Engaging Physicians in Patient Experience

Physician Executive Council

Beyond HCAHPS Scores

• Clarify the Physician’s Unique Role • Make the Case for Physician Engagement • Leverage Data and Strengthen Physicians’ Skills

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Executive Summary...... 4

Advisors to Our Work...... 6

Essay: A Call to Action...... 7

1. Building a Patient Experience Organization...... 19

2. Defining the Unique Role of Physicians in the Patient Experience...... 27

3. Leveraging Data for Performance Improvement...... 41

4. Strengthening Physicians’ Patient Experience Skills...... 47

5. Case Study: Cone Health...... 59

Organizations Still Struggling to Improve Patient Experience Performance

Increased emphasis on metrics (HCAHPS, Value-Based Purchasing), competition for market share, and growing consumerism continue to drive health system investment in patient experience. Patient experience was identified by 84% of health care leaders as a top-three priority and 85% increased time or resources invested in patient experience in the last 12 months. From a market perspective, patient loyalty (and thus patient experience) is one of the few strong levers remaining for capturing profitable growth. Yet, health systems struggle to make meaningful advancements in their patient experience performance.

Patient Experience Dependent on Physicians Embracing Role as “Influencer-in-Chief”

Many physicians view patient experience initiatives as tangential to their mission as physicians—to provide their patients the best care possible. In reality, patient experience is central to this quality mission. Research shows that through the physician’s leadership of and communication with the care team, he or she has the ability to drive patient experience improvement more than any other clinician in the enterprise. As such, this publication makes the case for the physician as “influencer-in-chief” of patient experience.

Physician Engagement Must Be Supported by Institutional Commitment to Skill Building

Even when physicians have the will to improve their patient experience performance, they often lack the knowledge or the means. Organizations must provide physicians with the necessary skills and support to excel as patient experience providers. This publication showcases best practices for leveraging physicians’ patient experience data as a first step to improving performance. It also explores coaching, training, shadowing, and the use of low-tech tools to develop and leverage physician empathy and communication skills. Finally, the publication highlights how one institution utilized several of these strategies to deliver a 30% gain in patient experience scores among hospitalists in one calendar year.

Three Strategies for Clinical Executives to Engage Physicians in Patient Experience:

1 Clarify the physician’s unique role: Examine the physician’s position at the center of the care team, and his or her influence in driving patient experience outcomes.

2 Make the case for physician engagement: Manage barriers to physician engagement in patient experience initiatives through strategic messaging and tested best practices.

3 Leverage data and strengthen physicians’ skills: Review proven tactics and case studies for sharing, teaching, and bolstering physicians’ patient experience competencies.

The Physician Executive Council (PEC) provides physician leadership Accompanying Resources to Related Acute Care teams with extensive resources to “Engaging Physicians in Patient Experience” Transformation Resources advance care transformation, some of which are outlined here. The The “Influencer-in-Chief”: Rethinking the Realizing the Full Benefit of comprehensive suite of resources, Physician Role in Patient Experience Palliative Care: Service optimization including webconferences, (webconference) and strategic growth publications, and toolkits, is available on advisory.com. Practical Levers for Raising Physician Ten Imperatives to Reduce Sepsis The content of this particular Engagement in Patient Experience Mortality: A playbook for optimizing (webconference) sepsis care publication is also available through one-hour, targeted webconferences. Strategies for Improving Patient Experience Building the Evidence-Based These sessions are available on- Skills; Cone Health Case Study Organization: Supporting system-wide demand on advisory.com and can be (webconference) clinical practice change used as learning and strategy sessions for the team(s) focused on these content terrains. Additionally, physician leaders play a critical role in advancing patient Beyond the Physician Executive Council: experience. Physician leadership Physician Leadership Resources Crimson Continuum of Care at a Glance development is not addressed in depth in this publication, but is covered The Clinical Transformation Leader’s • Web-based performance measurement tool facilitating rapid opportunity identification, peer extensively in other work, shown here. Toolkit: Strategic and project management resources for leaders cohort benchmarking, physician self-review, and If you would like guidance navigating clinical performance improvement these resources and selecting those Physician Leadership Effectiveness • Transforms siloed data into comprehensive most relevant to your organization, Compendium: Best practices for elevating dashboards and performance profiles at service please contact your Advisory Board physician leadership performance line, specialty, and provider level relationship manager. • Data-driven root cause analysis, cohort best New Quality Compact: Partnering with practice sharing via annual summit, quarterly physicians to advance a new performance intensives, webconferences, onsite workshops, standard and Dedicated Advisor support • For more information, please email Veena Lanka at [email protected]

The Physician Executive Council is grateful to those who shared their With Sincere Appreciation insights, analysis, and time with us. Catholic Health Initiatives Henry Ford Health System Rush University Medical Center We would especially like to recognize Englewood, CO Detroit, MI Chicago, IL the following people and organizations Manoj Pawar, MD Charles Coffey, MD David Ansell, MD for being particularly generous with Bruce Muma, MD Brian Smith their time and expertise. Christiana Care Health System Miles Schermerhorn Wilmington, DE Southwind Janice Nevin, MD Johnston Memorial Hospital Nashville, TN Abingdon, VA Alycia Ottesen Cleveland Clinic Hughes Melton, MD Cleveland, OH Stamford Health System James Merlino, MD MaineGeneral Medical Center Stamford, CT Augusta, Maine Sharon Kiely, MD Cone Health Steve Diaz, MD Greensboro, NC University of Virginia Health Chad Brough McLaren Northern Michigan System Petosky, MI Charlottesville, VA Duke University Health System Kirk Lufkin, MD Dan McCarter, MD Durham, NC Thomas Owens, MD Ochsner Health System New Orleans, LA Joseph Bisordi, MD

A Call to Action

Patient experience is a rising priority Payments Riding on HCAHPS Performance for health care executives. In a recent survey of health care executives, 84% Executive Incentives Tied to HCAHPS ranked it as a top-three priority, and Basis for Executive Incentive Payments are increasing the time and resources Adding Patient Experience devoted to it accordingly. to the Priority List n=262 The emergence of the Hospital Operating 67% Consumer Assessment of Healthcare Percentage of health Margin Providers and Systems (HCAHPS) as care leaders ranking Patient a key evaluation measure in numerous 84% patient experience as 60% Satisfaction pay-for-performance programs has a top-three priority fueled this shift in executive priorities. Clinical Percentage of health 54% Performance on HCAHPS inflects a Quality care leaders who significant portion of hospitals’ at-risk increased time or Financial payments in numerous risk-based 85% 44% resources spent on Efficiency payment programs, most notably patient experience in Medicare’s Value-Based Purchasing the past 12 months Opex 29% program. Reductions

Key Component of Reform HCAHPS as a Share of VBP1 Performance Risk

Percentage of Hospital Risk Payment Total VBP Payment Withhold Determined by Patient Experience Scores FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 30%

25%

20% -1.00% -1.25% -1.50% Medicare BCBSMA Medicare -1.75% ACO AQC2 VBP1 -2.00%

Source: HCAHPS, http://www.hcahpsonline.org/home.aspx; Zeis, Michael. Health Leaders Media, "Executive Compensation: New Metrics 1) Value Based Purchasing and Skill Sets." http://content.hcpro.com/pdf/content/286050.pdf; CMS; HealthLeaders Media, “Executive Compensation: New Metrics and 2) Blue Cross Blue Shield of Massachusetts Alternative Quality Contract Skill Sets,” November 2012; Physician Executive Council interviews and analysis.

Patient experience has also become a Improving Loyalty Is Lower Cost, Higher Impact Than Many Alternatives critical choice criterion for purchasers.

