• Patient-Centered Care: A Winning Proposition for All

    Chris Anderson Nov 02, 2015

    A shifting competitive landscape and the financial incentives in value-based purchasing spur hospitals to focus on improving the patient experience with more compassionate care.

    Only 10 years ago, the concept of collecting data and measuring a patient's experience with a healthcare provider had barely taken root. The Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality had just completed three years of work and a handful of pilot studies in preparation for releasing the HCAHPS survey, the first national, standardized, publicly reported survey of patients' perspectives of the care they received while in the hospital. CMS adopted the survey in October 2006 and began publicly reporting HCAHPS scores in March 2008.

    Starting in 2007, CMS required hospitals subject to the Inpatient Prospective Payment System (IPPS) to collect and submit HCAHPS data to receive their full annual payment update. In 2013, the agency began incorporating HCAHPS scores into Hospital Value-Based Purchasing (VBP) payment calculations.

    One of four domains used to determine a hospital's total performance score under VBP, patient experience accounts for 30 percent of the score in FY15 and 25 percent in FY16. Depending on the size of the health system and its mix of Medicare patients, falling short on HCAHPS scores can have a significant effect on a hospital's bottom line.

    Beyond Medicare payments, industry experts note an even greater incentive to improve the patient experience—as a key differentiator to help hospitals attract and retain patients in an increasingly competitive healthcare environment.

    Thomas Lee, MD, Press Ganey

    Thomas Lee, MD, chief medical officer, Press Ganey

    The Lost Patient Focus

    In the past 50 years, advances in health care and diagnostics have dramatically improved outcomes for patients in a number of disease states. But these advances have also increased specialization in a way that has slowly shifted the focus from the patient to the technology and methods that will cure the patient.

    "If you go back a hundred years to the time of William Osler, what it meant to be an excellent physician was to stay by the patient's bedside and really pay attention to them to help them understand what was going to happen and then relieve their suffering," says Thomas Lee, MD, chief medical officer for healthcare strategic advisory firm Press Ganey.

    "Then, in the second half of the 20th century, science advanced. We could do bypass surgery, we could treat and cure some cancers. But we focus on doing the things that we can do, even if sometimes they don't change the big picture for patients. By doing those things, it is very easy to get completely focused on the narrow and lose track of the big picture."

    Yet making the shift back to patient-focused care is not intuitive. According to Carol Majewski, RN, director of the office of patient experience at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., clinicians often relate to their own experience as a patient. "But I'm a very atypical patient: I know the system and can be more forgiving of the system than a patient would," Majewski notes. "I think one of the major things many of us have done is believe we knew what patients wanted rather than asking patients what they wanted."

    Elements of a Good Patient Experience

    At Twin Rivers Regional Medical Center, changing from a single-minded focus on outcomes to also providing a good patient experience started in 2012. The effort at the small, 116-bed rural hospital in the "boot heel" of Missouri is led by Steven Pu, DO, chief medical officer (CMO). Pu's major influences in this endeavor have been his experience with a healthcare system during his wife's illness and a presentation he saw in 2011 by patient experience advocate Bridget Duffy, MD, currently the CMO of healthcare technology company Vocera.

    "What resonated with me is she said it needs to be about humanizing the patient experience, reestablishing a more collaborative relationship between physicians and nurses, restoring spirituality as part of the care plan, and actually have the physicians lead the journey," Pu says. This squared with Pu's own experience during his wife's illness, where he observed care being delivered in what he considered the "right" way.

    "It opened my eyes to the fact that I think we are missing the boat on how we deliver care," he says. "You could do all the tasks you want, but from the perspective of patients and their families, what they want is empathy. They want people to care for them. You still have to focus on quality and safety and how that ties in and impacts care, but patient experience drives everything."

    At Twin Rivers, the centerpiece of providing a caring and compassionate patient experience is called the Sacred Moment, a concept developed by the medical center's chief of staff and the staff orthopedic surgeon. This encounter, shortly after admission, allows a physician or nurse to focus solely on the patient to gauge the patient's fears and concerns about being in the hospital. Even though it may last only 10 minutes, the Sacred Moment serves as a way to slow things down and put the patient back at the center of care.

    While the benefit to the patient has been significant—as Twin Rivers' continued year-over-year improvement in patient experience scores attests—it also has manifested in employees. "Once we had employees starting to do that, they realized they were getting as much out of it as the patient, because they were getting to sit down at the bedside with the patient and actually care for somebody again," Pu says.

