Patient Experience: A Global Opportunity and a Local Solution

Last week we held the second call of the new Global Patient Experience Network supported by The Beryl Institute. The call included Institute members from eight countries and spread across 18 time zones. Despite our differences in location, time of day, native language or accent, when the conversation started, we discovered that the concepts at the core of improving patient experience are fundamentally the same. Providing the best in experience for patients, families and the communities (and countries) we serve is an unwavering focus for people across healthcare systems and functions around the world.

As I listened to the conversation and we dug deeper in identifying what posed the greatest challenges and offered significant opportunities for improving patient experience, I was struck by the recognition (and even relief) that participants showed in how similar their issues were. One participant offered, “It’s comforting to know we are all contending with the same challenges and questions moving forward,” with a second individual noting, “It is amazing that at the end of the day we are all working towards the same end and facing the same issues.” This realization drew agreement and raised the excitement of the group in understanding that even with great distances between us, there are great similarities and therefore possibilities.

The group identified the same top issues central to patient experience efforts that I have seen in my travels. They included:

  • The importance of organization culture and our ability to manage change in today’s healthcare environment
  • The understanding and effective implementation of patient (and team) interaction processes from patient, physician and staff engagement and involvement to service recovery, post care follow-up and building consumer loyalty
  • The implications of measuring our patient experience efforts to gauge perception and understand the impact of each effort
  • The value of the structure of patient experience practice itself, ensuring a clear focus, supportive leadership, aligned roles and right structures to deliver on the best experience possible

While these are not the extent of the issues faced in addressing patient experience, it was evident that among peers separated by great distance, they still had closely knit similarities. This was especially significant for our team at the Institute as we have always approached our work from the belief that while systems may operate differently and policies might be distinct, the very fundamentals that drive a positive patient experience – the power of interactions, the importance of culture, the reality that perceptions matter and the realization that experience covers the continuum of care – as framed by the definition of patient experience, continues to hold true.

With this great commonality and the excitement generated in the discussion, it was also evident that our members recognized that patient experience is a local, dare I say personal effort. Each and every individual that plays a role along the care continuum has some level of responsibility. It is based on the sum of all interactions, as we suggest, that a patient and their family members gauge their own experience. Therefore in building a patient experience effort, it requires an understanding of your own organization, the people that comprise it, and the community (and demographics) that you serve. Patient experience success is not driven by a one model fits all solution, it is and forever should be something that meets the need of your organization and your patients whether in San Diego or Sydney, New York or New Delhi. Ultimately, patient experience is a global issue, but it is and will continue to be up to each of us locally to bring these grand ideas, the critical practices, and the day-to-day needs to life in every encounter. There is a great opportunity we have been given to move beyond policy to true cause, beyond process to effective practice and beyond “have tos” to “always dos”, that will impact the lives of patients and families globally. I have always suggested it is a choice…I maintain that and hope it is part of all our resolutions for positive and healthy New Year!

In reflecting on the launch of the Global Network and other Institute efforts in 2012, it is clear that this has been an amazing year for our growing global community, with now over 11,000 members and guests in 28 countries focused on improving the patient experience. We have all committed to something noble and important, the best possible experience and the health and well being for our fellow man. And we have been given a great opportunity, to turn a global need into something each and every one of us can impact directly. Happy Holidays to you all and I look forward to continuing to learn and grow together in the year ahead.

Jason A. Wolf, Ph.D.
Executive Director
The Beryl Institute

Your Patient Experience Priority for 2012 May Be as Simple as Taking the First Step

With all the predictions of new healthcare trends and the expanding requirements being placed on healthcare providers, one thing holds true – at the center of all these efforts and initiatives lies the patient. This is not patient-centeredness in the traditional sense of simply the care setting, but it is now clear that whether you are ready or not, the patient has taken center stage in our healthcare system.

