QUEST: Improving Patient and Provider Experiences

Tom Scaletta, MD

Disclosures

March 21, 2018

Finding the Right Balance: The Ideal Patient and Provider Experience

The Institute for Healthcare Improvement's (IHI) triple aim, published in 2007, is a framework for optimizing healthcare performance.[1] The three aims are great outcomes, low costs, and an improved patient experience. In 2014, to mitigate the rising frequency of burnout, the IHI added a new aim focused on the provider experience.[2] Combining the patient and provider experiences can be termed the "people experience."

Efforts to achieve the triple aim are challenged by escalating economic pressures facing US hospitals. In the past, when government insurance paid below cost, hospitals covered the difference with "profit" from private insurance companies paying above cost. Hospitals have come to rely on this cost-shifting, but now private payers are tightening the reins. Double-digit margins that were common a couple decades ago are now razor-thin. Hospitals will experience escalating financial losses unless they proactively and dramatically cut costs.

Because two thirds of healthcare expenses is staff compensation, the primary means to reduce expenditures is to trim the workforce. Another means is to avoid hospital admission, expensive testing, and unproven treatments whenever it is safe to do so. As the definition of healthcare finds a new normal, patient and family expectations must be recalibrated.

The stress of thinner coverage can be tempered by bringing humanness to the bedside. The emotional aspects of care (ie, empathy, compassion, and kindness) are often more effective and less expensive than the physical aspects of care (ie, tests, procedures, medications, and treatments), a concept not traditionally taught to providers in training. To up their emotional care game, providers need to reflect on the original reason they entered healthcare.

Patient Experience Drivers

The drivers to improve patient experience are many and, most important, bilateral. Improvements to the patient experience result in positive impacts to both patients and staff. When patient experience measures are up, patients highly regard the system and are likely to return and refer others. Meanwhile, staff have high employee satisfaction and want to stay.

Edward-Elmhurst Health (EEH), a health system in the western Chicago suburbs, is forwarding a vision of safe, seamless, and personal care across its healthcare system.[3] "Safe care" is high-quality and low-risk; "seamless care" is efficient and frictionless; and "personal care" acknowledges both patient and provider needs.

The Kano model depicts how each element of the EEH vision affects the patient experience.[4] Delivering safe care (ie, providing the right diagnosis, treatment, and disposition) alone only meets basic expectations and does not achieve high satisfaction levels (red curve). Seamless care (ie, on-time provider appointments, short door-to-provider times, and timelier scheduling of follow-up) results in a linear increase in satisfaction (green line). Personal care is best illustrated by a provider's ability to connect in an empathetic manner (eg, treating the patient like a friend) and exponentially improves satisfaction (yellow curve). So, optimal care is safe, whereas seamless and personal care assure a top-tier experience.

Empathy is underpinned by effective communication and authentic compassion. At EEH, patients discharged from the emergency departments and immediate care centers are surveyed the next day. They are asked, "What was the level of concern the provider showed for your situation?" The response "very high" suggests the perception of exemplary care. In fact, the percentage of patients who choose the top box score to this question (ie, "very high") is used to measure a provider's aptitude for inducing patient loyalty. To improve communication skills across the system, EEH trained all 7000 EEH employees using a program called G.R.E.A.T.™ The acronym stands for "greet, relate, explain, ask, and thank"—the elements of great provider/patient communication, sequenced in the ideal order.[5]

To better understand the drivers of loyalty (and disloyalty), I created a two-question survey that was completed by 192 healthcare professionals (from my LinkedIn contact list) in October 2017.

The first question (Q1) portrayed a low-performing emergency department. The answer choices reflect (in order as listed) lack of safe care, lack of seamless care, and lack of personal care. Respondents (N = 192) indicated that avoiding the antithesis of personal care (44%; P < 0.5) was more important than either safe care (32%; P < 0.5) or seamless care (23%; P < 0.5). In other words, these individuals preferred being subjected to a physician error resulting in an avoidable surgery rather than being treated in an abusive, unprofessional manner.

The second question (Q2) portrayed a high-performing emergency department. The answer choices reflect (in order as listed) seamless care, personal care, and safe care. Respondents indicated that personal care was twice as important (67%; P < 0.01) as safe and seamless care combined (33%; P < 0.01). In other words, empathy was valued far more than high-quality, efficient care.

Summary 

The triple aim should be top of mind as we do our part to improve the state of healthcare. The drivers of patient experience include all aspects of the triple aim: safe, seamless, and personal care. Personal care may be the most important aspect, which encourages a focus on empathy with great communication and compassion.

Assessing Idea Value With QUEST

High-performing healthcare systems are characterized by a constant flow of ideas from administrators, providers, and frontline caregivers. This flow should be nurtured by encouraging all ideas as a positive contribution. Although more ideas will be nonviable than promising, the key to finding the promising ideas is to welcome innovation and input of all kinds.

