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As a Board-certified orthopedist and hand surgeon, I was disappointed recently when the quality of my follow-up care after prostate surgery fell quite short of the hospital care I received. I elected to go 450 miles from home for the surgery because of the reputation of the surgeon and the hospital, and it was a very positive experience. In the hospital, every member of the surgi-cal team “managed up” the experience and expertise of everyone else on the team and demonstrated great care for my physical and emotional well-being.

Under CG-CAHPS, high-performing

medical practices will be better reim-

bursed for Medicare and Medicaid pa-

tients than low-performing practices,

which will be penalized.

However, when I returned for my follow-up ap-pointment at the surgical office, it was obvious that my surgeon and his advanced practice professional (APP) were both unfamiliar with my concerns and had not re-viewed my written responses to their intake questions. I’d been anxious to better understand the significance of the tumor breaching the capsule—or whether it was possibly a surgical artifact—given my recent normal prostate-specific antigen (PSA) test. And, I wondered whether the mild residual urinary incontinence I was experiencing was considered normal at this stage. However, the APP wasn’t even aware I’d had a recent PSA test, and the surgeon did not address my concerns. How could my hospital and office practice experiences differ so radically?

Closing the GapsThe aim of CG-CAHPS—or Clinician & Group

Surveys–Consumer Assessment of Healthcare Providers and Systems—is to close these kinds of gaps. The Cen-ters for Medicare and Medicaid Services is now using this patient survey to incentivize medical practices to

improve the outpatient experience, much like Hospital CAHPS (H CAHPS) is doing for hospital inpatients.

Under CG-CAHPS, high-performing medical prac-tices will be better reimbursed (for Medicare and Med-icaid patients) than low-performing practices, which will be penalized. As early as 2015, these (or similar) survey scores will provide the foundation for changes that potentially impact up to 70 or 80 percent of reim-bursements for those practices impacted by value-based purchasing. (For more detail about the different types of practice surveys, view the CG-CAHPS 101 webinar at www.studergroup.com/IPCclinic.)

CG-CAHPS is not about “smile school” but rather about getting back to the core of what we do as provid-ers: delivering quality outcomes for patients. Strong per-formance on the CG-CAHPS survey is usually associated with decreased liability risk, improved clinical outcomes, and reduced provider burnout. While it’s technically just a score, it serves as an important barometer for deter-mining the quality of the patient experience we deliver.

Patient’s Eyes and VoiceJust as we use lab tests to help determine whether

a patient has an infection (like a high white cell count), so too can CG-CAHPS help us understand where we can best focus our efforts to improve the patient experience, because it represents the patient’s eyes and voice. Just as the patient’s white cell count generally goes down when we treat the infection successfully, so too will CG-CAHPS results improve when we treat the underlying issues in the practice.

It’s important to understand that CG-CAHPS data is already publicly reported at www.medicare.gov/physicancompare.gov. Do you know what your patients are saying about their experiences in your office? Your communication? Your follow-up on test results? How helpful and courteous your office staff are?

Patients don’t live in our world and don’t share our training, so they cannot differentiate among providers on the technical quality of care. They see only bits and pieces of what we do and they assess quality based on their experience.1 If we don’t provide patients with a

CG-CAHPS Is Here New Tools Improve the Patient Experience

BY JEFF MORRIS, M.D., M.B.A., FACS

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MARCH 2015 AMGA.ORG x GROUP PRACTICE JOURNAL 39

positive experience, we place both our practice reputa-tion and market share at risk, particularly in today’s era of viral blogs and Facebook posts on wait times.

Similarly, numerous studies show that a poor patient experience correlates with high liability risk.2 Patients usually do not take legal action based on real quality of care concerns, but, more often, based on quality of communication (e.g., the provider was rude, did not accept phone calls, did not listen or seem to care). Communication is key3—even with unfavorable clinical outcomes—to retaining patient trust and reduc-ing lawsuits.

Burnout is rampant among healthcare providers.4 When patients have a positive experience because we have communicated well, shared an effective care plan, and made progress toward wellness through a shared mutual agenda, we feel a sense of renewed purpose, worthwhile work, and making a difference in our work. We connect with hearts and minds and are far less likely to suffer professional burnout.

Three ToolsIn coaching many group practices nationwide,

Studer Group has found three tools particularly effec-tive for improving multiple domains that measure the patient experience on the CG-CAHPS survey: (1) AID-ET®, (2) Individualized Patient Care, and (3) Integrated Office-Based Skills Labs. These tools build patient trust, align providers, staff, and patients with respect to treat-ment goals, and improve patient adherence to treatment protocols.

1. AIDET Builds Trust and Reduces AnxietyAIDET is an acronym for “Acknowledge, Intro-

duce, Duration, Explanation, Thank you,” a communi-cations awareness tool:

■■ “A” stands for Acknowledge the patient. This tells patients that you care about them and dem-onstrates respect (which are asked about on the CG-CAHPS survey). By making eye contact and sitting down, you begin to connect on a personal level and build a positive relationship.