For some, the patient experience was the fundamental driver of their efforts well before any requirements were raised; providing the greatest service and highest quality outcomes for the patients and families served at every touch point. Others have found new initiative in addressing patient experience with expanding financial implications. Yet many still struggle with where to focus, what to do or even if to act.

The harsh reality is that as of today over two-thirds of the initial performance period for Value-Based Purchasing is now in the books. With a closing date of March 31, 2012 and then the reality that reimbursements will be impacted just six months later, this is not the time to get stuck in a state of confusion. If you are not already moving, you still have time to act.

I have been asked by many healthcare leaders for the secret to the “best” patient experience. And while I will be the first to say I do not believe there is one specific formula that leads to patient experience success, I have offered a few considerations. In my recent blog with Hospital Impact, I reiterated the importance of four central strategies:

1. A clear organizational definition for patient experience.

2. A focused role to support patient experience efforts.

3. A recognition that patient experience is more than just a survey.

4. A commitment at the highest levels of leadership.

These suggestions are not complicated initiatives, but rather they should be a simple choice.

In every instance of high performance in patient experience what I observed above all else is that willingness to make a choice. For some it was a broad strategic effort where patient satisfaction was a key measure in performance compensation. For others it was finding that one area where they could begin to move the needle – creating a more quiet and relaxing environment, rounding with intention and empathy to ensure a patient and their family felt attended to, or simply communicating consistently that they were taking every action possible to ensure their patient’s pain was managed. I have suggested and will reassert here that excellence in patient experience emerges in the ability to balance its need to be a strategic imperative with clear measurable, tangible, and yes tactical action.

Most importantly, as my grandfather so wisely shared with me years ago, the more complicated we choose to make things, the more difficult they seem to accomplish. Patient experience is a critical issue, with increasing demands and pressures intertwined with a passion for care and an understanding that it is the right thing to do. This does not mean we need to make it bigger than we can handle. Or even that we need be discouraged if we have finally been able to make it a priority after others may seem “so far ahead”. The reality is that whenever and wherever you start is the right time and place if the intention is right and true. Now you have the choice, one as simple as committing to take that first step. My hope is that each of us, in every healthcare setting, has resolved to do something to improve the patient experience in 2012.

Jason A. Wolf, Ph.D.
Executive Director
The Beryl Institute

The Power of Interaction: You are the Patient Experience

In looking back at 2011, I have touched on a cross-section of topics on the patient experience – from service excellence and anticipation to value-based purchasing and bottom line impact. This year has led us to heightened awareness of the impact performance scores will have on dollars realized and increasing recognition that the patient experience is a priority with staying power. The Beryl Institute’s benchmarking study, The State of Patient Experience in American Hospitals, revealed both the great intentions and significant challenges that are at hand in addressing the critical issue of patient experience.

Our research supports, and I fundamentally believe, that there is a need for a dedicated and focused patient experience leader in every healthcare organization. Yet in the midst of all this attention, we may have overlooked the most important component – the immense power, significant impact and immeasurable value of a single interaction.

What does this mean? Interaction is simply defined as a mutual or reciprocal action or influence. The key is mutual action; something that occurs directly between two individuals. No interaction is the same, but it requires a choice by both parties to engage and respond as they best see fit. In healthcare settings, be it hospitals, medical offices, surgery centers or outpatient clinics, there are countless interactions every day. The question is: are they taken for granted as situations that just occur or are they seen as significant opportunities to impact experience? Perhaps in thinking about experience as a bigger issue, the importance of these moments of personal relationship has been missed.

What this means for improving the patient experience may be simple. Rather than waiting for that one leader to build the right plan or for your culture to develop in just the right way, you each instead recognize one key fact – you are the patient experience. I acknowledge there is a need for a strong leader and a solid cultural foundation on which to build, but at its core patient experience is about what each and every individual chooses to do at the most intimate moment of interaction. If these moments are used as the building blocks to achieve our greatest of intentions, patient experience will be the better for it. As you look to next year, whether you sweep the floors or sit in the c-suite, the choice should be clear. In today’s chaotic world of healthcare, the greatest moment of impact may be in the smallest of encounters. It is here that the most significant successes be they for scores, dollars or care will be realized. Happy holidays to you all!