Historically, health systems have Sources of Profitable Growth sought to achieve profitable growth through two levers—raising price and growing volumes. Traditional price levers continue to erode, and profitable Pricing Volume volumes are becoming more challenging to capture as demographics and utilization management chip away at profit Commercial Medicare Medicaid Demographics Utilization Share Shift sanctuaries. As such, share shifting remains the most viable path for securing profitable growth. ABC Unfortunately, traditional approaches to “Share Shifting” Strategy Opportunity Assessment share capture—capital improvements, marketing campaigns, and Shifting Capital Improvements acquisition—are expensive and Market Share • Growing unease in investing in fixed (acute care) assets increasingly challenging to execute. Away from • Non-accretive investments reducing available spend But, the emergence of the value-driven Competition Marketing and Advertising health care consumer presents • Low institutional confidence in marketing ROI providers with a new opportunity for market growth. • Fewer targets due to ongoing M&A Acquisition and Partnership • Growing regulatory scrutiny on M&A deals • Formal affiliation not sufficient to influence behavior Network Integration • Streamline referrals to increase efficiency and drive volumes • Support decision making to enhance quality, utilization Consumerism • Focus on convenience and access • Strengthen relationships through patient experience and loyalty

Source: Physician Executive Council interviews and analysis.

Patients today face greater cost Patients Gaining Greater Control Over Health Care Spending Decisions exposure than ever before. Seeking to control benefit spending, employers are shifting greater costs onto patients through “consumer-directed” health plans. These plans are typically Growing Out-of-Pocket Expenses Employers Dropping Coverage associated with high deductibles and Employees Choosing Consumer Employees Who Will Lose significant co-insurance requirements. Directed Health Plans Employer-Sponsored Coverage

The transformation in the health AON Hewitt CBO Estimate insurance market is best embodied by the emergence of private health exchanges which allow employers to 39% 8M move insurance to a defined contribution plan. When patients are provided a set amount to spend on insurance, they inevitably select leaner 3M health plans. 12% Moving forward, it will be difficult to gain substantial market share without attracting these new cost-conscious 2012 2013 ACA Passage Feb. 13 consumers who are actively making their own choices in health care.

Employers Moving to Defined Contribution Plans

With Private Exchanges Western Pa. Employers New Private Health Workers Dump Old Explore Private Insurance Insurance Exchange Health Care Choices Marketplaces to Lower Targets Small and Mid- Costs Sized Companies

Sources: “To Save, Workers Take On Health-Cost Risk,” Wall Street Journal, March 17, 2013; “Obama’s Health-Insurance Expansion Eroding, CBO Projects.” Bloomberg, February 5, 2013; Physician Executive Council interviews and analysis.

While increased cost exposure can Patients Demanding Greater Say Prior Experience Drives Behavior drive consumers to shop around for health care, evidence suggests that Consumer Viewpoint on Role in Care Select Factors Influencing Patient patients’ approach to health care Decision Making Likelihood to Return to Hospital for Care related decision-making is changing n=2,071 n=264,892 more broadly. Historically, a physician’s Doctor Is Completely in Charge of 0% recommendation was paramount, but Treatment Decisions Doctor 88% increasingly patients view themselves Recommendation as the primary decision-maker. Their Doctor Makes the Decisions with 6% previous experience with a care Some Input from Patient provider can also be hugely influential Previous Experience 83% when selecting a hospital for care. A Doctor and Patient Make a 29% Joint Treatment Decision with Hospital poor experience can prompt a patient to look elsewhere for future care. High Scores on Patient Makes Final Decision with 38% Patient Satisfaction 69% While always a priority, reducing Some Input from Doctor Report Cards patient leakage is particularly important under risk-based payment models as it Patient Is Completely in Charge of 26% can lead to duplication of services and Treatment Decisions gaps in care. Health systems cannot afford to lose patients due to their inability to deliver an adequate patient Network Integrity a Special Imperative in the ACO Era experience.

Risks for Accountable Care Organization

Unnecessary Unaligned, High- Poor Handoffs Back Information Gaps on Duplication Cost Providers to Primary Care Services Provided

Source: Altarum Institute, “Altarum Institute Survey of Consumer Health Care Opinions,” Fall 2012; NRC Market Insights Survey, 2010; Source: Hoangmai, P, et al., “Care Patterns in Medicare and Their Implications for Pay for Performance,” The New England Journal of Medicine, 356:1130-1139, March 2007; Physician Executive Council interviews and analysis.

In order to improve patient experience, Conceptualizing Patient Experience as Much More Than HCAHPS Scores we must first define it. Current definitions tend to focus on HCAHPS, overlooking many critical aspects of care that are not specifically addressed in the HCAHPS questions. For example: • The integration of the care team • Compassionate, empathetic caregivers Patient Experience • Clear, actionable patient education • Anticipation of emotional needs • Ongoing Patient Support HCAHPS • Care Team Integration Patient experience is about more than • Compassionate, • Communication cleanliness and noise management. Empathetic • Quiet at Night Focusing solely on HCAHPS scores Caregivers • Information About limits providers’ ability to achieve the • Clear, Actionable Medications Patient Education full clinical, quality, and market benefits • Discharge Information • Up-to-Date and of an excellent patient experience. By • Cleanliness Thorough Patient focusing on the more expansive vision • Responsiveness Information and of patient experience, providers can • Pain Management Care Plans ensure they achieve solid HCAHPS • Physical and Emotional scores while also reaping the full Needs Anticipated benefit of an exceptional patient experience.

Source: Physician Executive Council interviews and analysis.

Recognizing the need for a fresh Some “Customer Service” Models May Be a Forced Fit perspective on patient experience, many health care leaders have looked out-of-industry for lessons.

Organizations such as Disney,

Southwest Airlines, and Ritz Carlton have long been recognized for their ” Customer Service Experts for Hire expertise in customer experience. However, health care providers, USA Today particularly physicians, often struggle Not Resonating with All Clinicians to reconcile conventional notions of Hospitals turn to Disney for patient satisfaction advice customer service, such as “the “We are not in a “the customer is always customer is always right,” with the right” industry. Sometimes our customers are challenges of providing patient care. $1,100/person/day NOT right, but it is our job to do what is right for them. That makes the whole premise of Physicians strive to do what is right for their patients – which is not the same service training difficult for physicians. as the patient always being right. Not to say it isn’t important, it is, but it has to Sometimes, patients do not want to Fierce Healthcare play second fiddle to what we are here to do and what we do best. Making it our number follow the optimal clinical path. As Hospital or hospitality: Ritz- one priority takes away from what we have to such, many physicians struggle with Carlton provides hospitals offer, which is so much bigger. It has to what they view as an inherent tension customer service lessons enrich the care we are providing, it can’t try to between providing the optimal patient replace the care itself.” experience, and ensuring the optimal $500,000 for 4,000 patient outcome. employee health Chief Medical Officer system

Source: USA Today, “Hospitals Turn to Disney for Patient Satisfaction Advice,” http://yourlife.usatoday.com/health/healthcare/story/2011-09- 21/Hospitals-turn-to-Disney-for-patient-satisfaction-advice/50502308/1; Fierce Healthcare, “Hospital or Hospitality: Ritz-Carlton Provides Hospitals Customer Service Lessons,” http://www.fiercehealthcare.com/story/hospital-or-hospitality-ritz-carlton-provides-hospitals-customer-service-le/2011-08- 26; Disney Institute, http://disneyinstitute.com/dates_and_pricing/program_pricing.aspx, “Erlanger Attempts to Emulate Ritz-Carlton Service,” http://www.chattanoogan.com/2011/8/25/207720/Erlanger-Attempts-To-Emulate.aspx;\ Physician Executive Council interviews and analysis.

