Name 3 services that relate to patient satisfaction. How can these services be tracked, monitored, and implemented in a practice with technology. Incorporate PCDA, six sigma, or other pro

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Another set of data standards to review in healthcare are satisfaction scores. We’ve briefly discussed this but will go more in depth with this module. The electronic health record’s main function is to provide the data to diagnose and treat patients who are ill or injured. The patient's experience is also important, and depending on locality, is often the motivator on how much an entity should focus on this. Often, medical practices and hospitals that are in areas where there is a lot of competition will want to strive in customer service more than the only office or hospital in town. This module focuses on how satisfaction scores are collected and how the view of the patient will differ than the view of the treatment. Patient satisfaction will typically include the community of care rather than just the hospital visit itself. It is also important to consider the satisfaction of the healthcare staff and some of the programs that capture data and launch programs that benefit those providing care as well.

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The outcomes of this section focus on patient satisfaction scores and how healthcare organizations get these scores. This module also looks at how the patient experience is different than the treatment experience, and how patient experience differs from provider satisfaction. This unit also looks at some programs and relates to how empathy, change management, bedside manner, culture, and leadership have an impact on satisfaction.

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When looking at the outcomes of the electronic health records, there is an emphasis on order entry, the ability for physicians to enter orders that will allow diagnosis and treatment of patients. This creates a connection for health data to be available, for vital signs and results to be monitored, and actions such as medications are managed. The EHR may also function for capturing patient identity and guarantor information, and the charging system captures the charges for services to be reimbursed. There are also quality metrics that measure patient safety, from severe sentinel events to monitoring infections. All these systems support the health status of the patient but none of these capture the patient's experience. Patients as a consumer and customer is a relatively new concept as healthcare is becoming a market-driven industry instead of a scarce resource. Some communities only have one hospital or clinic available, however the growth of the industry in the last 30 years has enabled more available resources. There has also been a shift toward patient advocacy in healthcare leading to a growth in data about how the patient rates the level of service. This creates a new set of success metrics – the hospitals and clinics have to make patients well AND make sure patients are satisfied with the service they receive. This shift in focus to measure the experience as well as the medical outcome creates a "patient as customer" approach found in six sigma, PDCA, and other process improvement methodologies. It also means that we have to be able to determine “what are the customer needs” of the patient as an additional measure of success. Another factor to add here is the patient's family is also added to the collection of customers to consider. The scope of the customer on the patient side of the treatment needs to include areas like caregivers, transportation, people getting medications, medical supplies, and emotional support. This could also include spiritual support. Another consideration in patient satisfaction is the collaboration of care between acute caregivers and clinical primary caregivers. The diagram in the slide comes from a community effort between departments in the Providence hospital in Everett and several clinicians and long-term care facilities in the area to provide a transition of care for the patient. Click the PDCA that will take you to a video that reiterates what you’ve learned in strategic management and discusses patient The video is a quick overview about PDCA that you’ve learned about in strategic management and some PDCA items to review in a healthcare setting. Your discussion post asks you to use this concept or others to create ways of improvement in patient satisfaction with relation to informatics and technology. https://youtu.be/1hCWdJ_W9Ws

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Before 2008, most hospitals and clinics had various patient satisfaction surveys, but the results were not standardized across the industry. Hospital Consumer Assessment of Healthcare Providers is one of the most widely used surveys of the patient's perspective of their hospital care. The survey askes 29 questions about their recent hospital stay and is given between 48 hours and 6 weeks after they are discharged. The questions ask about the experience like the cleanliness and quietness of the hospital and their experience with physicians and staff members. This test was developed with the Agency for Healthcare Research and Quality (AHRQ) and validated by the National Quality Forum. Follow the link from the survey icon to watch a quick video. The effort was started in 2002 and testing was launched in 2008. The scores in each category are calculated and converted to percentiles called "top box" scores. A hospital that has a top box score with the category "communication with nurses" means that this rank is in the top 5% of hospitals that score 90 or higher, which comes out to be the 95th percentile. Another survey is the Press Ganey survey, a 20-question survey that precedes the HCAPS survey. Some hospitals use these surveys or develop their focus group or surveys. A survey is a form that is sent out to customers asking questions about their experience. Surveys are easy to send out but typically have a low response rate. The other issue is that the questions are often too vague to capture the patient's experience. A focus group is an interview with a group of former patients to ask them about their experience. In-person interviews are better in terms of the quality of the data, but often this is difficult to do. Another challenge with surveys is the impact of lagging indicators. One of the weaknesses of patient surveys is that the results are published after the patient leaves the hospital. In a project that I was working on where the results were based on surveys, the results would typically arrive 2-3 months after the patient's discharge. This means that it would take 2-3 months to know if any changes worked. This is a lagging indicator. The longer the available data takes to be recognized, the value of this data decreases. If the patient was asked at the time of discharge, they would still be leaving but the gap would be smaller. Attempting to reduce the amount of time in a lagging indicator helps the analytic process. A leading indicator precedes the event. If a patient is asked before they are discharged how their stay is going, the hospital staff can proactively make adjustments before the patient leaves. The focus on the timing of the data concerning the problem is typically impacted on whether this is a lagging indicator or a leading indicator. Efforts to reduce lags or shift to leading indicators improve data analytics. https://youtu.be/Jhl_JVkqVf0