Jason A. Wolf, Ph.D.
Executive Director
The Beryl Institute

The Smart Thing to Do: Patient Experience and the Bottom Line

Most now agree that patient experience is not just a nice to do, it is a must do. The idea of patient experience has recently taken on greater significance, first, through the emergence of surveys such as HCAHPS that make performance transparent and followed by the reality that reimbursement dollars, performance pay and compensation are being tied to outcomes through policy being implemented around the world. Improving the patient experience is also what is right to do. It is about providing the type of care experience for patients and families that you would want for yourself and your loved ones.

But recognizing patient experience as both a must do and a right to do, is not enough. It should also be addressed as the smart thing to do. Why? The patient experience has true financial implications for healthcare organizations that reach well beyond regulations. With all that is done to address patient experience from the cultural, organizational and process sides, we also need to consider its financial implications. This is perhaps the area that patient experience champions have focused on the least, but could have the most significant impact in making the case for the important work being done.

Patient experience influences the performance of healthcare organizations on a number of fronts. In The Beryl Institute’s newest white paper, Return on Service: The Financial Impact of Patient Experience, three perspectives are suggested as we look at the bottom line impact of the patient experience: financial, marketing and clinical.

  • From the financial perspective, it has been shown that satisfied patients lead to higher profitability. In a 2008 J.D. Power study, it was discovered that hospitals scoring in the top quartile in satisfaction had over two times the margin of those at the bottom. These findings were supported by the 2008 Press Ganey paper, Return on Investment: Increasing Profitability by Improving Patient Satisfaction. The paper revealed that when hospitals were ranked by profitability into quartiles, the most profitable hospitals had the highest average satisfaction scores.
  • From the marketing perspective, we need to look no further than the power of word of mouth. In her 2004 article, Jacqueline Zimowski shared that a satisfied patient tells three other people about a positive experience.  In contrast, a dissatisfied patient tells up to 25 others about a negative experience.  The issue worsens, as for every patient that complains, there are 20 other dissatisfied patients that do not. And of those dissatisfied patients that don’t complain, only 1 in 10 will return. When you run the numbers, for every complaint you hear, you could be losing a potential 18 patients. In essence by not focusing on experience we are potentially driving patients away.
  • From the clinical perspective, we must be clear to recognize that experience and quality are not distinct efforts but critically interwoven aspects of overall care. Patient Experience is not just about pretty or quiet environments, positive service scripting or even consistent rounding. At the end of the day it is about ensuring our patients leave better than when they arrived (as often as we can). This was exemplified in a powerful way in the 2011 study, Relationship Between Patient Satisfaction with Inpatient Care and Hospital Readmission Within 30 Days, reported by Boulding et al. They examined quality factors (as defined by CMS Core Measures, specifically on acute myocardial infarction, heart failure, and pneumonia) and satisfaction factors (as determined by the two HCAHPS questions – How do you rate the hospital overall? and Would you recommend the hospital to friends and family?) in relationship to readmission rates within 30 days of discharge. The finding was surprising. The HCAHPS scores, i.e. experience outcomes, were reliable and even more predictable indicators of readmissions than quality indicators. In essence, patient experience, herein measured by HCAHPS was a distinct and measurable driver of readmissions, a key quality issue and a significant financial issue for healthcare organizations and one taking on even greater interest as it will impact future reimbursements that hospitals are eligible to receive.

As healthcare leaders take on the challenge of patient experience, it is important to recognize that it reaches well beyond simple measures of satisfaction. A commitment to patient experience has significant and measurable impact, not only in doing what is right for the people and communities you serve, but also in ensuring the best quality and most financially sound experience for all who are in and who deliver your care. To be responsible stewards for healthcare systems that are both vital and viable, it is essential to recognize and be willing to address the bottom line issues influenced by patient experience efforts every day. It is the smart thing to do!