The value of a new idea for improving the patient care process can be assessed according to the acronym QUEST: quality, utilization, efficiency, satisfaction, and teamwork. Each letter represents a discrete, albeit interrelated, attribute that defines why an idea is promising. Of note, QUEST considers the people experience—the effect an idea has on both patients and providers.

Here is a mathematical depiction using QUEST to determine the value of an idea.

  • Idea value = idea benefit/idea cost

  • Idea benefit = QUESTf – QUESTc, the margin between the future and current state components

    • QUESTf = Qf + Uf + Ef + Sf + Tf, the future state components

    • QUESTc = Qc + Uc + Ec + Sc + Tc, the current state components

  • "Idea cost" is any obstacle linked to idea implementation. As an example, the idea cost of fast-tracking an electronic medical record (EMR) improvement may be that other impactful improvements are delayed. In addition, EMR improvements often provoke angst owing to alterations to workflow, increased computer interactions (ie, clicks), IT staff time and attention, and the expense of staff training.

Once an idea is deemed worthy to move forward, the team must decide on the timing of implementation. The traditional approach is to fully test and polish the idea beforehand. Alternatively, some ideas are so impactful and urgent that the "agile approach" is best: incorporating the idea into workflows in an early form and making incremental improvements through rapid iterations.

Pertinent benchmarks that demonstrate the impact of ideas in practice should be collected before, during, and after any process change. This regular data collection allows objective measurement of the current state, the implementation phase, and the future state. Ideal metrics are relevant and easily acquired.

Using QUEST on a micro-level quantifies the amount that a single idea moves us toward safer, more seamless, and more personal care. Using QUEST on a macro level defines an organization's culture, the basis of loyalty. As the title of this article suggests, we must always be on a "QUEST" for the ideal people experience.

Applying QUEST to Postencounter Contact

Contacting patients 1 day after an ambulatory encounter closes a blind spot in modern healthcare. Next-day contact is an effective way to assess well-being while positively engaging patients and family caregivers.[6,7] EEH began this practice in 2004 and believes it to be one of the reasons its emergency departments have achieved top-decile satisfaction every quarter for the past decade (according to Press Ganey surveys). Once the emergency department Consumer Assessment of Healthcare Providers and Systems (CAHPS) begins in 2018, boosting patient experience scores will directly relate to increased revenue tied to value-based purchasing incentives. Moreover, the loyalty created by uncovering and addressing medical and service issues in a timely manner has an even greater impact on the hospital's bottom line.

All facets of QUEST are managed by a novel technology system called SmartContact™ that is utilized by EEH in its emergency departments and immediate care centers. The system enhances safe, seamless, and personal care by quickly eliciting and addressing patient feedback.[8,9] A Health Insurance Portability and Accountability Act-safe electronic survey checks for any patient well-being and service issues after an encounter. Built-in automation routes alerts to the appropriate staff members. The system produces statistically valid performance metrics, and patient comments are shared with providers 2 days after each shift.

Quality

Postencounter contact enhances safety and health outcomes by uncovering problems with diagnostic accuracy, disease trajectory, medication adherence, and scheduling follow-up. Quality is the most medically relevant facet of QUEST because unsafe care harms patients, which then makes team members second victims and contributes to employee burnout.[10]

Even the most competent providers occasionally make unintentional errors. In fact, one question a provider fears most is, "Remember that patient you saw the other day?" These words often precede the announcement of a near miss or bad outcome, and a series of these can put one's job in jeopardy. About 2% of patients reached with SmartContact report feeling "worse," and of these, a true medical emergency is uncovered in 5% (or 0.1% of all patients reached). A time-sensitive, potentially life-altering event is far rarer, occurring at a rate of about 1 in 10,000 visits (0.01%). An example is described in the case report below.

Case Report

A 35-year-old man with no chronic medical problems came to the immediate care center with low back pain. He was afebrile and showed neither urinary nor neurologic symptoms. He received discharge instructions for lumbar strain, prescriptions for ibuprofen and hydrocodone, and a 3-day follow-up appointment. Upon receiving his next-day survey link, he relayed by text message that he had developed a mild fever and lower-extremity tingling. A few minutes later, the charge nurse called his cell phone and advised him to immediately return for an MRI. A lumbar epidural abscess was diagnosed. He had emergent spine surgery and subsequently fully recovered.