■■ “I” stands for Introduce. Share something posi-tive about yourself and your team that gives the patient confidence in your competency.

■■ “D” is for Duration. Describing how long the exam or test will be or how long the wait will be reduces anxiety.

■■ “E” is for Explanation. Explain your findings, about the pain involved, or what will happen next. Always use words the patient can under-

stand and avoid jargon. Use the “teach-back” method and ensure the patient is understanding by asking questions in an open manner (i.e., “What questions do you have for me?” rather than “Do you have any questions?”).

■■ “T” stands for Thank you. Always close with your appreciation for the opportunity to care for the patient and for partnering in their care plan.

As Rodney Tucker, M.D., associate professor and director for the Center for Palliative and Supportive Care at the University of Alabama at Birmingham, has said, “AIDET® is like a gift to physicians because it tests and validates ACGME [Accreditation Council for Graduate Medical Education]-required core competen-cies like professionalism, interpersonal/communication skills, and patient-centered care.” It also improves group practice performance in every domain of CG-CAHPS survey questions, including doctor communica-tion and courtesy/helpfulness of staff.

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40 GROUP PRACTICE JOURNAL x AMGA.ORG MARCH 2015

As healthcare providers, we owe it to our patients to ensure we communicate in a way that reduces anxiety. Calm, engaged patients are more likely to align with and listen to their provider for adherence to treatment plans. In fact, physicians who are rated high on empathy usu-ally achieve better clinical outcomes than their peers.5

AIDET is not a checklist, so be sure to adapt it for the person using it, for the patient being seen, and for the setting, but use elements of AIDET® every time with every patient. An example of AIDET for a provider might sound like this: “Ms. Jones, we have covered a lot of information in the last few minutes, so what can I explain better for you, and what questions do you have for me?”

Or: “Thank you for coming in today, Mr. Brown. It was important for us to make sure that your diabetes is under good control. And thank you for being so good about your diet and taking your medications as pre-scribed.”

Every member of your team has an important role to play in the patient experience! For example, a receptionist might begin with a thank you (“Mr. Minerman—Thanks for coming in today.”) and then introduce her/himself and “manage up” the providers’ expertise to a new patient (“I know you’re new to this practice, and I welcome the opportunity to take care of you. I’ve been here for 12 years and have worked with Dr. Smith the entire time. He’s a great physician. You’re going to be in very capable hands.”) She may save the AIDET “Duration” for the end of the encoun-ter (“Thanks for completing these forms. We will come get you in 10 to 15 minutes for the initial evaluation by Lisa, our nurse practitioner.”).

2. Individualized Patient CareAs the late Maya Angelou famously said, “People

remember how you made them feel.” Individualized Patient Care (IPC) is patient-centered care. As Okla-homa University (OU) Physicians Executive Director of Clinical Operations and Community Health Services, Holly Adams, M.H.A., FACHE, FACMPE, says, “Who better to speak to the unique needs and sensitivities that our patients have than the patients themselves?”

In a medical group practice setting, IPC is charac-terized by a high-touch personal greeting and uses an IPC card to elicit the patient’s objective for the visit. The IPC card also prevents unnecessary calls post-visit because key questions were answered. (To learn more about OU’s experience with IPC in a large multi-spe-cialty practice and improved CG-CAHPS results, watch a brief video at www.studergroup.com/IPCclinic).

Because CG-CAHPS measures the care continu-um—from before the patient encounter until well after it ends—many medical practices find that pre-visit calls are an effective way to begin IPC, and post-visit calls effectively complete it. Pre-visit calls reduce missed appointments by establishing trust and concern for the patient and identify what is most important to the pa-tient for that visit. This is then documented on the IPC card for follow-up during the visit.

When patients arrive at registration, the front desk staff acknowledges the stated concern or anxiety as noted on the IPC and puts them at ease. From the pa-tient’s perspective, this is evidence that the team is coor-dinating care and patient-focused. This has a powerful positive impact on how patients answer questions in the communication domain of the CG-CAHPS survey. JPS Health Network in Fort Worth, Texas, a 537-bed acute care public hospital with 15 affiliated primary care clinics and 100 contracted primary care providers, asks every patient to complete an IPC card at check-in. On the front of the card, the patient’s arrival and appointment times are noted. On the back of the card, patients are asked to check the reason for their appoint-ment to ensure their needs are met, (e.g., prescription refill, form for work, referral.) (Download a copy of JPS’ IPC card at www.studergroup.com/physamples.) In just four months after implementation of the IPC card, JPS improved patient ratings for “overall rating of provider” from the 23rd to 41st percentile compared to peers.

3. Skills Labs Break Down SilosJust as in baseball, hitting the ball out of the park

does not constitute a home run until the hitter touches all the bases, so too must we touch all the bases with every patient, every time, to ensure they always have an excellent experience. Said another way, because the patient experience is not based on a single interaction with any one individual in the practice, the quality of every interaction impacts the perception of every next interaction during the patient’s visit.

If a patient has a poor experience making a tele-phone appointment, she may be skeptical about the quality of the practice by the time she meets her pro-vider. Conversely, when the receptionist manages up the expertise of the provider using AIDET®, she’s prepared for a positive experience.

