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IHI ExpeditionPutting your Patient Experience Data to Work

Session 5: Fast and Slow Feedback – Best Practices for Both

December 1, 2015

These presenters have

nothing to disclose

Kevin Little PhDKristine White RN, BSN, MBAAngela Zambeaux

Today’s Host2

Rebecca Goldberg, Project Coordinator, Institute for

Healthcare Improvement (IHI), coordinates multiple

projects focused on increasing value in health care by

improving quality and reducing costs. Currently,

Rebecca’s primary responsibility is coordinating and

hosting IHI’s Expeditions, monthly virtual support

programs focused on specific topic areas. Rebecca is a

recent graduate of Georgetown University in

Washington, D.C., where she obtained her Bachelor of

Science degree in human science with a minor in public

health.

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Audio Broadcast3

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What is your favorite December activity or

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Expedition Director

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Angela G. Zambeaux, Senior Project Manager, Institute

for Healthcare Improvement (IHI), has managed a wide

variety of IHI projects, including a project funded by the US

Department of Health and Human Services that partnered

with the design and innovation consulting firm IDEO

around shared decision-making and patient-centered

outcomes research, the STAAR (STate Action to Reduce

Avoidable Rehospitalizations) initiative, virtual

programming for office practices, and in-depth quality and

safety assessments for various hospitals and hospital

systems. Prior to joining IHI, Ms. Zambeaux provided

project management support to a small accounting firm

and spent a year in France teaching English to elementary

school students.

Expedition Objectives

At the conclusion of this Expedition, participants will be able to:

List the variety of patient experience data available in your organization

Identify and avoid wasted effort in use of required data

Discuss the use of complaint data for improvement

Place patient stories in context

Define fast and slow feedback and provide examples of when each is appropriate

Explain the role of leaders in interpreting and using data to drive improvement

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Expedition Sessions

Session 1 – Data Sources: What’s Out There and What Do

You Have?

Session 2 – Understanding Potential Pitfalls and How to

Avoid Data Craziness

Session 3 –Using Surveys, Letters, and Complaints as Data

Session 4 –Storytelling: Patient, Clinician, and Staff Stories

Session 5 – Fast and Slow Feedback – Best Practices for

Both

Session 6 – Leadership from Where You Are and Where You

Are Going

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Faculty

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Kevin Little, PhD, Improvement Advisor, Institute for Healthcare

Improvement (IHI), is a statistician specializing in the use of

information to study, understand, and improve system

performance. His experience in application of statistical methods

includes direct work with scientists and engineers in a range of

disciplines. He has also coached improvement teams in a range of

industries. Dr. Little served as Improvement Advisor to the

National Health Disparities Collaboratives from 2001 to 2006, and

to IHI's Hospital Portfolio of projects from 2010 to 2012. Recently,

he has worked on the measurement strategy for the Healthier

Hospitals Initiative and led a pilot to improve physician

communication behaviors.

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Faculty

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Kristine K. S. White, RN, BSN, MBA, Principal, Aerate Consulting, and

Co-Founder, Aefina Partners, LLC, previously served in senior leadership

roles at Spectrum Health. Her areas of expertise include leadership and

system design for cultures of excellence and innovation, integrating

innovation practices and skills into organizations, and readying cultures

and organizations to solve problems and identify new tools and

processes for the future. Ms. White has worked with physicians to

increase the effectiveness of physician communication efforts and with

leaders and teams to drive meaningful improvement in the patient and

family experience in organizations of all types and understand and utilize

patient experience data sets. She has also coached senior teams to

strategically focus and prioritize efforts that yield value to patients within

their systems. Ms. White is passionate about integrating patient and

family advisors into the design and evaluation of health care and has

helped many organizations build the infrastructure and processes to do

so. Her aim is to connect leaders and health care teams to a clear

purpose, with measurable and sustainable impact and value to patients

and their families.