Not surprisingly, lack of physician Physicians Pushing Back on Experience Initiatives engagement is consistently cited as one of the top barriers to patient experience initiatives. Given their intellectual struggle with the concept of patient experience, along with numerous other demands on their time, What Are the Top Five Barriers to What Is the Biggest Stumbling Block to it’s no surprise that physicians are not Improving Patient Experience Scores Creating an Effective Patient Experience first in line to volunteer to lead patient at Your Organization? Strategy at Your Organization? experience initiatives.

Abundance of Higher Priorities 20%

Difficulty Obtaining Physician 14% Buy-In

Lack of Funding or Budgeting 11% Priority Lack of Support Lack of Overall Game Plan or from Physicians 11% Actionable Ideas Difficulty Providing a Consistent 9% Approach to Patient Inclusion Difficulty Obtaining Employee 9% Buy-In

Patient Behavior Is Difficult to 8% Predict Lack of Management 5% Commitment

None, We Have No Stumbling 8% Blocks

Other 5%

Source: The Beryl Institute, “The State of Patient Experience: 2013 Findings,” http://c.ymcdn.com/sites/www.theberylinstitute.org/resource/resmgr/benchmarking_study/2013_benchmarking_slides. pdf; Zeiss M, “Patient Experience and HCAHPS: Little Consensus on a Top Priority,” http://content.hcpro.com/pdf/content/282893.pdf; Physician Executive Council interviews and analysis.

Truly transforming the patient Physicians Have a Unique Role: Influencer in Chief experience requires reframing the dialogue with physicians to acknowledge their pivotal role. Elements of the Influencer-in-Chief Role Throughout the research process, for Physicians in Patient Experience CMOs repeatedly highlighted physicians’ unique contributions to patient experience: Leads by example • Physicians set the tone for other staff members (for good or ill) • Physicians’ communication with patients and staff is a prime driver Excellent patient Strong care team in determining clinical quality communication communication • Physicians make or break the patient experience Physician In sum, physicians are the influencer- in-chief—inflecting a patient’s Cultivates and experience—not only through their exercises patient interaction with the patient, but equally empathy through their leadership and communication with the care team. ? Key Questions About the Physician Role in Patient Experience

1 Does the physician have a unique role to play in patient experience? What is the physician’s role?

2 Is the physician well equipped for this role? If not, what would he/she need to succeed?

3 Who are the physician’s key partners in enhancing patient experience? What are the parameters and expectations of the partnership? Does it exist, and if not, how can organizations create or enhance it?

Source: Physician Executive Council interviews and analysis.

Unfortunately, while nearly all organizations are training most or all of their staff in HCAHPS and/or patient experience, very few health systems are providing physician support Hospitals Running Physician commensurate with their critical role. If Specific Patient Experience Training n=30 physicians are indeed the “influencers- in-chief,” we must communicate this vision, and provide resources and training to support them in this role. In general, health systems are neither 7% communicating that high performance Estimated percentage of is an expectation, nor preparing hospital systems currently physicians to perform in this area. operating a patient experience

training program specifically

designed for physicians ” ”

We’re Not Supporting the Skills

“We think our physicians could be doing a better job when it comes to patient experience but the truth is we aren’t giving them a lot of help. The training we do offer is hospital-wide and doesn’t necessarily apply directly to the physician role.”

CMO, Hospital in the Midwest

Source: Physician Executive Council interviews and analysis.

Securing physician engagement in the Must Help Physicians See Their Critical Frontline Role role of influencer-in-chief for patient experience requires successfully executing on two key imperatives. The first is centered on classic change management techniques: creating cultural momentum by signaling the importance of patient experience at the highest level of the organization, and ” then painting the vision for physicians’ Second Priority unique role. Having made the call to Building a program for action, the second imperative focuses 2 ongoing patient experience on the supporting infrastructure: First Priority skill development building a program for physician- Engaging specific patient experience skills physicians in their 1 development as a critical part of their unique role in practice of medicine. patient experience

Source: Physician Executive Council interviews and analysis.

Outlined at right is an implementation framework for a truly transformative cultural overhaul around patient experience—focusing on physicians. There are four foundational Implementation Strategy for Building components: Patient Experience Culture Among Physicians • Painting a vision for the entire organization for how and why patient experience matters • Building a bridge to physicians Strengthening specifically Physician • Utilizing data as a critical tool for Skills • Workshops target and improvement Leveraging develop physician Physician • Cultivating and supporting patient experience Data physicians as they continuously skill set Engaging improve their ability to act as • Real-time feedback • Develops physicians Influencers- leveraged to expedite effective “influencers-in-chief” of as patient experience in-Chief physician improvement patient experience leaders • All new staff participate in process Leading • Targets low The remainder of this publication will basic patient experience • Adds legitimacy to Skill Development Institutional performers and training and onboarding discuss each component in turn. Change system, leader, physician provides additional • Key staff groups efforts training, shadowing/ • Patient experience prioritized for • Mitigates “pushback” coaching program supported by executive further training leadership, instituted as a cultural norm Reinforces Institutional Commitment

Physician Investment and Commitment

Source: Physician Executive Council interviews and analysis.

Building a Patient Experience Organization

Hospitals and health systems that boast excellent patient experience share at least one common attribute: an institutional culture that supports patient experience and is championed by the organization’s executive level of Case in Brief: Cleveland Clinic leadership. • 18-hospital health system located in Cleveland, Ohio No institution embodies this attribute • In 2008, Cleveland Clinic CEO Delos “Toby” Cosgrove identified patient experience as an more than the Cleveland Clinic. Under area for improvement; HCAHPS scores were mediocre; overall patient satisfaction ranked in the leadership of CEO Delos “Toby” 55th percentile Cosgrove, the Clinic has made • Early 2009, CEO appointed Dr. James Merlino Chief Experience Officer; created Office of significant investments in patient Patient Experience with a staff of 112 dedicated to developing and implementing patient experience—including hiring a Chief experience improvement; provided office with $9.2 million annual budget Experience Officer and allocating a • Chief Experience Officer internally publicized Cleveland Clinic’s HCAHPS scores and multi-million dollar annual budget—and selected metrics for measuring patient experience improvement; commissioned research to has seen dramatic improvements as a understand top patient experience challenges and where to invest resources result. While most organizations • In 2010, all 43,000 staff members participated in a half-day training to enhance patient cannot replicate the Clinic’s financial experience, learning skills such as building patient rapport, active listening, and how to investment, there is much to learn from improve team communication by unit their broader strategy, as well as the • Across next two years processes were put in place to continually track and analyze patient individual tactics they deployed. experience performance • In 2012, Cleveland Clinic showed dramatic improvement on CMS Patient Satisfaction Survey: – Doctors’ communication increased from 14th percentile to 63rd percentile – Nurses’ communication increased from 16th percentile to 72nd percentile – Overall HCAHPS performance increased from the 55th to 92nd percentile

Source: Merlino J and Raman A, "Health Care's Service Fanatics: How the Cleveland Clinic Leaped to the Top of the Patient-satisfaction Surveys," Harvard Business Review 91, no. 5 (May 2013): 108–116; Physician Executive Council interviews and analysis.

Prior to their cultural transformation, Despite High Quality Care, Patient Satisfaction Scores Low Cleveland Clinic’s low patient experience scores were a direct outgrowth of their culture. Like most organizations, Clinic physicians had Barriers to Improved Patient Experience at Cleveland Clinic in 2008 competing demands and, due to ongoing financial pressures, were constantly managing increasingly scarce resources. Perhaps more importantly, there was a laser-beam focus on clinical quality, as it has been traditionally defined, leaving little room for a more holistic approach inclusive Financial Strict Clinical Physician Autonomy of patient experience. Pressures Definition of Quality These barriers were all contributors to the Clinic’s poor 2008 patient Cost-driven staff Staff emphasized Reputable physicians satisfaction scores: 14th percentile for cuts generate clinical excellence, hold leverage, difficult to resistance to major did not focus on enforce practice change physician communication skills, 16th change initiatives patient experience among resistors percentile for nurse communication skills, and 4th percentile for staff responsiveness.

