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Aine Cryts is a freelancer based in Boston. She is a frequent contributor to Managed Healthcare Executive on topics such as diabetes, oncology, hospital admissions and readmissions, senior patients, and health policy.
Hospitals innovatively improve the patient experience as the industry shifts to value-based care.
Bert Thurlo-Walsh, RN, associate chief quality officer, didn’t always have patient experience under his area of influence at Newton-Wellesley Hospital, which is part of Boston’s Partners HealthCare. In fact, leadership of the patient experience used to reside under three different vice presidents at the hospital.
That all changed when Michael R. Jaff, the hospital’s new president, took over the helm in 2016 and Thurlo-Walsh was subsequently promoted to his current role in February. As a result of his promotion, he now has Press Ganey, quality reporting, and patient experience as part of his responsibilities at the hospital.
With his arms fully around the patient experience at Newton-Wellesley, Thurlo-Walsh can help drive and monitor program results that are intended to improve the patient experience.
What follows are six initiatives hospitals have undertaken to improve the patient experience.
1. Educate patients about medication side effects
To provide education about medication side effects and to encourage adherence, patients in Newton-Wellesley’s rooms, including the emergency room bays, see posters prompting them to “Ask Me 3”-or three questions-about their medications of their physicians. Another component of the campaign, which kicked off in early 2017, is telling patients that their physicians may ask them medication-related questions.
“This way, they know it’s a bi-directional conversation,” says Thurlo-Walsh. “Usually, patient satisfaction tends to be one-sided, but this experience becomes a collaborative experience between the two. It also helps to engage the patient in their own medication management in ‘owning’ those [medications], which is what we need them to be able to do when they leave the hospital.”
Equally important to learning about side effects is adherence, which can be a challenge among the elderly and patients with fewer economic resources. If patients can’t afford their medications, there’s a downstream effect which can result in a hospital readmission. In situations where finances are a challenge, the patient is matched up with a member of the case management team who can help troubleshoot this issue on their behalf.
Once the staff began to roll out the campaign, Newton-Wellesley witnessed an initial increase in communication about medication scores. However, over time, it became clear that additional education was required.
“We saw a slight decrease in the [Hospital Consumer Assessment of Healthcare Providers and Systems] HCAHPS score, which continued until January and February, that correlated to an increased inpatient medical consensus. The nursing leadership have worked with teams to reinforce the need to be consistent,” he says.
2. Acknowledge and thank patients for feedback
Most patients spend about seven minutes completing the HCAHPS survey that gives feedback about their healthcare experience. Thurlo-Walsh wants to make sure Newton-Wellesley does something with that information-namely, reaching out to patients to acknowledge receipt of their comments.
“Patients make comments. Some are good, some aren’t so good. But you can drive improvements based on those comments,” he says. That’s why when the surveys come back to Newton-Wellesley, the results will go back to the manager or area director, who then calls the patient to thank them for their feedback.
These follow-up phone calls typically take place approximately four months after the patient submitted their survey, but it takes between six and eight weeks to receive the results from Press Ganey, says Thurlo-Walsh. Feedback from patients is broad, and can include comments about cold hospital rooms or that a “nurse was crabby,” for example.
When patients complain in person during their hospital stays, the employee’s manager will get involved in addition to the patient advocate to mitigate the situation, he adds.
Responding to patient feedback in real time at the hospital “lets patients know that they’re heard, that their feedback didn’t go into a ‘black hole,’” says Thurlo-Walsh. While it doesn’t happen often, he says the hospital will sometimes send flowers or a parking coupon to a patient who had a negative experience. That’s part of what he calls the hospital’s “service recovery,” which involves acknowledging that the hospital should have done better and is taking note of specific patient comments.
3. Drive change in response to feedback
Patient feedback goes to the service operations team on a monthly basis, says Thurlo-Walsh. At weekly team meetings, which include managers of all of the service lines and ancillary services, negative comments are selected and then randomly assigned to team members. Each team member is then responsible for following up with the patient impacted by the negative event and determining if there are more “global problems” impacting the larger patient population that need to be solved, such as an infection control problem, for example.
Other feedback from patients has included comments about the need for kosher foods, which the hospital’s new director of food services has addressed, and the need for more parking. Thurlo-Walsh explains that parking will likely always be a challenge on the suburban hospital campus because it’s landlocked.
One service that garners a great deal of positive feedback from patients and their families is Newton-Wellesley’s valet service, whereby patients can hand their car keys to a valet outside the emergency room entrance. For $9, the valet will park the patient’s car and retrieve it for them after their visit.
4. Give updates to families during surgery
About 1,300 miles southwest of Boston at Orlando’s Arnold Palmer Hospital works William DeCampli, MD, a pediatric cardiovascular surgeon and director of The Heart Center at the hospital. One challenge he has experienced throughout his career is figuring out the right way to keep patients’ families updated throughout the course of his patients’ surgeries.
The problem was that surgeries could be lengthy, and long periods of time would elapse when families didn’t know whether or not surgeries were progressing well-or if there were problems, he says.
After trying for a few years to deploy either a hospital intensivist or a nurse practitioner or physician assistant to check in on the status of patients’ surgeries and then update their families in person, he determined that this wasn’t the best way to utilize his medical colleagues’ time or medical education. Their “success rate” was typically no higher than 50% because family members were often anxious and went to the hospital cafeteria or left the hospital altogether, thus making it very difficult for them to receive in-person updates on their loved ones.