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The surveys that focus directly on satisfaction can be supported by some of the quality management metrics. Most of the attention on quality scores focus on keeping the patient safe, there are a few that also measure satisfaction. An example of two of these are responding to “never” events and the experience of children and their parents. Some agencies get reports of “never” events like operating on the wrong body part and in the quality metric, the score is how the hospital responds, like if they acknowledge their mistake and apologize. Another metric on children. The quality scores include communication to parents about their condition and medications and how well did doctors and nurses communicate with them. The quality metrics that focus on communication and response are tied to satisfaction scores. The YouTube video on this week’s discussion touches this topic a little further.

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Have you ever filled out a patient satisfaction survey? What did you think about the questions you were asked? Sometimes, the challenge of getting metrics around satisfaction is that the view of the patient journey is more comprehensive than the treatment itself. In most data-driven projects in hospitals and clinics, the focus starts when the procedure starts and stops when the procedure ends. When looking at an Emergency Cycle time project, the time starts when the nurse starts taking vital signs and ends at the decision to admit. This leaves out most of what the patient experiences. This means that metrics that are based on perspective, that are typically subjective instead of objective, qualitative instead of quantitative, makes analytics more elusive. Being able to connect with the patient and to capture this information is more interactive and needs to see the process from the patient perspective. The patient's family, especially those that accompany the patient also need to be taken into consideration. A project to define the path of the patient in a new diagnostic imaging department reduced the patient path from 60 feet to 25 feet, but the family who needed to get to the patient had to walk 800 feet to get to the discharge waiting room. The shift in focus from not only the patient but also their caregivers at home needed to be accounted for in this process.

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The focus on patient satisfaction has created a shift in the healthcare industry from treating diseases to treating people. This parallels the shift of the view of people that work in healthcare. One of the areas that is receiving increasing concern is compassion fatigue. In the emergency department and critical care units, there is a high volume of tension, stress, and dealing with injured patients that leads to compassion fatigue. This situation of long hours and dealing with the physical and emotional needs of patients leads to burnout, detachment and feeling overwhelmed. The result of compassion fatigue is that there is less ability for emotional support and communication from caregivers to enable patient satisfaction. A project in Swedish First Hill studied over 100 nurses and health unit clerks to measure data like the number of patients seen in an hour, length of hours worked, and emotional capacity. The results demonstrated that the higher the compassion fatigue, the lower the patient satisfaction score. This is different from employee satisfaction scores that gauge loyalty and satisfaction in working conditions. I have also been involved in projects that measured employee satisfaction scores. The lower the satisfaction score, the higher the employee turnover. Focusing on patient satisfaction has been improving and working on worker satisfaction is growing as well. Employee wellness programs are designed to address satisfaction and fatigue in the workplace and while they are voluntary programs, they are being offered by more employers.

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One of the challenges to improving patient satisfaction is that there needs to be a problem-solving methodology to get to solutions. Part of this is discovering the customer needs and defining metrics and data standards that meet these needs. Using a national scoring program like CAHPS or Press Ganey provides a comparison between institutions, but it doesn't always match up to user needs. This means that there needs to be a way to connect to patients to define user needs. Another challenge is the caregivers and patient's family satisfaction that needs to be quantified and measured as well. If we can get this data, getting to analyze the data means looking at the right information. The next step is the root cause analysis. Again, this requires connecting with the staff and the patients to get to a root cause. Finally, the solution needs to resolve the root cause and has its metrics for monitoring success. All of this is part of the value that informatics can bring to a healthcare organization and will take time, effort, and commitment from leadership to make this a priority.