2008 CMS Patient Satisfaction Survey Percentiles for Cleveland Clinic 14% 16% 4% Physician Nurse Staff communication skills communication skills responsiveness

Given these barriers, CEO Toby Establishing a Foundation for Improving Experience Cosgrove recognized incremental investments in patient experience would not be sufficient. Cosgrove instead opted for a major overhaul, announcing that patient experience Chief Experience Officer Appointed $11M would be the new frontier for the Clinic, and pledged substantial resource Cleveland Clinic appointed a Spent on half-day training for all 43,000 investments accordingly. respected surgeon who understood staff members to develop patient the challenges of delivering a great experience skills As a first step, Cosgrove appointed a patient experience Chief Experience Officer. He chose a well-respected surgeon from within the organization who understood the value $9.2M of patient experience and could make a Office of Patient Experience credible case to his peers. Created and Staffed Annual patient experience budget for The Chief Experience Officer was ongoing data analysis projects, advisory

Chief Experience Officer hired staff of armed with a sizable staff and multi- councils, and employee training 112 dedicated to developing and million dollar budget. The Clinic also ” implementing processes, creating made major investments in training to metrics, and monitoring performance ensure every employee of the organization understood his or her role in patient experience. “Hospitals leaders…should also remember this: Changing culture The final component of the overhaul Patient Experience Vision Established and processes to improve the patient was a comprehensive vision which experience can lead to substantial served as an umbrella encompassing Organization defined patient experience as “everyone and everything people encounter improvements in safety and quality. To every component of the new patient from the time they decide to go to the Clinic put it bluntly, a patient-centered approach experience infrastructure. Called until they are discharged” to care, which includes giving patients an “managing the 360”, this vision outstanding experience, is not an option; signaled to every employee that they Executives enfranchised everyone in the it’s a necessity.” enterprise as “caregivers” who play a role in had an important and expected role to James Merlino, MD play in the patient experience effort. patient experience Chief Experience Officer, Cleveland Clinic Harvard Business Review

The newly appointed Chief Experience Investigations Identify Targets for Resource Improvement Officer then commissioned two comprehensive studies to understand the root causes of the Cleveland CMS Satisfaction Survey Observational Examination Clinic’s poor patient experience Patient Follow-Up of Low-Scoring Unit performance. • Researchers contact randomly selected • Researchers observe interactions The first study followed up with patients group of former patients who have completed between patients and employees within who had completed the HCAHPS HCAHPS survey the nursing unit that received Cleveland Clinic’s worst HCAHPS scores survey to explore factors contributing to • Team clarifies factors contributing to patient their survey responses. The second responses, gathers more detail on patients’ • Conducted in-depth qualitative analysis examined the system’s lowest- experience during hospital stay to understand perspective of both parties performing units in patient experience to allow researchers to observe patient- provider interactions firsthand. ! Recognizing the need for a standard Select Research Findings metric set to evaluate and monitor performance organization-wide, • Patients do not want to be in hospital; feel confused, afraid, and anxious HCAHPS was selected for its • Patients seek improved communication about their environment and plan of care credibility, availability to patients, • Patients want better care coordination and communication among the care team familiarity to physicians, and link to reimbursement. HCAHPS scores at the hospital- and unit-levels were then widely publicized, enabling employees to better understand performance and Committing to a Sharing Performance Building a Platform thus helping to secure their buy-in. Standard Metric Problems for Ongoing Analysis Finally, the Clinic put tracking systems • HCAHPS selected as single source • Shared HCAHPS scores for • Implemented systems to track and in place to monitor patient feedback of progress measurement (as entire system, each hospital analyze patients’ attitudes and and investigate any reported problems. opposed to Press Ganey or other and unit to pinpoint shortfalls complaints, determine root cause Electronic dashboards now relay real- vendor) of problems • Employees shocked by low time patient experience information to • HCAHPS chosen because credible, performance, able to perceive • Business intelligence department managers. available to consumers online, and the need to improve patient set up electronic dashboards to tied to reimbursement experience relay real-time data to managers

Lastly, the Clinic sought to enfranchise all staff members in the patient experience mission. To do so, the Clinic instituted a half-day training session for all 43,000 employees, the details of which are outlined in detail at right. Trainings continued for one year All-Staff Training Supporting Individual Training Managers on until everyone in the system had Performance Team Engagement participated. • All 43,000 staff members • Managers provided coaching • Educated all 2,300 managers in Beyond the staff-wide training, the participate in half-day exercise to employees falling short of one-day training session every Clinic also provided individual support across one year expectations four months in a number of ways, including • Randomly assembled groups1 • Best Practices Department • Training helps managers coaching for low performers and of 8-10 meet with trained identifies and disseminates practice building emotional recognition and awards for top facilitator to share caregiver methods used by intelligence and communicating performers. challenges top performers about and implementing change campaigns To ensure that the change was • Learned and practiced • High performers recognized behaviors such as active by colleagues and eligible for • Managers submit annual plan to sustainable, the Clinic provided listening and building rapport awards increase satisfaction and additional training focused on with the patient engagement of direct reports emotional intelligence, communication, and the management of change to managers throughout the system. Notably, the manager training resulted in a nearly 20% increase in employee engagement and an even greater effect on patient experience. 38% 57% Increase in employee engagement after manager training

Source: Merlino J and Raman A, "Health Care's Service Fanatics: How the Cleveland Clinic Leaped to the Top of the Patient-satisfaction Surveys," Harvard Business Review 91, no. 5 1) Maintenance staff to neurosurgeon. (May 2013): 108–116; Physician Executive Council interviews and analysis.

Four years after the initiation of the HCAHPS Scores Not a “Teach to the Test” Result Clinic’s patient experience transformation, the organization saw a substantial return on its investment. Results of Cleveland Clinic’s Key Drivers of Cleveland Clinic’s Patient Experience Overhaul Holistic Transformation The Clinic’s HCAHPS Overall Satisfaction Score skyrocketed from th nd the 55 to 92 percentile. Physicians’ Fundamental Patient Experience Investments and nurses’ communication ratings 14% 63% showed even greater net • Institution-wide, mandatory patient experience improvements. Percentile increase in training for all 43,000 employees HCAHPS Doctors’ • Patient rounding, including leadership rounding The Cleveland Clinic‘s story serves as Communication Domain with the Cleveland Clinic CEO, Toby Cosgrove a robust example of the commitment (2008-2012) required to truly transform an organization’s culture to become more patient-centric. Establishing Institutional and Executive Accountability 16% 72% • Patient experience added to organizational scorecard and established as organization priority Percentile increase in • Appointed Chief Experience Officer and created HCAHPS Nurses’ and staffed Office of Patient Experience Communication Domain (2008-2012)

Supporting Physician Patient Experience Performance

• Physician performance data unblinded and 55% 92% shared among colleagues • Managers offer support to low performers and Percentile increase in additional training to direct reports HCAHPS Overall Satisfaction Scores (2008-2012)

Source: Merlino, J, and Raman, A. "Health Care's Service Fanatics: How the Cleveland Clinic Leaped to the Top of the Patient-satisfaction Surveys." Harvard Business Review 91, no. 5 (May 2013): 108–116; Physician Executive Council interviews and analysis.

