Clinical Quality &

Service Excellence

Jay Kaplan, MD, FACEPMedical Director of Care Transformation,

LCMC HealthClinical Associate Professor of Medicine,

Emergency Medicine, LSU Health Sciences Center

University Medical Center New Orleans

Upfront Question

What is

“ Service Excellence”

in Healthcare?

(It depends upon your perspective)

What Patients Want . . .

AccessConvenienceServiceCost (low)Quality OutcomesRelationship/Communication

Where’s the Beef

Where/What is the evidence to connect:

Clinical Quality

Patient Experience

???

What Do Emergency Physicians & Nurses Want?

•Quality Care for Our Patients

•Efficiency of Our Practice

•Responsiveness to Our Issues

•Appreciation for What We Do

•Balanced Life – “Work to Live”

•Good Income

CEO’s Want . . .

As Many Patients As Possible (especially high profit-margin cases)High Patient SatisfactionEfficient ThroughputNo Diversion/No LWOBSNo Patient ComplaintsNo Medical Staff ComplaintsNo Premium Labor Usage

CEO’s Will Say . . .

Here are my expectations.Get it done.

Problems:They don’t know how you can get it done.In most situations you are in charge of the emergency physicians but not the rest of the department.You have all of the responsibility but not all of the authority (you truly need).

Communication correlates STRONGLY with adherence rates by patients in acute and chronic disease. There are now over 100 observational and 20+ experimental studies published demonstrating the correlation of communication (patient satisfaction) with compliance. Compliance with treatment regimens has significant influence on quality measures in chronic disease and outcomes. Medical Care: August 2009 - Volume 47 - Issue 8 - pp 826

Higher Patient Satisfaction = Communication = Compliance = Quality

British Medical Journal 2013http://dx.doi.org/10.1136/bmjopen-2012-00157

Patient experience is positively associated with clinical effectiveness and patient safety.Associations appear consistent across a range of disease areas, study designs, settings, population groups and outcome measures

Positive associations 429 studies (77.8%)No association 127 studies (22%)Negative association 1 study (0.2%)

Academic Medicine - March 2011

Does a physician’s empathy impact a diabetic patient’s treatment?Hemoglobin A1c test results to measure the adequacy of blood glucose control according to national standards lower = better controlLDL cholesterol level lower = better control

“Empathic engagement in patient care can contribute to patient satisfaction, trust, and compliance which lead to more desirable clinical outcomes.”

Academic Medicine, Vol. 87, No. 9 / September 2012 (21,000 patients)

“The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy.” Del Canale, S. et al.Patients of physicians with high empathy scores, compared with patients of physicians with moderate and low empathy scores, had a significantly lower rate of acute metabolic complications (4.0, 7.1, and 6.5 per 1,000 patients, respectively, P < .05).

Risk Management

Relationship between patient satisfaction, complaints and lawsuitsEach one point decrement in patient satisfaction scores is associated with a –

6% increase in complaints (RR 1.06, 95% CI 1.03 – 1.08;p<.0001)

5% increase in risk management episodes (RR 1.05, 95% CcI 1.01 – 1.09;p< .008)

Lower performing physicians were at greater risks for lawsuits (RR = 2.10;p 95% CI 1.13 – 3.90; p<.019)

75% of complaints were related to communication issuesStelfox HT, et al, The American Journal of Medicine 2005; 118: 1126 –

1133

Hourly Rounding (ED)

Operational Efficiency: Call lights reduced 34.7%Operational Efficiency: Patients/Families approaching the nursing station reduced 39.5%Finance: LWOBS reduced 23.4%, LAMA 22.6%Clinical Quality: Falls reduced 58.8%Patient Satisfaction: Increased 20%ile in already high-performing ED’s

Does Staff Turnover Affect Quality?

Relationship Between Employee Turnover and Patient Outcomes

Blue Bar: Mortality Index = Clinical QualityYellow Bar: LOS = Operational EfficiencyY-axis: Employee Turnover = Service Excellence

.783.81

5.021.09

28% greater mortality24% longer stay

“Better Communication Was Associated with Higher Global Ratings of Health Care”

Annals of Internal Medicine, May 2006

Quality in the Government’s Eyes -The Transparent Environment

During your hospital stay, how often did doctors /nurses:treat you with courtesy and respect?listen carefully to you?explain things in a way you could understand?