The Integrated Office-Based Skills Lab is a diag-nostic and validation coaching tool that breaks down silo thinking in favor of teamwork so that the team has an experiential understanding of how their interactions impact the overall patient experience and how they can

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improve it. A receptionist may have never been in a patient room, for example, while someone who works in the back offi ce has likely never seen what occurs in the reception area. Integrated skills labs remedy that by gathering the team together in a safe environment (e.g., during non-patient hours) to trace through mock patient encounters from registration to discharge, while learning and validating the use of best practice commu-nication tools like AIDET® and IPC.

Alegent Creighton Clinic in Omaha, Nebraska, has conducted 54 integrated skills labs to date over 18 months at 46 of the system’s 100-plus individual sites. As a result, they’ve enjoyed a jump of 50 percent or greater in fi ve of the six CG-CAHPS domains (e.g., overall provider rating, helpfulness of offi ce staff, thor-oughness and completeness of exam). Integrated skills labs move performance improvement quickly.

“For the most part, participants are curious or a bit nervous at the outset, but 99 percent will express how much they learned by the end of the skills lab,” notes Larry Brown, M.D., FAAP, FACP, a practicing internal medicine and pediatrics physician and medical director of service excellence at Alegent Creighton. “The team concept is key in an ambulatory setting because of the false walls that exist between front offi ce staff, nurses, and providers. Skills labs allow everyone to see the en-vironment and individual encounters from the patient’s perspective. Also, they remove the excuse that the scores are poor due to the performance of a particular individual, certain patients, or the vendor survey. The team understands our score depends on everyone work-ing together.”

At Alegent Creighton Clinic, a skills lab typically includes up to 20 individuals (including four to six pro-viders) and lasts approximately one hour. Individuals at all skill levels—from physicians and advance practice clinician providers to radiology technicians and front offi ce receptionists—are expected to attend. A mock patient scenario is entered into the electronic health record teaching model. Observers follow the mock patient through all touch points during the visit, noting written observations on an evaluation form, and then highlight what went well as well as opportunities for improvement, during a facilitated group debrief.

Data are summarized and shared with the clinic manager, who follows up with information on tools or articles that address opportunities for improvement. “Providers can be humble, so we frequently need to connect the dots for them between the importance of narrating their patient care and managing up their expertise with reducing patient anxiety and ensuring better clinical outcomes,” adds Dr. Brown.

Suggested Reading A Framework for Integrated Offi ce-Based Skills Labs. At www.studergroup.com/skillslabframework.

Enhanced Verbal & Non-Verbal Communication Skills, Using AIDET® & Key Words. At www.studergroup.com/AIDETbasics.

Morris, J., M.D., M.B.A., FACS, Hotko, B., R.N., M.P.A., and Bates, M., M.P.H. Jan. 2015. The CG-CAHPS Handbook: A Guide to Improve Patient Experience and Clinical Outcome. Gulf Breeze, FL: Firestarter Publishing. ISBN: 9781622180073.

Comfort LevelsCommunicating differently is not always comfort-

able for staff and providers at fi rst. But there can be no progress, success, or achievement in life without some level of discomfort. It’s important to get comfortable being uncomfortable if you want to advance to the next level. It may take a little time to become comfortable with these tools, but you and your patients deserve it.

References1.J.T. Chang, R.D. Hays, et al. 2006. Patients’ global ratings of

their health care are not associated with the technical quality of their care. Annuals of Internal Medicine, 144(9): 665–672.

2.G.B. Hickson, C.F. Federspiel, et al. 2002. Patient complaints and malpractice risk. JAMA. 287(22): 2951–2957.

3.Chang, Op. cit.4.T.D. Shanafelt, S. Boone, et al. 2012. Burnout and satisfac-

tion with work-life balance among US physicians relative to the general U.S. population. Archives of Internal Medicine, 172(18): 1377–1385.

5.M. Hojat, D.Z. Louis, et al. 2011. Physicians’ empathy and clinical outcome for diabetic patients. Academic Medicine, 86(3): 359–364.

Jeff Morris, M.D., M.B.A., FACS, is a Studer Group physician coach and speaker and coauthor of The CG-CAHPS Handbook: A Guide to Improve Patient Experi-ence and Clinical Outcomes.

EHR Blues: A Barrier to Connecting with Your Patients? Sometimes the electronic health record (EHR) becomes an impedi-ment to engaging patients because of the way in which we position it both physically—between the physician and provider—as well in the patient’s mind. We may “manage it down” by sharing our frustra-tion or wishing we could go back to paper.

Instead, set up patient rooms so providers can sit next to patients to view the EHR together. Use key words to emphasize benefi ts around quality and safety. For example, “This is diffi cult for me because I don’t type very quickly, but it’s a really excellent tool. See how your x-rays and all your records are here? In the old ‘paper days,’ it was often diffi cult to get access to these at one time, but here you can see that your primary care doctor and surgeon have both documented everything in one place.”

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