Not every organization has the resources to invest in patient experience on the scale of Cleveland Clinic. However, the factors that led to Distilling the Hallmarks of a Successful Patient Experience Strategy the Clinic’s success are replicable at any institution. This graph maps patient experience Basic Patient Establishing Maximizing Experience Institutional Patient Experience initiatives by complexity and required Investments and Executive Performance resource investment. The strategies Accountability and tactics deployed by the Clinic span Real time data collection the continuum, illustrating how most and feedback are within reach—to some degree—to any organization. Those wishing to Executive replicate the Clinic’s success must compensation Mandatory identify the components most critical at risk physician focused Mandatory patient experience for their organization and the scale at patient skills training for all which to deploy them to achieve their experience physicians desired goals. While most Patient skills training organizations cannot invest millions in Patient experience on for all staff Experience organizational staff or training, most of these Integration score card Patient strategies are transferable to lower Mandatory patient experience resource settings. experience broadly disseminated orientation for all staff through communication Executive team channels champions Patient patient rounding experience

Resource Allocation

Source: Physician Executive Council interviews and analysis.

Chief Medical Officers and Chief “Drive” Striking a Chord Among CMOs Patient Experience Officers universally agreed that engaging physicians as partners is the top barrier to advancing patient experience performance. To effectively mobilize the medical staff, organizations must understand physicians’ motivation for practicing medicine and be able to articulate the Key Insights from “Drive” benefits of engaging in patient experience initiatives. Current motivational model of “carrots and sticks” Throughout the research process, (monetary incentive) does not maximize, and CMOs repeatedly referenced the possibly diminishes, performance framework for evaluating motivation and incentives outlined in Daniel Pink’s Peak performance dependent on: book Drive. The book takes a contrarian view, arguing that motivation • Autonomy asks for ability to influence what, doesn’t come from carrots and sticks. when, where, how, and who one works with

Rather, motivation is dependent on • Mastery required for engagement, capacity to see three factors: “Drive: The Surprising Truth abilities as infinitely improvable, effort, grit, deliberate practice • Autonomy and control over what, About What Motivates Us”

how, and with whom a person Daniel H. Pink • Purpose provides context to guide autonomy and works sustain mastery, calls on human motivation to be connected to something larger than ourselves • Mastery of tasks that require effort, grit, and practice • A connection to a larger purpose

Source: Pink D, Drive: The Surprising Truth About What Motivates Us. New York, NY: Riverhead, 2009; Physician Executive Council interviews and analysis.

The Drive framework can be applied to A “Drive” Informed View of the Physician Role in Patient Experience engaging physicians in patient experience improvement. In enlisting physicians as partners, executives should communicate that patient experience should be: Autonomy Purpose • Aligned with the physicians’ purpose of delivering the best possible Encourage physicians Inherent to practice of quality care to take on leadership medicine, accessible roles and form through connection to • A challenging skill set which must committees and work patient, sacred duty be mastered over time groups to guide practice assumed upon entering the profession • Structured to allow the physician to Mastery function autonomously as the influencer-in-chief of patient Strong physician culture experience signals performance as infinitely improvable; When utilized effectively, the Drive feedback, data sharing, and framework provides physicians with an opportunity for improvement opportunity to better align their practice support deliberate practice with the underlying drivers that ” ” attracted them to medicine in the first place.

“While incentives can help change simple behaviors and improve productivity of rote tasks, they may actually reduce creativity and dull motivation for the complex tasks and broad thinking required in medicine…We need to capitalize on the inherent motivation of physicians and support underlying drivers of excellent care like professional purpose, mastery, and autonomy.” Dhruv Khullar, MD, The New York Times

Source: Pink D, Drive: The Surprising Truth About What Motivates Us. New York, NY: Riverhead, 2009; Khullar D, “Medicine Is More Than Carrots and Sticks,” The New York Times, Sept. 19, 2013; Physician Executive Council interviews and analysis.

While the Drive framework may appeal to physicians’ intrinsic motivation, it is also necessary to build a rational case for physicians’ engagement in patient Five Key Messages for Physicians on their experience. Role in Improving Patient Experience There are five key messages that must be communicated, outlined at right. 1 Physician Stake The material shared across the next Explain financial liability and business incentives for ten slides has been designed to physicians in relationship to HCAHPS support physician executives in engaging physicians in the patient experience. This information is 2 Correlation to Quality available for download on Show how improved patient experience links to improved health outcomes advisory.com and can be shared as a short presentation with the medical staff. 3 Importance of Physician Communication Double-click on critical role of physician communication for patient and care team alignment

4 The Issue of Time Clarify communication expectations in relation to time spent per patient interaction

5 Unique Physician Role Share vision of physician as influencer-in-chief

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“The Unique Role of Physicians in Patient Experience” is available for sharing with physicians on our website: advisory.com/PEC/2013meetingresources

Source: Physician Executive Council interviews and analysis.

The first step in making the case for patient experience to physicians is to clearly articulate the “WIFM”—also known as “what’s in it for me.” The easiest place to start is the financial implications associated with poor patient experience performance. Impact of Experience Metrics on Physician Finances First, a plethora of data supports the finding that dissatisfied patients are more likely to sue their physicians. Second, physician patient experience performance metrics are already linked to financial outcomes in inpatient Medical Liability Greater Public Reporting Tied Increase in Online facilities and are scheduled to be linked if Patients Dissatisfied to Future Payment Consumer Information to financial outcomes in outpatient Physicians with low • Medical groups must publicly Social media platforms facilities in the near future. Specifically, patient satisfaction report CGCAHPS scores (Facebook, Twitter) and reporting of the CGCAHPS survey, scores more likely to starting in 2013 review sites (ZocDoc, which is designed for the clinic setting, be sued for malpractice Angie’s List) influence • In 2015, all physicians must will commence in 2015 and scores will market share report CGCAHPS results, with eventually be tied to Medicare proposed Physician Value payment. Modifier beginning in 2017 Lastly, patients are accessing publicly available information on physicians‘ patient experience performance on sites like Yelp, Consumer Reports, and Healthgrades when selecting providers.

Source: Center for Medicare and Medicaid Services, “Summary of 2015 Physician Value-Based Payment Modifier Policies,” http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf; Stelfox, HT, et al., “The Relation of Patient Satisfaction with Complaints Against Physicians and Malpractice Lawsuits,” The American Journal of Medicine, 2005, 118(10): 1126-1133; Physician Executive Council interviews and analysis.

Beyond financial implications, patient experience has been repeatedly shown to correlate with clinical quality Representative Studies About the Relationship outcomes. Numerous studies support Between Patient Experience and Outcomes the link between satisfaction and critical quality measures such as readmission rates and mortality. American Journal of Circulation: Cardiovascular Journal of the American Board That said, it is difficult to prove Managed Care Quality and Outcomes of Family Medicine causality in many of these studies due to challenges associated with Relationship Between Patient Patient Satisfaction and Its Patient-Centered Care Is Satisfaction with Inpatient Care Relationship with Clinical Quality Associated with Decreased Health controlling for confounding factors. and Hospital Readmission Within and Inpatient Mortality in Acute Care Utilization Rather than focus on individual data 30 Days Myocardial Infarction points, discussions should focus on the “Higher patient satisfaction with “Higher patient satisfaction “Patient-centered care overall magnitude of the improvement inpatient care and discharge associated with improved associated with decreased effect. Put simply, a positive patient planning associated with lower guideline adherence and lower utilization of care services and experience is associated with better 30-day readmission rates” inpatient mortality rates” lower total annual charges” outcomes across numerous conditions and clinical settings, and there are no known side effects.