Agenda

Assignment Review

The Prius Principles for Feedback

Case Example 1: Access Community Health Center

Case Example 2: Christiana Care Chemotherapy

Outpatient Unit

Case Example 3: Improving Physician Communications

in acute care

Summary

Assignment for Session 6

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Assignment for Week 5

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The Assignment: Fast and Slow Feedback

Fast Feedback: Information about performance that gets

studied and acted on within 24 hours-- the "S A" steps of

PDSA for control or improvement.

Over the next two weeks, be a bit of a detective:

– Find out if your organization is doing anything around “fast

feedback” to improve patient experience.

– Look at a recent formal project to improve patient

experience in your organization, did the project incorporate

"fast feedback?" Why or why not?

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What is Slow Feedback?

Any feedback that is not fast.

Typical slow feedback will be formal patient

experience surveys required by government

agencies and similar formal surveys. The survey

response is usually separated by days or weeks

from specific care experiences.

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Pinnacle Health Fast Feedback

Rounding by Nurse Manager

Patient Experience Coach interview process"These individuals not only round on the staff, they coach and validate staff on their patient interaction skills. This program also provides tools that helps ease and improve communication between our patients, providers, and staff members. Another facet of this program is interviewing patients directly, to gather information on their experience and determine if the coaching has had a positive effect. This project does incorporate fast feedback. Coaching and validation occurs in real-time and is presented after live observations of the staff members between patients. The use of fast feedback in this case gives staff members support on behaviors and actions that they are performing well and one area for improvement that can help their interactions with our patients in the future."

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Be Careful with Question Wording!

"The questions asked of our patients cover subjects relevant [to HCAHPS], but may not be directly related to the HCAHPS surveys "

--Pinnacle Health example emphasis added

HCAHPS regulations limit the kinds of questions and wording you may ask of patients in hospital. Is

this true of other government surveys?Reference: http://www.hcahpsonline.org/Files/QAG_V10_0_2015.pdf pp. 22-24

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Feedback Example: Driving a Prius

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Informing Ecological Design, LLC has designed and developed feedback

systems related to energy use in buildings since 1999. The feedback

systems have had only intermittent impact. Why?

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Does Feedback Change Behavior?

“The next big force for behavioral change

may be technology that brings consumers

face-to-face with their energy consumption.

A simple version of such energy feedback is

the dashboard of a Toyota Prius hybrid car,

which displays the rate at which the car is

burning gasoline. No one has carried out a

controlled study of how drivers react to it,

but ‘every person I know who has a Prius,

they get a big grin when I mention feedback,

and they have to tell me their personal story

about how they’ve reduced their energy

use,’ says Armel [Carrie Armel, Stanford

University].”

Science 14 August 2009: Vol. 325 no. 5942 pp. 804-811, "Leaping the Efficiency Gap" by Dan Charles

Prius 2010: display above steering20

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Why feedback works in a Prius-I

Performance measurements are defined and captured reliably--Toyota engineers figured out how to

(a) calculate the instantaneous mileage;

(b) capture the right values; and

(c) transmit signals to drive the dashboard display .

They’ve worked out the data plumbing and have refined the display design over several model cycles.

http://www.hybridcars.com/hybridcarscom-gets-75-mpg-2010-toyota-prius-25680/

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Why feedback works in a Prius-II

(1) Display in your face, all the time;

(2) Easy to interpret display for better mileage;

(3) You change accelerator and brake behavior to

move the display;

(4) You control the pedals--you're in the driver's

seat!

(5) Prius drivers are motivated to actually drive

differently and many do so.

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Given the data plumbing…

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Chat Question

Is the Toyota Prius mileage feedback

designed to be

Fast?

or

Slow?

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Feedback changes performance if…

You can get the data (the data plumbing works)

and you:

(1) sense the data (see, hear, smell, touch…)

(2) interpret the data: what do the data mean?