    Providing a good patient experience also entails simply getting to know patients on a more personal level, finding out what is important to them and how the care they are receiving relates to their values and priorities. According to Majewski, this information can help health systems tailor care to individual patients.

    "It should affect the conversations we are having with patients," she says. "So if your passion is downhill skiing and now you are in Hitchcock having a knee replacement, we don't just say you need to get out of bed and walk so many feet, but instead relate it to your goal to be back out on the ski slopes this winter. So everything we are working with you on is about getting you back to the things that are important to you."

    Gaining Employee Buy-In

    Creating programs to improve the patient experience represents a significant change in the culture of how care is delivered. With health care transforming so rapidly, this change might be seen as yet another in a long line, and it is one that could be difficult for staff to embrace. Majewski acknowledges that referring to her work as "culture change" can be intimidating to staff who are worn down by changes in care delivery or are generally resistant to change. Instead, she refers to it as "culture acceleration."

    That said, employee buy-in and empowerment are important factors in making the organizational changes needed to improve the patient experience. At Twin Rivers, that approach entailed finding not only staff who would be open to the change, but those who could lead the effort. "From my perspective, this needed to be physician led," Pu says. "They needed to be involved at the very outset."

    Pu introduced his ideas to a limited audience, the hospital's physician leadership, to warm them up to the concept. But even this phase, he realized, would require a little nuance. "If you go to physicians and tell them it is about patient satisfaction, they are going to think it's all fluff, so my initial conversations with them were about quality," Pu says. "Everybody understands quality as far as the metrics there, so you talk about quality. You can make that case."

    With the conversation opened, Pu acted to get physicians what he termed some "quick wins" that represented improvements in their work and patient outcomes. After hearing that physicians and nurses had concerns about care quality, Pu collected four or five ideas for improvements the physicians wanted to see implemented. He then made the business case to executive leadership as to why the changes were good for patients and good for the hospital. "We got some resources and made some changes that some didn't think we could get, because we made the business case for them," he said. "Once that happened, all of sudden, the physicians were engaged."

    To take the effort to the next level, Pu sought to develop a collaborative relationship among the physicians, nurses, and the rest of the hospital staff. The key elements were a focus on communicating to staff the physicians' appreciation for all the work they did to make hospital operations run smoothly, and that the physicians were open to hearing their concerns and acting on them.

    To kick off this next phase, Twin Rivers held employee "town meetings" in which employees could voice their ideas and concerns. To get the employees to open up, Pu stood up at the first meeting to run the discussion and asked all the hospital administrators to leave. What followed was "an hour and a half of people bleeding their hearts out about not being able to come to work and feel like they have actually done their job, and that was tragic," he says. As with the physicians' concerns, hospital administration quickly approved a short list of changes designed to help the nurses and other staff—again, after hearing a strong business case.

    This early work highlights a cornerstone of the Twin Rivers program to improve the patient experience. "You can't improve patient experience in your facility if you don't focus on employee satisfaction as well," Pu says.

    Carol Majewski, RN, Dartmouth-Hitchcock Medical Center

    Carol Majewski, RN, Dartmouth-Hitchcock Medical Center

    Data Drive Improvement

    As health care becomes increasingly digital and data driven, collecting and crunching patient experience data is at the center of many improvement efforts. While HCAHPS scores can provide a broad snapshot of a hospital's performance, many turn to outside vendors to take a deeper dive and provide statistically significant patient data tied directly to individual physicians and other care providers.

    Joan Becker, RN, patient experience partner at Barnes-Jewish Hospital in St. Louis, says the health system began using data differently soon after her current boss, Sean Rodriguez, chief experience officer, came aboard in 2011. "Before then we didn't have a lot of access to our patient experience data," Becker says. "Sean really took the bull by the horns and made sure our sample size was big enough, and he went out and showed everyone data that they may not have even known existed."

    In conjunction with a program that requires nurses to make hourly rounds and provide bedside shift reports, the health system has tried to bolster the amount of patient experience data it collects to ensure the data are statistically relevant. It then makes all the data available to the staff to help drive improvement. Becker says this change "woke managers up" to the idea that they were responsible for improving patient satisfaction and that patient experience was a priority at Barnes-Jewish.

    At Dartmouth-Hitchcock, Majewski says, patient experience data take on enhanced significance in the health system's southern region via a program called Achieving Excellence. In this initiative, a small group of physician leaders whom patients rated highly in various metrics have become ambassadors who shadow other physicians and mentor them on aspects of caregiving ranging from their body language and how they communicate with patients to how they interact with their computer during a patient visit. "We have seen some measurable changes in the numbers of physicians who have taken part in this program or requested this assistance to help with their professional development," she says.