Source: Boulding W, et al., “Relationship Between Patient Satisfaction with Inpatient Care and Hospital Readmission Within 30 Days,” American Journal of Managed Care, 2011, 17: 41-48; Glickman S, et al., “Patient Satisfaction and Its Relationship with Clinical Quality and Inpatient Mortality in Acute Myocardial Infarction,” Circulation: Cardiovascular Quality and Outcomes, 2010; 3: 188-195; Bertakis K, et al., “Patient-Centered Care Is Associated with Decreased Health Care Utilization,” Journal of the American Board of Family Medicine, 2011, 24: 229-239; Physician Executive Council interviews and analysis.

In fact, patient experience is increasingly viewed as a quality metric in its own right. The New England Journal of Medicine published a Key Takeaways perspectives piece in January of 2013, signed by many quality experts and thought leaders, stating that they 1 Overall satisfaction with care is positively unanimously agree that there is a New England correlated with clinical adherence to treatment causal link between patient experience Journal of Medicine guidelines and quality outcomes. Most importantly, the piece argues that The Patient Experience and Health Outcomes patient experience metrics are quality 2 Patient-experience measures don’t simply reflect outcomes themselves, reflecting clinical adherence-driven outcomes but also dimensions of care that are otherwise represent a different dimension of quality that is difficult to capture. otherwise difficult to measure objectively

3 Increased patient engagement leads to lower

resource use and greater satisfaction ” ”

“We believe that when designed and administered appropriately, patient-experience surveys provide robust measures of quality, and our efforts to assess patient experiences should be redoubled.”

New England Journal of Medicine Matthew P. Manary, et al.

Source: Manary MP, et al., “The Patient Experience and Health Outcomes,” The New England Journal of Medicine, 2013; 368: 201-203. Physician Executive Council interviews and analysis.

This focus on the quality benefits of a Excellent Communication Skills Needed to Reach Common Understanding positive patient experience shines a light on components of physician practice that were previously seen as less important. For instance, data Percentage of American Adults Percentage of Medical Information increasingly supports the potential for Not Proficient1 in Health Literacy Forgotten Immediately by Adult Learners strong physician communication to directly impact patient outcomes, n|19,000 n=151 particularly for the chronically ill. Studies show that patients listen more closely when the doctor is talking and care most about the doctor’s opinion. This finding is especially important 89% 60% when 89% of American adults are not 89% proficient in health literacy and 60% of 60% patients are immediately forgetting the medical information explained to them. While other providers can contribute to better patient comprehension, physicians are uniquely positioned to engage the patient as a partner and ” advocate in the improvement of his or her health because of the special emphasis the patient is placing on the relationship. Can We Learn to Speak Their Language? “The doctors are trying to map out exactly what is wrong with you, and they’re giving it to you in sophisticated neurologic terms. It’s like being in a foreign country: you don’t speak the language and you’re trying to find directions.”

45-year-old male diagnosed with multiple sclerosis

Source: U.S. Department of Education Institute of Education Sciences, “The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy,” http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483; Physician Executive Council interviews and analysis.

Better communication does not Untangling the Issue of Quantity Versus Quality necessarily require more of the physician’s time. While there are aspects of an improved patient experience, like health coaching, that ” take more time, physicians should not be engaging in these more time- Time-Intensive Patient intensive aspects of an improved Communication Activities patient experience. These Make Better Use of Time Physicians Spend responsibilities should be delegated to • Health Coaching other members of the care team, such “I am not one of the naturals. I still have a memory of as case managers and health coaches. • Patient Care Plan Development an elderly patient—I gave her all of the information about what we were doing, her condition, etc. I was However, physicians still have an • Problem Resolution, Dispute Mediation about to exit the room and I could still see her out of opportunity to improve the quality of the corner of my eye—she seemed anxious. I turned the time they are already investing in back, put my hand on her shoulder, and said “Mrs. patient experience. Small gestures to Smith, we are going to take good care of you today.” reassure the patient or to communicate That took me one second—reinforced the “we,” and that their concerns have been heard made the nurse smile. I have used that tactic ever can have a significant impact. since. And that one statement took less time than everything else I had said to her before.”

Utilize non-physician care team CMO, Hospital in the Midwest members at top of license

Source: Physician Executive Council interviews and analysis.

To further clarify that it is the quality, and not quantity, of time that physicians are investing in patient interaction that makes the difference, an academic medical center in the 1 Southeast uses the following exercise Case in Brief: Amazon Medical Center frequently with their physicians. • 500-bed not-for-profit academic medical center based in the Southeast The organization sets up a simulation • Simulated exercise demonstrates time needed to complete positive patient interaction and times the difference in duration • Physician timed using exemplary and non-exemplary greeting communication between a physician entering a room and delivering the information he or she wants to communicate without knocking or introducing him or herself, Introduction Adds Seconds, Yields Improved Outcomes versus knocking, entering the room, introducing him or herself and then delivering the communication. The average time difference between = these two approaches is seven seconds, yet the difference from a patient experience perspective is Physician fails to knock Dialogue between profound. One is a perfunctory Before on door or introduce physician and patient is interaction, the other turns the Intervention him or herself after perfunctory and leads to interaction into a mutual dynamic, entering the room poor patient experience building trust, fostering respect, and 7 seconds easing anxiety. Difference between Physician knocks on Communication between poor and excellent After door and introduces physician and patient is greeting practice Intervention him or herself after a conversation and leads entering the room to improved patient experience

1) Pseudonym. Source: Physician Executive Council interviews and analysis.

Patient experience is not about the amount of time physicians spend with patients. Patients want to be understood. They seek acknowledgement that they’re in a difficult and sometimes scary situation with little control. ! All too often, patient satisfaction Common Patient Satisfaction Initiatives Higher-Level Patient Expectations initiatives target issues like noise at night, replacing carpeting in the lounge, and expanding clean-up initiatives. However, what patients are really looking for is to be comforted when they are frightened and anxious, to feel that safety is a top priority, and to have • Implement initiative on all units • Being comforted when anxious and frightened to reduce noise at night full knowledge of their care. Physicians • Being treated as an individual have the ability to inflect each of these • Expand “Clean Up!” initiative to • Having caregivers listen to and respect needs. include step-down, rehab units patient and family opinions and preferences • Repaint hallways and replace • Being supported by an effective care team carpeting in patient lounge • Always feeling that safety is a top priority • Train all clinical staff on scripting • Having full knowledge of diagnosis, for entering and exiting patient rooms medications and medical information

Source: Physician Executive Council interviews and analysis.

In fact, a 2011 study in the American Patient-Provider Interaction More Important Than Cleanliness, Noise Journal of Managed Care found that communication with doctors and nurses has a stronger correlation to overall satisfaction than cleanliness or noise levels. Notably, all the top-ranking domains— communication with nurses, pain Domains of HCAHPS in Order of Correlation management, and timeliness of with Overall Satisfaction assistance—all require excellent patient-provider interaction and flawless care team coordination. 1 Communication with nurses These are all domains that suffer with Pain management poor physician-care team 2 Patient-Provider Interaction communication. 3 Timeliness of assistance and Coordination Within Patients are not really looking for a Care Team cleaner room or better food. They seek 4 Explanation of medications administered caregivers who communicate with them, and with one another. 5.5 CommunicationCommunication with with doctorsdoctors 6 Cleanliness of room and bathroom

7 Discharge planning Standard Service 8 Noise level at night Measures; Cleanliness and Noise Level

Boulding W, et al., “Relationship Between Patient Satisfaction with Inpatient Care and Hospital Readmission Within 30 Days,” American Journal of Managed Care, 2011, 17: 41-48; Manary MP, et al., “The Patient Experience and Health Outcomes,” The New England Journal of Medicine, 2013; 368: 201-203; Physician Executive Council interviews and analysis.

The impact of strong physician communication on patient experience appears to be more far-reaching than the data might indicate.