Never/Sometimes/Usually/Always

The ED PEC Survey

20. During this emergency room visit, how often did doctors treat you with courtesy and respect? Never Sometimes Usually Always21. During this emergency room visit, how often did doctors listen carefully to you? Never Sometimes Usually Always

22. During this emergency room visit, how often did doctors explain things in a way you could understand? Never Sometimes Usually Always

23. During this emergency room visit, did doctors spend enough time with you? Yes, definitely Yes, somewhat No

The ED Global Rating Question

23. Using any number from 0 to 10, where 0 is the worst care possible and 10 is the best care possible, what number would you use to rate this emergency room visit?0 Worst care possible12345678910 Best care possible

2015-2018 2019 2020 2021 2022 2023 2024 2025 2026+

Base 0.5% 0.0% 0.25%

EHR

+/-4%MIPS

+/-5%MIPS

+/-7%MIPS

+/-9%MIPS

Merit Based Incentive Payment SystemPQRS

VM

With the Repeal of the SGR MACRA

Online Patient Exp. RatingsDriving Physician Selection

Source: The Advisory Board, advisory.com

High Deductible Insurance Plans

The average deductible for a single person enrolled in

an employer-sponsored health plan reached $1,217 in 2014 and now is $1438, and now 80% of employer sponsored plans are high

deductible. Projections are that by 2019, providers will see a 50% increase inn the

amount of revenue they are collecting directly from patients, with 30% of that

written off . . .

Workers in High-Deductible Insurance Plans -$1000 or more for single coverage

Clinical Quality&

The Patient Experience

The New Paradigm

= IncomeOutcomeCare $$$

The Old Paradigm

Simple Truth #1: We Live in a Service Economy

Key Words for Us

Satisfyto please, to be adequate to an end in view, to meet an obligation

Astonishto strike with sudden and usually great wonder or surprise

Memorableworth remembering

Every Patient

Every Time

•“I am careful to make eye contact with every patient so that they know I am giving them my attention.”

•“I put a blanket over and under every elderly patient to preserve their body heat.

•“I tell seriously injured patients that they are at Vanderbilt, and that they are safe now”.

•“I keep patients informed and carefully explain their treatment to them.”

•“I turn the TV to the education channel, when it can help them.”

•“I tell the patient that it has been my honor to care for them.”

•“I use fun bandaids or decorate them!”

•“I always sit down when I talk to my patients”

•“I like to use warm blankets and footies to keep the patient comfortable.”

•“I remember to put my name on the white board.”

•“I keep a bag of angels. I wear one, and pass them on when I’m asked about them.”

•“I ask the patient about their family, pets, etc. to personalize the relationship.”

Simple Truth #2: We All Believe We Give Great Service

= =Patient Satisfaction

Employee Satisfaction

We assume

Simple Truth #3: We think we’re doing better than we actually are . . .

Strategies to Improve Quality

Pro-ActiveLeader Rounding

Discharge Follow-Up Phone Calls

Performance Improvement

Six Sigma

Lean

Leader Rounding on Staff

Harvest Wins:“Are there any staff or physicians you would like me to compliment

or recognize?”Focus on the Positive:

“What is going well today?”Identify Process Improvement Areas:

“What systems could be working better?”Repair and Monitor Systems

“Do you have the tools, equipment and assistance to care for your patients well?”

Coach on New Behaviors “We’re trying to improve our patients’ experience. One way to do that is . . . “

Leader Rounding on Patients

Shadow Rounding With Physicians

"As physicians, we can work individually to improve our technical skills of evaluation and treatment with literature/chart review, outcome data, etc. But analyzing and improving our communication with patients--which affects their perception of the evaluation and treatment we provide--requires an objective point of view. Shadow rounding with Dr. _____ provided this needed third-person assessment in a relaxed and non-judgmental setting. It gave me a different perspective of my interactions with patients that will help me to continue to self-critique my approach to patients and hopefully improve my overall technique.“ Hospitalist, March 2019

How To Complete the Patient Experience: Follow Up Phone Calls

Engel K, Heisler M, Smith D, Robinson C, Forman J, Ubel P, “Patient Comprehension of Emergency Department Care and Instructions: Are Patients Aware When They Do Not Understand?,” Annals of Emergency Medicine. July 11, 2008•78% did not have full understanding•80% of that 78% did not understand that they did not understand