    The hospital also relies heavily on nonemployee volunteers called patient and family advisers (PFAs), who serve on committees and task forces that are working to optimize how staff members deliver care. Another team of PFAs does real-time rounding in the hospital to get patients' impressions of the care they are receiving and to collect stories and comments, about both good and bad experiences, which they bring back to the department leaders. "Having a patient as a member of a committee or task force changes the conversation and helps us think about the decisions we are making—how the changes impact patients—and that is something that has not necessarily been a part of our culture," Majewski says.

    The unstructured data collected by PFAs are vital to improving the patient experience. "Some of the stories are positive, and some of them are constructive to help us change," Majewski says. "And it has been very helpful for our staff to see these comments because they may not have realized how they are coming across to their patients."

    Press Ganey's Lee endorses this data-centric approach to improvement. "You can't simply do a few hundred patients via paper surveys once a year," he said. "That may get CMS off your back, if you've met the criteria of 300 surveys per year by paper. But if you want to actually drive improvement so you can compete, then you need data on lots of patients so you can begin to have accountability down to the individual clinician level."

    Top Drivers of HCAHPS Ratings: Overall “Top Box” Within Service Lines
    The top drivers of HCAHPS ratings in a sampling of service lines.

    Better Patient Experience, Better Competitor

    Experts tout patient experience as a key differentiator in today's consumer-driven, competitive healthcare landscape. According to research by Press Ganey, the three most important things that create peace of mind for the patient are, in order: confidence in the clinician, teamwork, and empathy.

    "The really interesting thing is, after you take into account those variables, things like waiting time, convenience, access, and making an appointment didn't matter for likelihood to recommend," Lee says. "What patients really value is: Do you have good people who are working well together and are listening to them?"

    Lynn Barr, chief transformation officer of the National Rural Accountable Care Consortium, notes that the rural hospitals she works with are usually the only game in town and are not included in the IPPS penalties for low HCAHPS scores. Yet even these perceived monopolies have much to gain competitively by improving patient satisfaction.

    What stands out to Barr, when she analyzes data from the organization's 175 member hospitals, is how poorly many perform at capturing the customers closest to them. "We are working with rural health systems and clinics in isolated areas that are a monopoly in their town," Barr says. "They should have 70 percent of the claims, and instead they have 30 or 35 percent—and those are of their attributed lives. Those are their most loyal patients. These are facilities with high costs because their volume is low. If you are a business and want to drive volume, how do you do that? Customer satisfaction."

    It's a dynamic Pu understands well. Although Twin Rivers is the only hospital in town, he estimates five hospitals are within 30 minutes to one hour of his facility. "We have always had significant out-migration, particularly for specialty care," he says. "Patients didn't have as many choices years ago as they have today. So if patients know they are going to get quality care with us, as well as compassionate care, they are more likely to support us.

    "At the end of the day, if we care for patients with empathy and allow staff to serve their purpose for getting into health care in the first place—which is to care for people—we will develop loyalty with our staff and community that no one can regulate or take away from us. This is the key for long-term sustainability for our facility."

    The need for hospitals to compete is also apparent in the terminology now used around creating a better patient experience. Words such as "brand" and "product," once confined to the retail industry, are taking on relevance in health care.

    As Majewski says, "From an organizational perspective, it is about patients wanting to interact with us, their loyalty, and their affiliation with us. They want to see us as creating value for them if they are to continue in the relationship over time to achieve their health goals."

    Lee adds that patient satisfaction and the peace of mind it produces is a product unto itself. "I would make the case that peace of mind is a core product; it may be the product, to tell you the truth," he says. "This is where patient experience comes in: Are we organized to produce that product and stop doing things that destroy peace of mind? I think of peace of mind as an outcome, as a product that is of extreme strategic and historic importance."


    Chris Anderson is a freelance writer.

    Interviewed for this article: Thomas Lee, MD, chief medical officer, Press Ganey.

    Carol Majewski, RN, director, office of patient experience, Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

    Steven Pu, DO, chief medical officer, Twins Regional Medical Center, Kennett, Mo.

    Joan Becker, RN, patient experience partner, Barnes-Jewish Hospital, St. Louis.

    Lynn Barr, chief transformation officer, National Rural Accountable Care Consortium.

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