Susan Edgman-Levitan, Principal Physician Communication with Care Team Sets Tone for Patient Experience Investigator of the CAHPS survey and ” an HCAHPS expert, posits that nursing communication is a proxy for two critical dimensions of the patient experience: physician communication Most Domains are and teamwork. Edgman-Levitan says Proxies for Teamwork that when a patient reports strong Communication nurse communication, it is often a with Doctors “Some of the nursing communication reflection of how well the nurse and items are really a proxy for teamwork. doctor are communicating with one When you ask a patient to report how other. well the nurses could answer their questions, that is often a reflection of This suggests that the physician role in how well the nurses and the doctors patient experience is not limited to his are communicating so that the nurses or her direct interaction with the actually have the information to share patient, but is deeply engrained into Care of Patient Communication with the patient.” many of the operational relationships with Nurses in the clinical setting. Susan Edgman-Levitan CAHPS creator and HCAHPS expert1 Many physicians believe that their impact on HCAHPS is limited because only three questions specifically refer to physicians. This research clearly indicates that physicians’ influence is felt across the entire HCAHPS question set, and that their impact is significant and primary.

1) Susan Edgman-Levitan, Director of the John D. Stoeckle Center for Primary Care Boulding W, et al., “Relationship Between Patient Satisfaction with Inpatient Care and Innovation at Massachusetts General Hospital, Boston, Co-Principle Investigator on the Hospital Readmission Within 30 Days,” American Journal of Managed Care, 2011, 17: 41-48; Yale/Harvard Consumer Assessment of Health Plans Study (CAHPS) from 1995 to Manary MP, et al., “The Patient Experience and Health Outcomes,” The New England Journal present, involved in HCAHPS since inception. of Medicine, 2013; 368: 201-203; Physician Executive Council interviews and analysis.

Physicians clearly have a significant Physician Plays Key Leadership Role Among Staff, with Patient role to play in improving the patient experience. Their influence is both primary, through their direct interactions with patients, and far • Physician engages in top-notch reaching, via the downstream impact patient communication, verbally, • Physician sets precedent for on care team performance. through body language, facial patient experience emotional indicators, and actions performance for staff Physicians have the power to amplify or diminish other positive and negative • Serves as care giver, pillar of Leads by • Takes control of clarifying example aspects of a patient’s care experience. knowledge and guidance, teacher, care team and care plan for patient as needed As such, the physician truly is the shared decision maker, leader Influencer-in-Chief, leading by example, in his or her communication • Physician demonstrates with the care team, by cultivating Excellent Strong Care exemplary communication empathy with the patient and by patient Team skills when working with delivering excellent patient communication Communication care team Physician communication. • Serves as strong leader, resolving problems, and • Uses resources available Cultivates and mediating disputes (family, patient posters, exercises as needed medical records, etc.) to patient empathy understand patient, condition, and develop empathy • Exercises compassion towards patient and family

Access This Presentation

“The Unique Role of Physicians in Patient Experience” is available for sharing with physicians on our website: advisory.com/PEC/2013meetingresources

Source: Physician Executive Council interviews and analysis

Leveraging Data for Performance Improvement

While sharing quality data with Unleashing the Power of Peer Pressure physicians is always challenging, patient experience data is particularly difficult to manage. Physicians are resistant to the metric and the fact that it captures an aspect of physician practice that is hard to measure and Steps to Unblinding Data Physician Performance on HCAHPS therefore seemingly disputable. May 2008–April 2009 As such, many physician executives are reluctant to unblind and share data Performance data with physicians. However, unblinded 1 presented, importance of initiative explained data sharing can be one of the most 25% effective tactics to drive performance improvement. Unblinded, individual Pseudonymed organization Lena 2 physician data posted in staff lounge Health System did this to great effect, improving their HCAHPS scores by May April 25%. When done in a supportive and collegial environment, unblinding data can positively leverage physicians’ natural competitiveness.

Case in Brief: Lena Health System1

• 14-hospital health system in the Southwest • Blinded performance data encouraged initial but limited improvement • Release of unblinded data motivated physician performance improvement and achieved significant results

1) Pseudonym. Source: Physician Executive Council interviews and analysis.

Research shows that the majority of Physician Support for Full Transparency Surprisingly Strong physicians actually support the unblinding of data, as shown by Covenant Health Partners’ experience. Covenant, a clinically integrated network in Texas, signed payer contracts that rewarded the group under a shared-savings model, giving physicians a vested interest in quality and cost management. Survey of Physicians in Covenant Health Case in Brief: Covenant Health Partners After several years spent reviewing Partners’ Clinical Integration Program blinded performance data, the • 300+ physician clinically integrated network physicians themselves asked the affiliated with Covenant Health System located in Lubbock, Texas network to unblind the information, arguing that they needed greater • Physicians pushed for greater visibility across the network to find new data transparency to spur competition and change referral patterns performance opportunities. Supportive 70% 30% Opposed • Backed by physician support, administrators 70% of Covenant physicians were recently shifted from blinded to unblinded supportive of the unblinding initiative. data among peers in same specialty Data was first unblinded within • Currently considering sharing data specialty divisions and will soon be across specialties unblinded across the entire network. Transparency sparked competition within the medical staff, a change in referral patterns, and improved performance on their patient experience scores.

Source: Covenant Health, Lubbock, TX; Physician Executive Council interviews and analysis.

Issues associated with patient Up to Six Weeks from Discharge to Survey experience data, such as attribution and time lag, must be addressed prior to sharing data with physicians. HCAHPS Data Collection and Reporting Process Put simply, “old” data is less relevant to physicians, because they are not able to immediately tie the feedback from the data to their practice. May be several Physician months after talks to patient Unfortunately, there are multiple points initial interaction within the HCAHPS data collection and reporting process where data lag can Administration Patient leaves reviews occur. hospital physician data That said, solutions do exist to overcome these hurdles. Peer mentor May be up to shadowing can provide physicians with 6 weeks after immediate feedback from a highly patient leaves credible source. Home-grown, tailored Data returned Patient takes hospital patient exit surveys can also provide to hospital survey more targeted, in the moment feedback. Finally, patient feedback systems, like The Advisory Board Company’s iRound system, enable real-time monitoring and trend-tracking Vehicles for Providing Faster Feedback of patient satisfaction, allowing for the resolution of patient experience issues while the patient is still in the hospital.

Peer mentor shadowing Homegrown patient Real-time mobile data with immediate feedback exit polling strategies collection

Source: Physician Executive Council interviews and analysis.

Physicians must become more University of Utah First in Nation to Make Performance Reviews Public comfortable with sharing patient satisfaction data, as it will increasingly become available to patients. According to one study, 70% of consumers trust web reviews as much as a personal recommendation. As 70% consumers, patients expect data to be Percentage of consumers who trust readily available for their review. web reviews as much as personal University of Utah Health Care viewed recommendations from friends and this consumer demand as an family, but only if there are multiple reviews and only if the reviews are opportunity to control the narrative. Physician survey scores and comments Executives decided to publish the believed to be authentic online and available to the public system’s physician survey scores on their website and allowed the public to comment. The University collects more than 40,000 survey responses a year, which it then aggregates and shares Case in Brief: University of Utah Health Care with consumers. The comments section is regulated but not curated. • Four-hospital health system based in Salt Lake City, UT Openly slanderous or inappropriate • Consumers have online access to physician’s patient satisfaction scores and comments comments are removed, but otherwise • Physicians’ score based off of nine-question Press Ganey survey, more than 40,000 consumers are free to share their survey responses collected for University of Utah Health Care patients annually feedback. • Each physician must have survey response of n>30 and at least six months employment Executives at Utah decided they would with University of Utah Health Care to be included in the public system prefer to lead with high-quality data • University of Utah Health Care first system to make physician patient satisfaction scores and control the source, rather than publicly available; decided to publicize after seeing low “n” reviews with slanderous address concerns arising from low- comments on various open review websites quality sites like Yelp and Angie’s List. • System experienced 37% rise in patient satisfaction scores between 2011 and 2013 • Success attributable to several factors, including unblinded, publicly available data and organization-wide prioritization of patient satisfaction scores

