Quality & Performance Improvement in Healthcare: Patient Centered Care Tiffany Berry, MD Chief Patient Experience Officer Angie Hochhalter, PhD VP Patient Centered Care Redesign Baylor Scott & White Health Office of Patient Experience Objectives 2 After this session, the learner will be able to discuss how performance improvement tools can be applied to improve outcomes tied to patient- centered care. Define patient-centeredness and patient experience Describe sources of data representing the perspectives of key stakeholders for patient experience improvement Discuss strategies for engaging patients in health and healthcare as solutions to prioritized issues What is Patient Centered Care? 3 Patient-centeredproviding care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. Crossing the Quality Chasm, 2001 4 MorganGleason.com 5 Patient Centered Interactions Patient Experience Provider and Staff Experience Clinical and Operational Outcomes 6 Patient Centered Interactions Patient Experience Provider and Staff Experience Clinical and Operational Outcomes Why Is Patient Experience Performance Increasingly Important in Healthcare? 7 Efforts to improve outcomes Individuals are responsible for more of their healthcare costs Transparency of pricing and quality have increased, allowing more informed choice among options Transparency of experiences on social media and crowdsourcing sites Individuals are taking more control of their personal health Many products/services are available outside of traditional healthcare Other industries have focused on consumers and human-focused design Many healthcare systems are improvingimprovement is necessary to keep pace and compete Payments and other healthcare metrics are affected by our degree of patient-centeredness BSWH Patients Will Experience 8 Compassionate We will put ourselves in the unique position of the individuals we serve and ask how we would feel in that moment. What would we want to experience? Exemplary We will meet the needs of our patients by ensuring the experience is safe, of the highest quality, and will always based on the best evidence available. We will be open and honest in all aspects of the care we provide. Personalized Because we respect our patients as consumers and individuals, we will customize the experience of the patient based on his/her individual goals, values and preferences. Collaborative We collaborate with patients, families, and other members of the care team to empower patients to achieve their best possible outcomes. Patients and families have input on organizational decisions that affect those we serve. How do we measure patient experience? 9 Typical Healthcare Patient Experience with Surveys Consumer Assessment of Healthcare Providers and Systems Set of surveys developed, tested, and managed by AHRQ Measure constructs consumers are in the best position to rate Measure what consumers identified as important to themextensive consumer testing CMS and others usually use CAHPS surveys to evaluate performance relative to others (administration is regulated when used for this purpose) 2. Vendor Survey Questions Additional questions either with or without CAHPS surveys Intended to drive improvement and capture other information Not used by CMS or other agencies to measure performance Compare to others in the vendor database Example: HCAHPS (hospital) questions Scored in domains Communication with nursing Communication with doctors Staff responsiveness Pain management Communication about medicines Cleanliness and quietness Discharge information Overall rating Centers for Medicare and Medicaid Services (CMS) and Experience 12 Specified surveys are required in several settings: Hospital, Clinic, Home Health, Hospice, Dialysis, and more coming soon Hospital performance is part of Value Based Purchasing, which impacts hospital revenue Hospital performance is publicly reported on Hospital Compare at Medicare.gov Case Study: Improve HCAHPS Performance: Communication with Doctors Domain 13 All data and comparative analysis are fictitious; created solely for this case study 1.Review your recent performance handout with your group. 2.Generate a request for the additional information your team needs to begin working on improving performance. For each, list a.What question do you want to ask? b.What is the source of the information? c.What are your top 3 priorities on the list? Domain Score Performance This Month Fiscal Year Goal Top Box %79.9%86.4% Percentile Rank64 th Approx. 