Postencounter surveys can uncover an unexpected decline in a patient's medical condition.[11] The decline may be due to the natural progression of illness, a missed diagnosis, medication noncompliance, or a follow-up gap. Next-day contact gives providers, charge nurses, and case managers an opportunity to intervene before any harm occurs. Research suggests that in comprehensive emergency departments, about one liability claim is prevented every 3 months and one payout is negated every 2 years.[12] This decrease in claims and payouts equates to an opportunity of up to $450,000 per year in an emergency department with an annual volume of 50,000 patients (assuming $50,000/$500,000 attributed to each prevented claim/payout).

Utilization

"Optimal utilization" means providing a necessary service in the proper setting at the lowest cost while preserving quality. One of the most significant ways to lower costs is to avoid unnecessary admittance. In "borderline cases"—those that could have been discharged but were admitted—the hospital usually assigns observation status because next-day discharge is expected. These days, observation cases are a financial lose/lose proposition because patient copayments are steep and hospital reimbursement does not exceed the cost of care. Postencounter wellness checks make providers more comfortable with dismissing patients without hospital admission because they know the system will check on them the next day.

SmartContact features a workflow optimizer for frequent emergency department visitors. The system identifies these patients; facilitates care plan creation; and organizes members of the patients' care team, who are electronically contacted when revisits occur.[13] This approach reduces costs associated with unnecessary emergency department visits and avoidable admissions and readmissions.[14] It also improves health outcomes, particularly of superutilizers (those with 12 or more annual visits).

Efficiency

The ability to send survey links by text message significantly reduces cost. Legacy postencounter contact systems relied on telephone calls and cost $5 per patient to implement. SMS communication reaches patients in their native language for well under $1 per patient.

These days, texting is a common means of communication. At EEH, 95% of patients are reached by inserting a survey link into a text or email message. Of these, 35% offer feedback and only 0.25% opt out. Issues requiring action are dovetailed into the regular workflows of on-duty nurses, case managers, providers, and department leaders. Only those patients who report feeling "worse" (2%) are forwarded to the charge nurse for reassessment and advice.

SmartContact has a built-in provider shift report function that shares performance metrics and patient comments with providers a couple days after a shift. This information allows providers to understand and self-monitor their performance. In addition, monthly aggregate reports allow medical directors to identify provider performance gaps and drive improvement through coaching.

A performance decline in a high-achieving provider is often a sign of a serious personal problem. Early identification of burnout, depression, substance use, or family issues allows a medical director to counsel the individual and get them back on track, which exemplifies the IHI's focus on provider experience.

Satisfaction

Satisfaction is patient perception of quality. Not surprisingly, most laypeople can accurately determine whether they received high-quality care.[15] Significant differences between actual and perceived quality should be viewed as a patient knowledge gap and closed whenever possible.

Traditional patient surveys are neither timely nor succinct and do not inquire about patient well-being. Long surveys induce survey fatigue (eg, CAHPS exceeds 35 questions). Low completion rates induce hostility in providers because more responses are needed for statistical validity in judging individual providers.

Well-being surveys sent to patients after an encounter fortify loyalty through the act of reaching out. It is not surprising that asking "How are you doing?" before asking "How did we do?" endears a patient to the institution. By receiving timely patient comments while the interaction is fresh in mind, providers can become keenly aware of how to improve patient interactions. High-frequency feedback with granular provider comparisons is a powerful way to identify opportunities and drive improvement.

Prompt complaint resolution is an essential tactic in any business. Uncovering service issues right after the encounter permits a proactive approach and prevents formal grievance letters. Moreover, satisfied patients are more adherent to their care plans, enjoy improved clinical outcomes, and file fewer malpractice claims.[16]

Teamwork

Service line teams consist of administrators, providers, and frontline caregivers. Nothing defines a satisfied team more than staff who are excited to bring their talents to the table with other high performers to achieve mutual goals that benefit patients.

Teams are accountable for their CAHPS scores. Although administrators typically monitor the overall unit performance, there is deeper benefit in identifying strengths and weaknesses of individuals. High performers can become skill teachers and model key principles for others. Low performers improve when their deficiencies are exposed. It is important for leaders to know when an employee is discontent with a job, enduring a personal or family hardship, or needs performance coaching.

Job discontentment is a cardinal sign of burnout and should be promptly addressed. Burnout is the result of mounting frustration and compassion fatigue, and leads to job turnover. When a job is simply a poor fit, another should be sought.

Great teams have smooth workflows and symbiotic relationships. Professionally satisfied healthcare colleagues enjoy an effective environment where patients are well cared for and staff happily come to work each day. When staff is happy and patients are satisfied, this leads to the ideal people experience.

Conclusion

Implementing a postencounter contact system is a high-value practice that improves all aspects of QUEST. Providers who are unaware of patients having difficulties once they are at home is a gap that can be closed through technology in an effective, inexpensive manner. When providers reach out and issues are resolved, loyalty is created with both patients and staff.

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