Jason. A. Wolf, Ph.D.
Executive Director
The Beryl Institute

Patient Experience – A Delicate Balancing of Science and Art

With the emergence of HCAHPS in the US and similar measures in other countries and the financial implications now associated with these scores such as under Value Based Purchasing and the Excellent Care for All Act in Canada, efforts to address patient experience are at an all time high. Surveys such as the Institute’s Benchmarking Study now show patient experience to be a top priority for healthcare leaders. It seems these new regulatory pressures have heightened awareness, increased executive support and created a burning platform for action.

This elevation in attention has also presented a challenge. With new regulations, especially those tied to financial reward, arises the need to perform to the test. Our research has shown that US hospital’s priorities aligned often with the very domains being asked in the HCAHPS survey, from reducing noise to providing proper discharge instructions. These are not bad things on which to focus, but by simply focusing improvement on the questions themselves, the ‘science’ of patient experience, we miss the foundation, the culture (the ‘art’) on which to build.

In some ways addressing the questions is easy. We can measure our quietness at night and we can time ourselves on responsiveness, but we cannot manage service elements in the same manner as core quality measures, which are truly process driven, can be tracked via checklist and easily monitored. The science of service is not that cut and dry. Instead, it relies on a delicate balancing with the culture of the organization in which it is performed.

John Kotter and James Heskett (1992) have a nice way of framing culture in the workplace at two levels, the deeper level of shared values and the visible level of shared behaviors. This is the art of patient experience. We cannot create a checklist to ensure a shared base of values or behaviors exist, but without them the performance of the items being measured is at risk. We are presented with a need for delicate balancing – a measure set to manage what we are being evaluated (and paid) on and a culture on which our performance relies.

Through my On the Road visits and other discussions with healthcare leaders I have been privy to hearing about this delicate balancing first hand. The organizations that perform well in scores are doing more than teaching to the test or focusing on scores. Our paper The Four Cornerstones of Patient Experience helped frame the importance of a dedicated role and organizational focus in driving better outcomes (a clear blending of art and science) and my visits to leading performers have reinforced this message. For example at Inova Fair Oaks Hospital they insisted that you can try all the service tactics you want, but you first need a strong culture on which to build and at Medical Center of Arlington they helped us see that it is about aligning leadership and people, establishing clear expectations and living to them at all levels that was the foundation of their success.

The challenge is clear (and perhaps daunting); that true success in patient experience comes from our ability to manage the balancing of the science and the art. I say “balancing” as this effort is in constant movement, from a focus on measures to a focus on culture. There is not one perfect spot to stand, but sustained success comes from our ability to acknowledge the impact that both measures and culture have on providing the best experience for our patients overall. Here is to effective balancing!

Jason A. Wolf, Ph.D.
Executive Director
The Beryl Institute

Value-Based Purchasing is Underway…How Will You Distinguish Yourself?

I would not be the first to express concern if the only motivating factor for a healthcare organization or system to address the patient experience was due to the pending threat of reduced reimbursement connected to Value-Based Purchasing (VBP). Yet, I can also say that the attention this possibility has brought to the cause for how patients are engaged in the healthcare setting is also warmly welcomed. Managing this juxtaposition of feelings is what I find many organizations are now struggling with in addressing their patient experience efforts.

Many leaders accountable for improving patient experience outcomes are both supported by this elevated attention to policy, but also challenged by its parameters. Through the use of the measures incorporated in VBP one path for addressing the issue of service is seemingly set out. Succeed in certain domains of the HCAHPS assessment and you have a better chance of getting more of your withheld reimbursement dollars. (While I will not get into the full details of VBP, you can read more here.)

This sets up an interesting game of sorts in which many have seemingly begun to focus completely on the test (performance on the HCAHPS domains). This is not an impractical route to take (in fact we at The Beryl Institute are launching a series of interactive dialogues for members on these very topics), except that every other hospital aware of the ramifications of inaction are at least doing the same thing. The dilemma this poses is that if reimbursement through VBP is based on comparative measures to your peer organizations and everyone is prepping for the same test, what are you going to do to distinguish yourself?