(3) connect interpretation to timely actions that can improve

performance

(4) have the power to act based on (3) "be in the driver's seat"

(5) actually act

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Prius Principles and Rounding by Nurse

Manager: Why it Works-I

The "data plumbing" doesn't need computers or

wireless connections to the cloud—data acquired

and summarized by brains of smart people who

are adaptable, flexible and able to sense

performance.

Maintenance does not require IT technical support

(though may require caffeine and strong culture

focused on great patient care)

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Prius Principles and Rounding by Nurse

Manager: Why it Works-II

Principle Details

Sense Hear patient words, see face and body language….

Interpret Use training and human experience to get meaning

Connect to timely action

Mitigate service/care problems right away; identify coaching opportunities for staff to improve use of standardized work

Have the power to act

Nurse manager has authority and accountability--in the driver's seat!

Actually act Management system should expect Nurse manager to act--standard work for leader.Director of Nursing can round to study!

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Access Community Health Centers Primary Care Clinic Case Example

Dan Martin, Director of Quality

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Background

Federally Qualified Health Center, not required

to submit patient experience surveys to U.S.

Government but have used CG-CAHPS

Have used Avatar to manage patient experience

surveys; will terminate contract with launch of

new system (in the past, patients might get both

Avatar and CG-CAHPS surveys)

Focus: Core patient experience questions

related to access and provider interactions

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Informing Ecological Design, LLC • Madison, WI12/1/2015

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CG-CAHPS type questionswill be asked (no more than eight); can also add two optional, for each clinic's focus

Informing Ecological Design, LLC • Madison, WI12/1/2015

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Primary Care Clinic Patient Experience Daily/Weekly Data Flow—Plan Fall 2015

Pat

ien

tC

linic

Man

ager

3rd

Par

ty D

ata

Syst

em

Phase

Answer questions about experience

after visit using iPad at kiosk/station

Review Daily Report

Process Daily Patient

Responses in close to real

time

Generate Daily Report on N Patients via email

Follow up with individual patients if

flags raised (logic TBD)

Generate Weekly report on patients for entire clinic

and by provider via email

Review Weekly report for trends and opportunities entire clinic and by

provider

Interact with Clinic Manager, depending

on review of daily report

Identify changes to test to improve performance; allocate staff time and

resources

Update Dashboard, accumulate data

Surveys anonymous but may be

able to match pt to

comment?

Dan will monitor the response rate: surveys

completed/clinic volume

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Degree of Belief-1 Why will patients take

time at check-out to respond?

(1) If clinic staff see the data demonstrate

improvements (e.g. in access to appointments)

and if data are used to acknowledge individual

staff members from comments, then staff will buy

into the use of fast(er) feedback.

(2) If clinic staff buy into the use of fast(er)

feedback, then they will encourage patients to

take the time to respond at checkout.

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Degree of Belief-2 Why will patients take

time at check-out to respond?

Call with a community health center using the

system "just like us" sealed the deal on this

approach to fast(er) patient experience feedack.

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Strengths of the Plan

Outsource the data plumbing and management to

experienced vendor; sister CHC has used vendor and

been satisfied.

Dedicated project team has tackled the challenges

systematically (e.g. how surveys and data will affect

workflow)

Addressing challenge of preferred language (e.g. Hmong

patients will need translator initially)

Initial question focus will be on access, improvements

already planned (e.g. adding providers); match admin data

T3NAA to patient perception.

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Plan strengths, generalized

Outsource tasks that are not core value-adding

services

Systematic approach to addressing problems:

dedicated work group with schedule of tasks and

decisions

Attentive to population differences

Focus initial application on area where the data

can demonstrate change

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Poll Question about response rate

One clinic will use a kiosk with iPad in the waiting area, one clinic will have an iPad at the check out desk.

Which clinic do you expect to see a higher response rate?