For the last 18 months, DeCampli and his pediatric surgery team at Arnold Palmer Hospital have used Electronic Access to Surgical Events (EASE), to provide real-time updates to patients’ family members. They receive updates via an app, which can be downloaded at the iPhone App Store and on Google Play. Before deploying the app, DeCampli and his team determined the appropriate cadence of updates in 20-minute intervals by studying family members’ anxiety levels by direct interview.
(The EASE application is developed by an Orlando-based company of the same name, where DeCampli serves as chief clinical safety officer and co-founder.)
The app functions by having patients’ family members download it onto their smartphones. Smartphones are available to people who don’t have their own phones. Every 20 minutes or so, parents receive an update on their family members’ status in the operating room. This starts once the patient is successfully put under anesthesia and continues at other critical stages during surgical procedures. The events are highlighted for updates by a nurse on the team because they’re also the source of potential complications during surgical procedures, says DeCampli. Options for messages sent to family members include short, personal text updates, and images and video.
The process of communicating this flow of information with family members starts before the surgery when DeCampli has to explain the procedure and its associated risks-that’s when the anxiety begins, he says.
With ongoing communication, their anxiety is relieved. For example, there’s the induction of anesthesia, which is done in the operating room for babies. That’s another source of anxiety for parents because the anesthesiologist has told them about the associated risks. To help allay parents’ concerns, the operating room nurse takes a photo of the baby and sends it with a message letting them know the baby is asleep.
Another benefit of ongoing updates is, when he goes out to talk to the families after surgery, they look completely different than they would have without such updates. “After a four-hour heart operation, [family members typically] look haggard, exhausted, hungry, tearful, and with sweaty palms. It’s completely different now because they already know what I’m going to tell them.” Thus, his in-person conversations with family members can focus on recovery, he adds.
In the event that a problem occurs during surgery, DeCampli says the surgical team relies on a physician or other clinician to provide in-person updates about the patient on a similar schedule as they experienced with the app.
According to an eight-month comparison study, surgical patients who were involved in EASE-based surgical updates reported 3.9% higher Press Ganey scores.
5. Provide urgent care options
Anselmo Nuñez, MD, chief executive officer of Bon Secours Medical Group at Bon Secours St. Francis Hospital in Greenville, South Carolina, says approximately 30% of the patients served by his health system aren’t interested in having a relationship with a primary care physician. But these patients still get sick and need access to healthcare, which is why the health system now provides access to six urgent care centers where patients can go if they have a cold or need an immunization, for example.
“We’ve found that even patients who have relationships with primary care providers often prefer to walk in [to the urgent care center], get their problem solved, and walk out-and not have to deal with insurance and co-pays … it’s things like that that are pretty bureaucratic and impose on peoples’ time,” says Nuñez.
While he admits that Bon Secours St. Francis’ urgent care centers are a good fit for the needs of young people in their twenties who only want to interact with the healthcare system when they’re sick and young families in which parents are juggling work and family lives, Nuñez highlights that urgent care centers also increase access for all patients, including seniors.
“We also see older people who may have a primary care provider, but can’t get in to be seen for a problem they want solved right away,” explains Nuñez.
The reality is, many patients aren’t looking for a primary care provider. What matters most is that patients have a choice. “They may be briefly educated on the advantages of wellness, continuity [of care], and prevention, but there are a lot of 28-year-olds who are kind of invincible and don’t want to get involved with the healthcare system,” he says. “We try to respect consumers’ choices, while at the same time providing appropriate care.”
6. Leverage lean methodologies
Another approach Bon Secours St. Francis is taking is to adopt the concept of “lean methodologies” to re-engineer how patients receive their healthcare. The end result is simplified scheduling and workflow changes, which mean that it’s easier for patients to schedule appointments.
For example, there’s been a dramatic decrease from 120 days to as few as two days for a patient to get a “third next-available appointment,” which is defined by the Institute for Healthcare Improvement as the average length of time in days between the day a patient makes a request for an appointment with the physician and the third available appointment for a new patient physical, routine exam, or return visit exam.
Nuñez’ journey began about eight months ago when his medical group of approximately 300 physicians, which provides services to the healthcare network, kicked off the process of reorganizing how they deliver care. Fifteen of the practices-half are primary care and half are specialty practices-undertook this work, which required both clinicians and administrative leaders to determine the roadblocks to delivering care.
For example, one senior physician was particularly devoted to a “pod” structure at his practice, which means that the exam rooms are clustered in pods around the physician who has dedicated clinicians to help him with patients. After being educated on lean processes-and while working alongside a “very data driven” administrator at the practice--that physician became convinced to break away from the pod system and to have team members rotate throughout the practice to provide care. The end result was that physician, who used to see about 24 patients a day, was able to see approximately four more patients daily.
As a result, the medical group’s HCAHPS score has gone up 7%, says Nuñez. He adds that much of that improvement is driven by increased access to care, which is possible because the practices have simplified appointment types, moved from rules-based scheduling to time-based scheduling, and worked through a backlog of appointment requests.
“Understanding all of that and being able to measure and manage it is key to being able to really improve your access to care. It requires our managers to manage a lot of data and analytics,” he adds.
Aine Cryts is a writer based in Boston.