Post Visit CallsLikelihood of Recommending - ED

Source: New Jersey Hospital, Total beds = 775; 3Q2007 – 2Q2010

27

47

32

62 63

47

2538

70

4451

77

62

38

7688 87

95 93

77 76

9399

83 8897 95 96

0102030405060708090

100

1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q

Perc

entil

e Ra

nk

Likelihood of Recommending - ED

No Call Call

Improves Physician Performance… (January-June 2008, Press Ganey National %tile rank)97th 94th

81st72nd

51st

28th

0

10

20

30

40

50

60

70

80

90

100

Doctors Section Likelihood ofRecommending

Doctorsmaking d/ccalls

Other callsbeingmade

No call

Discharge Calls: Improved Clinical Quality

2.9%

2.1%2.5%

1.9% 2.0%

0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%

Month 1 Month 2 Month 3 Month 4 Month 5

Emergency Department: Volume Adjusted 24-hour Emergency Department Returns

Source: The Regional Medical Center, South Carolina, Total beds = 286

Follow Phone Calls: 6 Reasons Why

QualityRisk managementPatients love itYou will love it (lots of kudos)You will be a better clinicianDecreased return visits/hospital admissions

People - For Our Patients

Think Bakery

Sit Down/RTR

Rounding on Patients

Key Strategy #1: Think Bakery

What Do Our Patients See?

Take a Fresh Look – Change the Signs

In the interest of improving the quality of care and patient safety in our hospital, we now have an electronic health record. When you see our physician and staff working on computers, they are caring for you. If you have any questions about this, you may ask any member of our team for an explanation.

Thank you.

Dress Professionally

What Do Our Patients Feel?

Sit Down

To Sit or Not to Sit?(Annals Emerg Med 2007))

Sitting: time overestimated 15%

Standing: time underestimated 7%

Providers overestimated time 6%

Patient Education Counseling2012 Feb;86(2):166-71.

Effect of Sitting vs. Standing on Perception ofProvider Time at BedsideSurgeon on post-operative visits (admitted for elective spine surgery) - 120 patientsRCT to sit vs. stand, rest of visit sameResults:Position Actual time Perceived time- Stand 1’ 28” 3’ 44”- Sit 1’ 4” 5’ 14”*Positive patient feelings: sit= 95%, Stand = 61%

What Do Our Patients Hear?

People (Patients) will not hear all of your words . . . Use Key Words or Phrases to express your caring.

Use Key Words

“For your safety”“Sounds like what you’re telling me is . . . ”“Let me put you at ease . . . ”“To keep you informed”“I’ve reviewed the nurse’s notes so let me go over what I already know about you.”“What questions do you have? Is there anything I can do for you right now ?”

Key Strategy #2: Do Not Assume Our Patients Know . . .

Who we are;How good we are;How much we careHow long some process takes;What the process will involve;What will follow.

Communication Strategy: Think Baseball -Touching All the Bases

Every Patient Interaction Has a . . .

Beginning Middle End

or seen in another way . . . It’s about . . .RelationshipTaskRelationship

64

Relationship

RAI

Acknowledge patient and significant othersIntroduce self and anyone else on team with their titles and/or rolesInspire confidence by managing up

Task

T DDo These Things:Sit downActive Listening Paraphrasing Demonstration of empathyArticulation of physical findings

E Explain in a way that is understandable to the patient and family; include expected duration of work-up/illness/healing process

Relationship

RT Teach Back to ensure that patient and family

understand Thank patient/family for their involvement in their care

65

Old Vs. New Paradigms of Patient Contact

Old Way: See the patient, order your diagnostic tests, wait for all the results to come back, go tell the patient what you found.

New Way: Touch base with your patient as often as possible, no less than every 30 mins. As results return, advise the patient.

“Pollinate the Rooms”

Patient Perception Quality

Self –Test for Emergency Physicians/APP’s

Self –Assessment

Self –Test for ED Staff

Summary

We live in an experience economy.

“Satisfy” is not enough.

If the other guy’s getting better . . .

Quality gets you in the game.

Service helps you win.

It’s about the TEAM.