(1) "Waiting Area" clinic

(2) "Check out desk" clinic

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Christiana Care outpatient Chemotherapy Case example

Ann-Marie Baker, Senior Program Manager Patient Experience

Christiana Care

P36

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Informing Ecological Design, LLC • Madison, WI12/1/2015

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30-50 patients a day for GYN Oncology chemotherapy unitsUnit A operated/owned by Christiana Care, with CC physicians (10-15 pts/day)Unit B operated by Christiana Care, with mix of community and CC physiciansUnit C managed by another entity, CC responsible for the physical space

Informing Ecological Design, LLC • Madison, WI12/1/2015

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1. Press-Ganey patient experience surveys have flagged issues:We're not explaining what to expect during treatment; not explaining side effects, not explaining follow up.

2. Incomplete information shared by office practices, leading to gaps in information and inability of CC to provide seamless care, e.g. re: follow up after treatment.3. Very low number of PG surveys returned (e.g. 6 patients of 28 replied to recent survey request); PG survey results are delayed--many days after service event.

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Informing Ecological Design, LLC • Madison, WI12/1/2015

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Chemotherapy Patient Experience Daily Data Flow—Plan Fall 2015P

atie

nt

Un

it M

anag

erV

ice

Pre

sid

ent

CC

Dat

a Sy

stem

Phase

Answer questions about experience

during Chemo session

Review Daily Report

Accumulate Daily Patient Responses

Generate Daily Report on N Patients; looks like existing Daily Clinical

Report

Follow up with individual patients if

flags raised (logic TBD)

Generate Weekly report on patients; looks like existing

Weekly Clinical Report

Review Weekly report for trends and opportunities

Review Weekly report for Trends and opportunities

Interact with Clinic Manager, depending

on review of daily report

Identify changes to test

to improve performance; allocate staff

time and resources

Informing Ecological Design, LLC • Madison, WI12/1/2015

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Review of Questions Oct/Nov 1. Patient-Family Advisors reviewed the initial draft of questions, suggested focus2. Ann-Marie and managers discussed the key items that managers were working on to tie questions to a few items.

Too Many questions!

Proposed Question Topics September 20151. Ease of scheduling appointment1.1 Easy to check in2. Wait to be seen3. Suite clean and tidy4. Communication with patient topics5. Nurse listening re concerns and questions6. Doctor conversation prior to visit7. Expectations met question8. Change one thing to be better question9. Open Comment Box

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Informing Ecological Design, LLC • Madison, WI12/1/2015

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Strengths of the Planning

Unit Managers are eager for faster and more complete

data on patient experience.

Pt Family Advisors reviewed the draft questions.

Will deploy in the smallest unit starting 23 November;

this unit is owned and operated by CC.

The questions and report can be further refined; IT

support person available/skilled.

Leveraging existing investment in iPads and in-house

data acquisition/report preparation related to depression

screening.

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Planning strengths, generalized

Data systems should start with end-users

engaged

Get Patient perspective

Start small and learn by doing

Assure resources available for revision of data

system

Manage costs of your data systems (bang for

buck)

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Poll Question

In the current plan, every patient will be asked to respond to the experience survey. In addition some patients will receive a similar experience survey from Press-Ganey.

Based on your experience, do you expect the response rate on the Press-Ganey surveys to

(a) increase (b) stay the same or

(c) decrease

once the new in-clinic surveys are in place?

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Physician CommunicationProject: From theory to feedback

Kevin Little, Ph.D. IHI Improvement Advisor

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Background

Six hospitals explored an intervention to improve

patient evaluation of physician communication

(as measured by U.S. HCAHPS survey)

Focus was on hospitalists; several hospitals

extended the work to ER docs, surgeons, OB

GYNs.

HCAHPS survey data viewed as slow feedback.

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47Driver DiagramOutcome Primary Drivers

HCAHPS raw scores and

percentile scores will improve in 12

months

Bundle 101-Four Behaviors

1. Knock

2. Introduce self

3. Sit

4. Ask the most worried/concerned

question.

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Our Fast Feedback Method

The feedback form

– Behaviors

– Patient perceptions

Method to administer form (steps)

– Feedback to physicians: Who, What, When.