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One local hospital had a loyalty program that they used to determine patient satisfaction from responses in the patient portal. The loyalty index was connected to the incentive given to department managers. One of the main issues with using top box scores to improve hospital processes was that they were usually lagging indicators, that a result would be reported three months after the patient was discharged. The loyalty program results had a faster response rate but there were fewer responses, resulting in less confidence in the data. I’ve worked with centers who completed a phone call within 24 hours and text message after 1, 3, 5 and 7 days approach. This data can be skewed because there was no way to track if the answers were duplicated via phone call and text messaging. While the texts stopped if it captured your phone number, it didn’t counter with the verbal response you may have previously given. Another approach is patient wellness plans that include education and motivation given for keeping up with wellness checks. Cardiac wellness programs have seen lots of success through offering classes and sponsoring events to build community and support. Some hospitals have created an executive position called chief experience officer that is specifically accountable for patient satisfaction. One place that the CXO or chief experience officer worked well was at Cleveland clinic. They created a process called service recovery to specifically address how to handle patient issues from a simple mistake in addressing responses to sentinel events. Even though every event was specific, it was handled in the same process. Once the staff learned the steps, there were able to address many of the patient satisfaction issues. The program that was created was Service Recovery or Respond with HEART. The focus is to engage the patient and promote empathy. The steps are to Hear the story and Listen attentively, Empathize, and say, "I can see/hear that you are upset," Apologize and say, "I'm sorry you were disappointed," Respond to the problem and say, "What can I do to help?" Then Thank them and say, "Thank you for taking the time to tell me about this." By having this established script and practicing it, the staff can build trust and empathy to build satisfaction.

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One of the hardest things about patient and provider satisfaction is that the outcomes are intangible. Being able to measure needs like waiting time can be measured, but qualities such as kindness, compassion, helpfulness are values that are difficult to quantify. Data standards have been a means to identify the importance of patient satisfaction, however there is only a limited number of policies and procedures that can be used to enable change. There also must be a shift in the culture. The culture includes the values, unwritten rules, and behaviors of the group of people. One of the approaches to start with is behavior-based actions to measure satisfaction outcomes. The number of times that a staff member speaks directly to a patient and asks how they are, may not be able to gauge the staff member's intent, but the observable behavior counts. When specific behaviors can be identified, then motivation around the behaviors can be reinforced. Another important part of growing a culture of satisfaction is to build joint accountability. When reviewing opportunities for satisfaction are missed, and each member can admit their contribution, improvements can be made. Trying to assign blame breaks down a culture of satisfaction. Another impact is to create opportunities for active communication and empathy. These are interpersonal skills that can be used to improve the experience and increase satisfaction. This requires some education in emotional intelligence and the reinforcement of using these skills. One of the leading ways to strengthen a culture of satisfaction is through leadership and sponsorship. Being able to express, model, and reinforce desired behavior is part of the leader's work. A leader can shift the focus of reactive to a proactive response. One of the examples of improving the culture of satisfaction is from the Thetacare clinic in Wisconsin. When programs on patient engagement were introduced, the leadership (including the doctors), thought this was for front-line workers, like admin. The programs didn't improve until the leaders realized that they needed to promote this as well.

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Jenny

Plan, Do, Check/Study, Act (PDCA) Cycle helps the healthcare organization plan how they will test the change (Plan), try the change on a small scale (Do), observe results of the change (Check/Study), and take action on what was learned by adapting, adopting, or abandoning the plan (Act). Another PDCA cycle can be created to implement the new changes on a small scale and over time, the change can be implemented on a large scale. Ensuring the implementations are tested on different staff, shifts, units, and seasons will help reduce breakdowns. Listening to those who are part of the small scale implementations also help prevent future errors or delays.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) ask patients what happened when they received care, rather than focusing on how they felt about it. CAHPS uses a standard set of questions, which enables healthcare organizations to compare their scores with others. This helps them pinpoint where improvements need to be made. Providers can use this information to look for trends in the scores over time and comparing the results with patient complaints.

The Press Ganey survey is made up of 20 questions and asks about a patient's experience during their visit. Surveys are best asked while the patient is still admitted, the hospital staff is able rectify any concerns before the patients discharged. Surveys typically have a low response rate and the data that is received may be from a visit that happened 2-3 months ago. This causes lags in improvements.

References:

AHRQ Patient Safety. (2019, April 4).  Reasons to choose a CAHPS survey. YouTube. Retrieved November 2, 2022, from https://www.youtube.com/watch?v=Jhl_JVkqVf0

Khilnani, S. (2022).  HCI 320: HCI Data Standards & Interoperability.  Week 7 Patient Satisfaction. Bellevue College. Retrieved November 2, 2022.

Mastroma, M. (2016, August 30).  Plan-do-study-act (PDSA) cycle. YouTube. Retrieved November 2, 2022, from https://www.youtube.com/watch?v=1hCWdJ_W9Ws

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