Month one of the initial nine-month performance period is complete. In essence, the first inning is over and the question this raises is what have you done to move beyond simply increasing performance on the key HCAHPS domains? (Note I said moving beyond, not overlooking.) We have suggested, along with many others, that patient experience success is grounded in broader cultural improvements, in engaging your workforce in positive solutions and in finding new and powerful ways to involve patients in your delivery of service, before, during and after care. At the Institute we have gone as far as to suggest you need to consider such components of your patient experience process, from people’s first encounter with you through a scheduling experience to their post clinical interactions when dealing with the revenue cycle and collection process. It also encompasses the programs you initiate such as Patient and Family Councils, the processes you implement such as experience mapping or the important considerations you give to cultural competence.

While the domains being tested and tied to VBP drive you to look at internal issues, it is important to recognize that the respondents to these surveys – the patients and their families – are assessing you on encounters well beyond their clinical experience at the bedside. With that you still have an opportunity to distinguish yourself. Take some time to examine the results you have achieved so far and consider areas in which you can create broader opportunities for patient experience impact. You will find that by in engaging beyond the test, you can achieve even stronger and lasting results.

Jason A. Wolf
Executive Director
The Beryl Institute

While we can’t please all of the people all the time, any goal short of 100% is unacceptable

For those of you lucky enough to hear Dr. David Feinberg give the closing keynote at The Beryl Institute Patient Experience Conference 2011, you heard a story of an organization with a clear commitment to patient experience. I was struck by the clarity with which Dr. Feinberg stated the mission of UCLA Health System – Healing humankind one patient at a time, by improving health, alleviating suffering, and delivering acts of kindness. While Dr. Feinberg reinforces that UCLA may be the only healthcare organization that incorporates kindness into its mission, I am also struck by the essence of this mission with its focus on “one patient at a time”.

Since my On the Road visit to UCLA I have been churning with this idea of what one patient at a time truly means, so it is only fitting that in another encounter with Dr. Feinberg something he shared helped me frame this in a way that should cause anyone committed to improving patient experience take pause.  In a new era of measurement where scores will equate to dollars, it seems there is new motivation to address patient experience issues. The challenge I think this continues to raise is that scores do not equal people.  Dr. Feinberg challenged this very notion by stating that his commitment was not to achieving percentile improvement, but rather percentage improvement.

Ah-ha!  This is where one patient at a time truly lives and should live for any of us committed to the highest quality, safest and best service-driven care. Percentages are the people themselves, percentiles becomes faceless statistics that will eventually numb us to what we committed to in the first place. We cannot let a new focus on scores actually pull us farther from our mission of care. This is something Dr. Feinberg was clear in sharing, that in looking at percentages, nothing less than 100% is acceptable.

Now I can already hear my friends in healthcare administration roles around the world asking me, Jason haven’t you ever heard the quote “You can please some of the people all of the time, you can please all of the people some of the time, but you can’t please all of the people all of the time.”  While the quote has been attributed to many, namely Abraham Lincoln (who it was noted used the word “fool” where “please” has been substituted), it raises the very issue that in healthcare we are dealing with human beings.  We are unpredictable and curious creatures that are driven both by personality and habit, yet influenced by the things that happen around us in any moment.

So how can I suggest and support Dr. Feinberg’s assertion that nothing less than 100% is acceptable? Easily. In healthcare we are, and must be, about one patient at a time. Experience is not a generality found in statistical comparison; rather it is found in the eyes, smiles and hearts of the patients, families and support networks we provide experiences for every day.  We do this not for our scores and dollars, though this now incentivizes us to act with greater vigor. We do this for those individuals who put their trust in us that we will give them our greatest of care, attention and service, as we did for the person in the bed, outpatient suite, exam room or waiting room that came just before them and who will follow.  If we play the game of numbers, while we may retain some short-term financial viability, we all lose. And while we will still not please all of the people all the time, our patients deserve nothing less than our commitment to 100%.