Summary feedback table and graph

– Used to engaging physicians

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Fast and Slow Feedback Together

Fast Feedback

– Allow patients to assess specific physician

behavior in Bundle 101, proposed to "make a

difference"

– Show that use of Bundle 101 corresponds to

better patient perceptions of an encounter

Slow Feedback (HCAHPS)

– To show connection with Fast Feedback

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Fast Feedback

1. Feedback form on

paper

2. First four questions—

yes or no on behaviors in

the bundle

3. Next four questions—

patient perception of the

conversation

4. One open-ended item.

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Using Fast Feedback

Purpose Which encounters?

Feedback Cycle

Action Focus

Cement link between providerbehavior and pt perception

Encounters of specific providers testing or using the behaviors

Minute to hours

Provider

Track group performanceover time

Randomencounters

Days to weeks Group(s) of providers

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Individual Events History 53

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HCAHPS Physician Communication Scores Top Box Jan 2011-Oct 2013 with median thru Aug 2012 (vertical dashed

line and start of intervention) ; national percentiles 12 months ending

Sept 2012, Hospital A

Use of Bundle 101 is associated with better immediate patient perception of communications and

higher (better) HCAHPS scores

good

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Weakest Points in our work

Data Plumbing: Maintaining the effort to acquire

the patient feedback

Actions to align behavior with Bundle 101:

physician agreement to behave consistently in the

defined way.

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Summary

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Key Points

• The Prius principles apply to fast and slow feedback.

• Slow feedback typically is weak in helping you interpret & connect data signals to specific actions.

• Fast feedback has the potential to drive fast improvement but it is not just a matter of hardware & software

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Prius PrinciplesPerformance measurements

are defined and captured

reliably

AND you

1. sense the data

2. interpret the data

3. connect the

interpretation to timely

action

4. have the power to act

5. actually act

Assignment for Session 6

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Assignment

If you were the CEO of your organization, what

would you do starting today to get greater impact

from patient experience data?

From your current position, what is ONE thing you

will do and ONE thing you need to create a

sustainable and balanced data plan?

Expedition Communications

• All sessions are recorded

• Materials are sent one day in advance

• Listserv address for session communications:

patientexperienceexpedition@ls.ihi.org

• To add colleagues, email us at info@ihi.org

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Session 661

Leadership from Where You Are and Where You Are GoingDecember 15th, 1-2pm EST

Thank You!

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Angela Zambeaux

azambeaux@ihi.org

Rebecca Goldberg

rgoldberg@ihi.org

Please let us know if you have any questions or

feedback following today’s Expedition webinar.

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Appendix: Method Notes

If you want to test and then implement fast feedback about patient

experience in your organization, we offer a few reminders.

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Hypothesis: Dr Chris Hayes

Change initiatives

that do not add

additional workload

and have high

perceived value

are more likely to

be adopted, cause

less workplace

burden and

achieve the

intended outcomes

More adoptable

Less adoptable

Perceived value

Workload

SameReduced IncreasedSource: Chris Hayes, MD, MSc, MEd, FRCPC http://highlyadoptableqi.com/

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Informing Ecological Design, LLC • Madison, WI

source: Table 7.1 G. Langley et al. (2009), The Improvement Guide, 2nd edition, Jossey-Bass, San Francisco © Associates in Process Improvement, used with permission.

Guidance on Scale of a Test

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

A P

S D

A P

S D

Investigation Demonstration Implementation

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Unless changes are integrated into "daily work", changes will not stick. E.g. job descriptions and job training following current best known methods, link to supervision, etc.

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Core competency: training and coaching

1. Identify key jobs

2. Teacher* breaks down job

“Know what”“Know how”

“Know why”

3. Teach one-on-one

4. “If the student hasn’t

learned, the teacher hasn’t

taught.”

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”the way to get a person to quickly remember to do a job correctly, safely and conscientiously.” p. 73

*supervisor!