90 th 14 What data do you need? Why? Case Study: Improve HCAHPS Performance: Communication with Doctors Domain BSWH Improvement Pyramid 15 Examples: Organizational and Team Culture 16 Bedside nurses have lower engagement scores than nurses who do not do direct care Nurse engagement is highest in the first 6 months on the job and then drops off Bedside hospital nurses often see communication improvement tactics as just another thing to do. Depsey et al, 2014 In 2012, 54% of physicians would choose medicine as a career if they could do it over againdown from 69% in 2011 (Medscape Physician Comp Report) BSWH Improvement Pyramid 17 Patients and Families are Important to Improvement Efforts 18 Survey comments Feedback on exit surveys and rounding Patient and Family Advisory Councils Crowdsourcing and social media BSWH STEEEP Academy Version: Model for Improvement 19%20Toolkit%20Booklet%202014%20print.pdf Case Study: Use Additional Data and Group Input to Identify Issues Leading to Your Identified Problem 20 Problem: Top box performance on the HCAHPS Doctor Communication Domain for October 2015-January 2016 is 85.1%, which is below the hospital goal of 86.4% for Fiscal Year Issues Identified: Case Study: Prioritize Issues 21 BSWH Office of Patient Experience Support 22 Survey contracts, management, and ad hoc reports Goal-setting and strategic planning Process improvement support and sharing best practices Staff & Provider training Internal and external transparency Patient engagement and shared-decision making Informing Potential Patients through Transparency in Performance 23 Transparency Can Drive Performance: University of Utah Case Example 24 Began star ratings in 2013 Increased traffic to physician search website over 2 years Improved survey performance by approximately 25 rank scores over 2 years (physician communication, recommend) Increased percent of providers scoring in 99 th percentile (17% to 26%) 25 Patient Experience Clinical and Operational Outcomes Patient Centered Interactions Provider and Staff Experience 26 What may be unintended consequences of patient experience survey use in healthcare? Example: Unintended Survey Impact on Physicians 27 Zgierska et al, 2014; Patient Prefer Adherence Esurvey of state medical society on influence of patient experience surveys on job satisfaction and clinical care (N=155) 28.3% considered quitting current job or leaving profession because of survey use 19.8% had employment threatened because of surveys Part of a Bigger Picture? 28 29 Example: HealthPartners 30 Boffeli et al, 2012; Perm J. Stages of physician reactions to low patient ratings What do physicians believe about patient experience surveys and productivity? What do high-performing (experience + productivity) physicians do? 31 Boffeli et al, 2012; Perm J. (Table 1) 32 Boffeli et al, 2012; Perm J. Stages of Reactions from Physicians Leaning of Weak Patient Experience Scores Stage 1: Resistance/Denial Im not a salesperson. I didnt go to medical school to please people. Im providing great care, so why does it matter? Stage 2: Initial Acceptance I want to make my scores better because Im tired of seeing bad numbers. Resolve to general actions like try harder, do better Stage 3: Initial Frustration I just spent a year trying to improve, but its not getting better, and it may be worse. And I dont even know how to measure it. Stage 4: Seeking Meaningful Help Im looking for answers. Tell me what I need to do to change. 33 Boffeli et al, 2012; Perm J. (Figure 1) Productivity relative to targets Negative Recommend Office Score High-High 34 Boffeli et al, 2012; Perm J. (Table 2) 35 Patient Centered Interactions Patient Experience Clinical and Operational Outcomes Provider and Staff Experience Levels of EngagementConsultationInvolvement Partnership and shared leadership Direct care (individual level) Organizational design and governance Policy making Factors influencing engagement: Patient (beliefs about patient role, health literacy, education) Organization (policies and practices, culture) Society (social norms, regulations, policy) Continuum of Engagement Carman et al., Health Affairs, Levels of EngagementConsultationInvolvement Partnership and shared leadership Direct care (individual level) Organizational design and governance Organization surveys patients about their care experience Care delivery sites involve patients as advisers or advisory council members Patients co-lead hospital safety and quality improvement committees Policy making Factors influencing engagement: Patient (beliefs about patient role, health literacy, education) Organization (policies and practices, culture) Society (social norms, regulations, policy) Continuum