know that the best ideas don't come from me. The group will eventually make a good decision if you let people participate and give it some time.
Interestingly, the group's patient satisfaction scores began to climb even before its first round of ideas was implemented (see Exhibit 1.1). Simply raising awareness of the issue prompted the doctors to make subtle changes in the ways they engaged with patients.
FPC started its improvement journey by providing the following educational materials to each member:
• Slides from an EM conference presentation on improving patient satisfaction
• Improvement tips from the group's patient satisfaction survey vendor
• A recent article on patient satisfaction from Consumer Reports that included scores from Massachusetts doctors
At the same time, it made the decision to share individual satisfaction scores with physicians on a periodic basis. Each provider received her individual patient satisfaction scores by e-mail, along with the scores of every other provider in the group. At first, the peer data were blinded; each provider knew her scores and could view the anonymous scores of everyone else in the group.
Six months later, FPC leaders unblinded individual provider names in the results. Each provider would know exactly how he stacked up against everyone else.
Rather than being fearful of exposure, the providers saw this step as a natural evolution of the information sharing that had come before. Furthermore, it caused a great deal of discussion among providers about the results and how some in the group were able to achieve higher scores. Tsang emphasizes that the scores weren't seen as measures of the providers' value as human beings but merely as another important measure of performance.
Finally, the doctors decided that the initial educational materials they received, while helpful, didn't go far enough to aid in their continued improvement. So they interviewed outside coaches who could provide one-on-one shadow coaching and facilitate group conversations about especially challenging issues.
Importantly, the group never lost sight of the big picture. The cross-town competitor was threatening the entire Charlton Memorial ED, and the FPC doctors understood their role in helping the ED improve the patient experience. Tsang says:
We had to take ownership of what we could do to address the problem. Our ED was facing a new competitive threat. And if we didn't respond, our livelihood could be threatened.
It was tempting to play the role of the victim and blame the hospital and its ED staff, who had at least as much room for improvement as our group did. We decided we had to fix our own house first. We knew that the reason patients come to the ED is to see the doctor. If we could improve that part of the experience, overall scores for the total experience might rise, and we would have caused that to happen through our efforts.
The other benefit of making headway on our own performance is that we could show the rest of the ED team that it could be done. We could be the role model. They couldn't credibly make excuses once we had proven it could be done.
We worked with the hospital ED staff to support them and reinforce positive behaviors, but the most important thing we did was to get our own house in order.
FPC doctors began to work with ED staff on basic scripting and raising awareness. Two early examples were making sure that staff never left a patient without inquiring about his comfort and always greeting patients upon arrival with, "Welcome to Charlton Memorial Hospital. How can I help you?"
Coaching Intervention
In September 2012, I spent a week with FPC, mostly shadowing and coaching individual providers but also providing education and facilitating discussion in small groups. FPC's "naturals" — those who were born patient-interaction superstars — received minimal coaching time, perhaps one or two hours each. Most "typical" providers received two to four hours of shadowing and coaching, depending on their historical patient satisfaction scores.
I gave each provider immediate, individual feedback on his strengths and opportunities for improvement. Following these discussions, each provider identified a short list of key changes he could make to improve interactions with patients.
Some immediately began practicing their "single most important change" so I could be available to watch and provide support. All received a written report summarizing key strengths, a prioritized list of change opportunities, and goals.
Examples of Strength Feedback Comments
"Very nice job of putting the chest pain patient at ease. He was very anxious, and you made his anxiety go away just by explaining how you were going run some tests to rule out the potentially serious causes."
"You connected with all your patients almost immediately. You greeted them all by name."
"You always paused before leaving the exam bay and asked if they had any questions or if anything was unclear. Very nice job."
"You always took a few extra seconds to share your clinical thinking with each patient. They understood the 'why' behind everything you did. They appreciated that, and as a result they had very few questions for you."
"You made a point to say good-bye to that lady as they were transporting her upstairs. She was so pleased to hear that. And she sincerely thanked you for your help."
Examples of Opportunity Feedback Comments
"When you have to leave the room for just a minute to get supplies, remember to tell the patient why you're leaving and that you'll be right back. Don't make them guess why you're leaving or how long you'll be gone."
"Always say good-bye, wish them well, and shake their hand."
"You left the room several times without asking for questions. One time the patient's family member shouted a question at you as you were leaving. Remember to pause and ask for questions before each time you leave."
"Slow down — especially when you first meet a patient. Give it a moment for you to build a rapport before beginning to rattle off your questions."
"Nice job with that elderly patient with many medical problems. The only suggestion I have is to pause toward the end of your interaction and summarize your main points and what's going to happen next. There were a lot of things going on with her, and I'm not sure she totally understood everything that was happening."
In the small discussion groups I facilitated, the providers took the opportunity to ask questions, learn from each other, and share personal insights. From this process, Tsang recalls:
We had to reset our thinking as emergency medicine providers. As EM doctors we like to treat critically ill patients. But most ED patients aren't very sick. In fact, most have non-life-threatening conditions, but the symptoms have made them so worried that something terrible is happening that their fear and anxiety actually become their most acute problems.
The fact is that we never thought our noncritical patients needed much of our attention. We also felt powerless to help them if they did not have a treatable acute diagnosis. Once we knew that a patient wasn't seriously ill, we mentally moved on to the next patient, hoping they might have a problem that we could actually fix.
We needed to change that mind-set. We needed to see ourselves as caring for not just a few critical patients but an entire community, and embrace the noncritical patients as just as important as anyone else. We needed to understand that even if there was no treatable emergency, these patients needed something from us, that we could provide that something, and that they would appreciate our help just as much as or more than the patient we had just resuscitated in the next room.
Our thinking matured so that we understood that satisfying our noncritical patients was not really that hard. It just required a shift in focus — away from the ABC's and critical actions and toward active listening, empathy, connection, and validation. It doesn't take that much more time, but it does require investing more of our real selves (as opposed to our doctor selves) in patient interactions. The unexpected benefit is that this approach turns potentially frustrating patient interactions into positive ones and makes the job more rewarding overall.
Post-coaching Acceleration
To maximize and leverage the impact of their investment in shadow coaching, the doctors looked for opportunities to hardwire what they had learned into their practice. One especially effective method was a quarterly "confessional," a mechanism that allowed the group to maintain a conversation on individual patient satisfaction improvement efforts over time.
(Continues…)
Excerpted from "The Best Patient Experience"
by .
Copyright © 2016 Health Administration Pres.
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