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Introduction to Improving the Patient Experience Part 1 – April 1, 2010. Jill Steinbruegge, MD Diane Stewart, MBA. Agenda. An Evidence-based Approach to Improving the Patient Experience. Jill Steinbruegge, MD. First, a definition. Health Outcome. +. How Care is Delivered. Patient Value.

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Introduction to Improving the Patient Experience Part 1 – April 1, 2010

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introduction to improving the patient experience part 1 april 1 2010

Introduction to Improving the Patient ExperiencePart 1 – April 1, 2010

Jill Steinbruegge, MD

Diane Stewart, MBA

first a definition
First, a definition

Health Outcome


How Care is Delivered




Price Paid


Non-monetary Costs

The Patient Experience

How care is delivered = interaction with patients and their families

Price paid = out-of-pocket costs to patient (premium and co-pays)

Non-monetary costs =impediments to obtaining care (e.g., delays, waits, hassles)

business case for improving service
Business Case for Improving Service
  • Research in service in other industries shows
    • 40% of customers who switch to a competitor cite poor service as the reason
    • Increasing customer retention by only 5% produces a 30%-80% increase in profitability in other industries
    • Customers judge quality based on their experiences
    • Value is always determined from the customer’s perspective
  • KP found the same is true in health care
    • Member retention reduces cost
    • Improved access reduces cost
measuring improvement in the patient experience
Measuring Improvement in the Patient Experience
  • Moving CAHPS (health plan) scores
    • CAHPS and PAS (physician group) scores
    • Timing of improvements
  • CAHPS and geography
    • East vs West
    • North vs South
key drivers of the patient experience
Key Drivers of the Patient Experience

Effects of key drivers on overall measures of satisfaction are cumulative

  • Satisfaction with physician
  • Ability to see primary care physician
  • Access
    • Appointment – days wait for an appointment
    • Telephone – time on phone to schedule appointment
  • Ease of seeing a specialist
  • Helpful staff
satisfaction with physician
Satisfaction with Physician
  • The physician-patient relationship is at the heart of the patient experience
    • All MD questions are highly correlated
  • Satisfaction with PCP affects
    • Health outcomes
    • Satisfaction with specialist
  • Improving satisfaction with physician
    • Physician communication training
    • Incentives tied to MD scores
satisfaction outcomes
Satisfaction Outcomes

Patient-centered care increases physician satisfaction and retention

Enhanced physician-patient communication is highly correlated with patient satisfaction and trust in the physician

health outcomes
Health Outcomes

Improved patient perception of overall health status

Increased adherence to physician recommendations and better self-management of chronic conditions

Better physical functioning in daily activities

Improved health outcomes: Diabetes, high blood pressure

financial outcomes

Selecting a physician most highly influenced by how well the physician communicates and shows a caring attitude

Doctor-patient communication and visit-based continuity are key factors in patient retention

Patient-centered communication results in fewer diagnostic tests and referrals

Good communication reduces malpractice risk

access primary care
Access – Primary Care
  • Appointment and telephone access (tend to be correlated)
  • Access to primary care physician (as defined by the patient)
    • Seeing own PCP has a halo effect on other PAS measures
    • Loss of continuity increases utilization of ED and hospital
access specialty care
Access – Specialty Care
  • Access to specialty care physician
  • Total days wait for appointment (includes waits for PCP, lab, radiology)
  • Ease of referral
  • Patient perception of “wait time”
    • Impact on daily life
improving access
Improving Access
    • Advanced access – Capacity management (supply-demand) system
      • Know what you need, know what you have, act on the gap
    • Appointing system – Simple rules with adequate appointment supply to PCP
  • Leadership
  • Constant focus
leadership actions
Leadership Actions
  • Visible leadership at all levels to set expectations and motivate staff
  • Leadership structure with clear accountability for improving service
  • Resources
    • Staffing
    • Analytic
    • Training
  • Reward and recognition
leadership is critical at all levels
Leadership is Critical at All Levels
  • High performing teamshave high patient satisfaction, high morale and high quality measures
  • Leaders of these work units
    • Put patients at the center of all work
    • Motivate team members to improve team performance
    • Involve all team members in decision-making
    • Reward and recognize team members for their contributions

Leadership creates a service culture

  • Effective tactics
    • Tools and resources
  • The evidence
  • How and where to start

Based on the experiences of three year-long efforts with 15 medical groups / IPAs

High impact changes with tools and resources

Changes at the practice and organization

Strategic changes

need both strategic and tactical changes
Need Both: Strategic and Tactical Changes



  • Practice:
  • Physician-patient communication
  • Care coordination
  • Access to care
  • Organization:
  • Communication training
  • Access training
  • Lab reporting system
  • Organization:
  • Leadership and culture
  • Systematic measurement and feedback
  • Communication
  • Improvement Infrastructure
changes for physician practices
Changes for Physician Practices