of Engagement Carman et al., Health Affairs, Levels of EngagementConsultationInvolvement Partnership and shared leadership Direct care (individual level) Patients receive information about a diagnosis Patients are asked about their preferences and treatment plan Treatment decisions are made based on patients preferences, medical evidence, and clinical judgment Organizational design and governance Policy making Factors influencing engagement: Patient (beliefs about patient role, health literacy, education) Organization (policies and practices, culture) Society (social norms, regulations, policy) Continuum of Engagement 38 Carman et al., Health Affairs, What does it look like when patients engage in direct or self care? 39 Find good care Communicate with providers Organize health care Pay for care Make treatment decisions Participate in treatment Get preventive care Plan for the end of life Seek health knowledge Center for Advancing Health Engagement Behavior Framework, How do physicians, nurses, staff, and organizations engage patients to make sure care is patient-centered? 40 Patient-centeredproviding care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. Crossing the Quality Chasm, 2001 41 How do you engage patients in healthy behaviors? Rational Actors 42 People pursue the option that maximizes self-interest based on information, price, quality and function Butpeople are sometimes uninformed and forgetful To engage Educate Remind Give feedback Scare Offer incentives 43 Simple, plain language prose Easily-identified quantitative information One-step calculations 36% US Dept Education; National Assessment of Adult Literacy, 2003 HL component 44 https://www.youtube.com/watch?v=BgTuD7l7LG8 American Medical Association Health Literacy Video 45 Typical interventions to engage patients require effortful processing Educate Remind Give feedback Scare from risks Offer incentives 46 Originally, Becel Heart Health Institute Some need it more than others https://vimeo.com/ 47 Health Decisions Ambiguous evidence Complex Emotional Sometimes rushed Automatic processing is often guiding decisions Tendencies of the Automatic System (intuitive, affective, guided by heuristics) 48 Aversions: Ambiguity Fear (ostrich effect) Loss (will take smaller gains over bigger losses) Preferences: Familiar, likable, and expert sources Consistency in choices Short-term Reciprocity What others are doing Assumptions: Cost = quality Anecdotes/experiences are in the majority Martin & Cialdini, 2010; Kanehman, Tversky et a. 2002 Example 1 49 Framing Choices Choices depend on gain and loss We give more weight to certainty Which lung cancer treatment do you prefer? 50 AB During Treatment Year Years3422 Number Alive out of 100 Treated Both Treatment A and Treatment B are medications administered to the patient hospitalized for cancer. Both are given intravenously and neither one has significant side effects. Treatments A and B are considered equal except in their survival rates. 69% 51 AB During Treatment100 1 Year Years6678 Number Dead out of 100 Treated 68% 52 Radiologists and grad students were also influenced by framing Subjects choosing Treatment B DeadAlive Male pts with chronic illness 6831 Radiologists 6251 Grad students 5327 Example 2 53 Use precommitment to leverage consistency bias Consistent self-image Doing what we said we would do 54 Milkman et al.2011 Levels of EngagementConsultationInvolvement Partnership and shared leadership Direct care (individual level) Patients receive information about a diagnosis Patients are asked about their preferences and treatment plan Treatment decisions are made based on patients preferences, medical evidence, and clinical judgment Organizational design and governance Policy making Factors influencing engagement: Patient (beliefs about patient role, health literacy, education) Organization (policies and practices, culture) Society (social norms, regulations, policy) Continuum of Engagement Carman et al., Health Affairs, Understanding cognition helps us understand patient behavior, but is insufficient for building meaningful partnerships. How do you partner with patients? 56 Communicating Empathy Effective Explanations 57 https://www.youtube.com/watch?v=1e1JxPCDme4 Cleveland Clinic Empathy Series. Patients: Afraid and Vulnerable https://www.youtube.com/watch?v=1e1JxPCD me4 Quality & Performance Improvement in Healthcare: Patient Centered Care 58 Tiffany Berry, MD Chief Patient Experience Officer Angie Hochhalter, PhD VP Patient Centered Care Redesign Baylor Scott & White Health Office of Patient Experience