Jason A. Wolf, Ph.D.
Executive Director
The Beryl Institute

Do we need “rules” to do what is “right”? And are ACOs and Value-Based Purchasing reasons to now take action?

Accountable Care Organizations and Value-Vased Purchasing RulesWe have all heard the quote “what gets measured, gets done”.  What this reveals is how leaders have been conditioned to act, yet this has not always led us to our desired results.

This quote also touches the very issues facing patient experience. For years we have discussed patient-centered care, domains have been identified that define patient-centeredness, and patient satisfaction measurement is now not only an accepted practice, but also a growing and profitable industry. These standards and measures have helped remind us who our customers are and provided data on which to act. Yet, even with this information, while some have tackled this important issue, many have not.

Now with the emergence of new policy measures such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey in the U.S. and the Excellent Care for All Act in Ontario, Canada, as well as efforts in other locations around the globe, a patient’s experience is now a variable in not just ratings, but also a component of individual and/or organization compensation formulas. Even more so, these scores are being publically reported in an attempt to provide transparency (or is it to truly capitalize on the competitive nature of the healthcare business – see my blog from November 2010)

Even with the advent of the HCAHPS survey, when we conducted a survey of The Beryl Institute’s membership last summer (almost 4 years since the launch of HCAHPS), just over 50% of the respondents had a comprehensive patient experience strategy. So can we say what gets measured, gets done?

But perhaps now, specifically in the U.S., the stakes and implications have been raised with the introduction of the proposed rules on both the measurement and payment process for Accountable Care Organizations (ACO) and Value-Based Purchasing (VBP). The headline of these rules in relationship to patient experience is simple – perform well on the standard metrics, specifically HCAHPS, and you will reap the “benefit” of maintaining reimbursement dollars (VBP) or of obtaining payments resulting from the new shared savings arrangement (ACO). Simply stated, patient experience is now a measure that equates to dollars lost or gained.

This leaves me with the question, why the frenzy now when we have always been in the business of delivering care to patients? Has health care become something we simply do to people for revenue? I am not saying we do not need effective financial performance, as this is critical to sustaining services.  What is disconcerting is that it seems we have carefully crafted our processes and practices, structures and systems to accommodate us – meaning the deliverers versus the recipients of our services.

Perhaps it has been a harmless oversight on our part, though I have heard many healthcare leaders emphatically say, “We are not in the hospitality industry”.  With that I can agree. People do not usually choose to spend their hard-earned dollars with us, but rather circumstances, some dire, bring them to our doors. I do suggest instead that we are in the service business. We always have been and always will.  Care is not the privilege of a few (though with the current systemic issues it could be perceived and even experienced as such by some) – care is a service we provide – be it in our medical practices, long-term care facilities, outpatient centers or hospitals.

I am not advocating for or against the measures or processes put in place, rather I am holding up a mirror to ask why it has taken these policies and programs to truly see action and activity on improving patient experience. What has been our motivation to act now? Perhaps more importantly what slowly had us move away from service to process, from relationships to transactions, from patient to diagnosis?

During my recent On the Road visit with the UCLA Health System, both CEO, Dr. David Feinberg and CMO, Dr. Tom Rosenthal said a key to their success was helping their staff uncover and rediscover the passion that brought them to healthcare in the first place – the care and service of others. My hope is that while we may now be motivated by measures to get things done, this is not the fundamental reason we respond to this expanded commitment to the patient experience. Let’s use this as an opportunity to exceed expectations and provide quality care, not because it is in the rules (or being measured), but because we know it is fundamentally the right thing to do.

What are your thoughts on the implications of these new rules around Accountable Care Organizations and Value-Based Purchasing?  And how can continue to do what is right for our patients regardless of what we may be required to do?

Jason A. Wolf, Ph.D.
Executive Director
The Beryl Institute