Improving Physician-Patient Communication

Refer to page 3 in the guide

  • Tips
    • Negotiate the agenda with the patient at the start of the visits
    • Make a personal connection and demonstrate empathy through eye contact and empathic statements
    • Provide closure by summarizing next steps and action plan
  • Resources
    • Sample concern (aka agenda setting) form
    • Script for Improving Doctor-Patient Communication
    • CQC’s Improving Physician-Patient Communication Teleconference Series (tentative May 2010)
changes for physician practices24
Changes for Physician Practices

Refer to page 4 in the guide

  • What does “care coordination” mean to patients?
  • Tips
    • Notify patients of all test results
    • Review patient chart prior to the visit
  • Resources

Improving Care Coordination

changes for physician practices25
Changes for Physician Practices

Refer to page 5 in the guide

  • Tips
    • Handle more than one medical problem during the visit and extend return visit intervals when appropriate
    • Open same-day appointment slots
  • Resources
    • Improved Access Tip Sheet

Improving Access

tactical changes for organizations
Tactical Changes for Organizations

Refer to pages 7-8 in the guide

  • Provide communication training to physicians and staff
    • Teleconference Series in TBD in May
  • Provide advanced access training to physician practices
  • Provide a systematic approach to reporting lab results to patients and physicians
strategic changes
Strategic Changes

Refer to pages 9-11 in the guide

  • Provide direct and visible leadership at all levels of management throughout your organization
  • Provide routine feedback at the physician level and act on slippage
  • Communicate regularly and effectively across all levels of your organization
  • Provide technical support and training
evidence these practice changes work
Evidence These Practice Changes Work

Study Design: Matched control physicians within same IPA

  • Greater improvements in all communication and care coordination measures compared to controls (2-3 points)
  • Changes sustained over time (re-survey 6 months post-intervention)
  • Physicians with Largest Gains:
    • Started with lower scores at baseline
    • Demonstrated greater engagement as compared to controls (6 point gain)
practice level results cont d
Practice Level Results – cont’d

Qualitative Results based on semi-structured interviews with 10 of 12 practices

  • 100% believe they can sustain changes
  • 80% believe staff satisfaction improved
  • 80% believe practice culture improved
  • 80% report improved personal job satisfaction
  • 72% report improved relationship with IPA
  • 71% reported that their practice is a “better place to work than 12 months ago” compared to 58% pre-intervention
cqc collaborative 1 results
CQC Collaborative #1 Results

CQC Avg = 4 organizations, 400,000 pts State Avg = 225 organizations, 10 million pts

getting started the short list
Getting Started: “The short list”
  • Patient experience feedback at least quarterly (pg 10 of the CQC Guide)
      • Teleconference # 2 on April 7 will review options
      • $150/clinician/quarter
  • Training on patient communication techniques for clinicians (pg 7 of the CQC Guide)
      • Doctor-Patient Communication teleconference series TBD in May
      • $400/clinician for 8 hrs of training over 2 days
where do i start
Where Do I Start?
  • Identify “gaps”
    • By Domain Use PAS Survey report
    • By Practice Use Clinician Survey (if available)
  • Choose your improvements based on gaps and organizational “energy”
  • Start Small, with a few Practices, then Scale up
identifying gaps by domain
Identifying GapsBy Domain

Find your scores on Page 6 of 2009 PAS Report

identifying gaps by practice
Identifying Gaps By Practice
  • Look for:
  • Practices with lots of your patients
  • Average, or just below average, scores
  • When you are just getting started, find some potential “champions” to engage early
start small then scale up
Start Small, then Scale Up

3 -10


6 – 8 months

6 – 12 months

  • Learn about getting results at your practices
  • Develop physician and staff champions
  • Understand what it takes from the group to support practice changes

Design systems and tools to support changes across many sites



Thanks to Chuck Kilo, MD

some notes on engaging clinicians
Some Notes on Engaging Clinicians...
  • To start, one-on-one face-to-face conversations
      • To start, medical director with manager and patient reports
  • Offer assistance, invite participation
  • Anticipate stages of reacting to data
      • May 26 Engaging Physicians in Change Workshop, Long Beach
some practices need more time patient ratings for 2 physicians receiving the same training
Some Practices Need More TimePatient Ratings for 2 physicians receiving the same training

Mission Viejo Family Physician

Newport Beach OB/GYN

final thoughts
Final thoughts...

Improving the patient experience benefits physicians, patients and the organization

Improving physician-patient communication is key to improving the patient experience

Measurement and training are the foundation to improving physician-patient communication