Electronic Survey Speeds Feedback, Pleases Patients

Making patient experience data Email Shortens Feedback Time, Raises Responses and Scores available to the public proved to be an effective lever for driving performance improvement. After publishing their data, Utah saw patient satisfaction scores jump 37% in one year. While public data sharing was one Survey Questions component of a broader campaign • Likelihood of recommending doctor around patient experience, executives Utah Patient Satisfaction Scores strongly believe it was a core driver of • Confidence in doctor the improvement. • Time spent with doctor Implementation Utah executives equally credit their • Doctor’s use of clear language of electronic survey success to their electronic patient yielded higher patient • Doctor’s effort to include satisfaction scores 37% survey. Rather than a traditional paper patient in decisions and pen survey, Utah distributed a home-grown survey via email and • Doctor’s concern for questions and worries received a substantial number of responses in less than 72 hours. This • Doctor’s explanation of allowed physicians and other condition/problem practitioners to immediately connect • Wait time at clinic 2011 2013 the patient experience data with their • Doctor’s friendliness and courtesy practice.

Electronic surveys distributed via email raise response rate, provide results in less than 72 hours

Source: Rodak S, Becker’s Clinical Quality and Infection Control, http://www.beckershospitalreview.com/quality/university-of-utah-health-cares-5-pronged- approach-to-patient-satisfaction.html; Wilets K, University of Utah Office of Public Affairs, http://healthcare.utah.edu/publicaffairs/news/current/12-10- 2012_physician_reviews%20.html; Thomas M and Mulvihill S, "University of Utah Health Sciences,“University of Utah Health Care, http://healthsciences.utah.edu/blog/postings/december_2012/120712physicianreviews.php; Physician Executive Council interviews and analysis.

Strengthening Physicians’ Patient Experience Skills

Improving physician performance on Building Empathy and Ability to Connect patient experience requires more than just securing their buy-in. Many physicians want to perform better, but they may not know how. Two skills lie at the core of the physician-patient interaction. The first is more challenging: to understand the patient’s Physician and Patient Perceptions Two Key Interpersonal Skills context, or more simply, to have of Emotional Comfort empathy. Second are the verbal and non-verbal communication skills 98% necessary to make the interaction 1 Creating Patient Context meaningful. These are soft skills that • Strategies for developing empathy cannot always be improved simply by • Tools to develop understanding of reading a book, watching a webinar, or patient’s history and circumstance 46% trying harder. Further, cultivating these skills can be 2 Making Interactions Meaningful challenging due to a disconnect between physicians’ actual and • Refining communication and behavioral skills to maximize perceived performance on their patient interaction communication skills. Most physicians Physicians Patients Who are not aware that they are not meeting Who Reported Believed • Practicing techniques to Addressing Physicians build patient rapport patients’ needs. However, Patients’ Fears Addressed Their improvement is possible with targeted and Anxieties Fears and training. Anxieties .

Source: Olson DP, et al., “Communication Discrepancies Between Physicians and Hospitalized Patients,” Archives of Internal Medicine, 2010, 170(15): 1302-1307; Physician Executive Council interviews and analysis.

Empathy has long been perceived as MGH and Massachusetts Eye and Ear Test Innovative Curriculum an innate capacity—people simply are or are not empathetic. A group of researchers at Massachusetts Eye and Program Objectives Ear Institute recently demonstrated that Share the scientific foundation for the neurobiology empathy can in fact be cultivated, 1 practiced, and learned. and physiology of empathy training Increase physician awareness of the physiology of emotions The program was based on the 2 neurobiology and physiology of during typical and difficult patient-physician interactions empathy. Over a period of four weeks, 3 Improve skill in decoding subtle facial expressions of emotion researchers trained groups of residents and fellows to detect subtle nonverbal signs of emotion in themselves and 4 Teach empathic verbal and behavioral responses with self-regulation skills utilizing diaphragmatic breathing exercises and mindfulness practices their patients. A control group was also created and tracked to establish a baseline for comparison.

Study in Brief: Increasing Physician Empathy Through Neurobiological Training

• Massachusetts General Hospital and Massachusetts Eye and Ear Institute and Infirmary, 950-bed medical center located in Boston, Massachusetts • Residents and fellows participate in empathy training protocol based in neuroscience education • Program training goals: 1. Improve physician awareness of patients’ emotional verbal and nonverbal communications 2. Respond to these communications with empathic understanding 3. Increase physician emotional and physiological self-awareness and self-regulation 4. Use these skills in challenging patient interactions • Participants randomized into control group or training program of three 60-minute training modules • Training delivered over four weeks to groups of six to 15 residents and fellows in the inpatient and outpatient settings • Empathy training group showed greater changes in patient-rated CARE Score than control group

Source: Reiss H, Kelley JM, et al., “Empathy Training for Resident Physicians: a Randomized Controlled Trial of a Neuroscience- Informed Curriculum” Journal General Internal Medicine. Oct 2012; 27(10):1280-6. Epub 2012 May 2. Massachusetts General Hospital, Boston, MA; Physician Executive Council interviews and analysis.

The training program used video- Program Thoroughly Explores Patient and Physician Experience based, didactic, and experiential modules to teach the value, meaning, and power of empathic connection. Diverse teaching tools were deployed to ensure the training would appeal to Components of Empathy Training different sensibilities across the physician cohort.

Video-Based Module Didactic Module Experiential Module

• Videos of clinical • Introduction and • Nonverbal interactions with real- context for empathy communication time physiological training of emotion responses • Neurobiology and • Decoding facial • Physicians see physiology of emotion expressions concordance between themselves and their • Empathetic and • Physician self-regulation patients, including patient-centered exercise and discussion physiological activation delivery of bad news by attitudes

Source: Reiss H, Kelley JM, et al., “Empathy Training for Resident Physicians: a Randomized Controlled Trial of a Neuroscience-Informed Curriculum” Journal General Internal Medicine. Oct 2012; 27(10):1280-6. Epub 2012 May 2. Massachusetts General Hospital, Boston, MA; Physician Executive Council interviews and analysis.

At the end of the intervention, the Physicians Self-Report Improvement Through MGH/Mass Eye and Ear Program training group showed a greater change in each of the evaluation metrics. Notably, the control group experienced a decline in empathy over the period of the intervention, which suggests that the intervention not only had a positive, but also a protective Self-Assessed Improvements effect. Among Training Participants Pre Post Change Scores by Treatment Group While the data supported the value of the intervention, the strongest • Listening carefully to Training Control endorsement of this science-based Measure P-Value patients without interrupting Group Group training came from the participants • Making meaningful eye contact themselves, who reported CARE1 0.7 -1.5 0.04 improvements in their own behavior • Interpreting nonverbal cues • Greater self-awareness and Neuro2 2.3 0.4 <0.001 ability to manage physiological and emotional reactions to challenging patients Ekman3 2.1 0.2 <0.001

Empathy training group showed greater change in patient-rated Attributable to CARE scores than control decline in empathy (difference 2.2; p=0.04) during residency

Source: Reiss H, Kelley JM, et al., “Empathy Training for Resident Physicians: a Randomized Controlled Trial of a Neuroscience-Informed Curriculum” Journal General Internal Medicine. Oct 2012; 27(10):1280-6. Epub 2012 May 2. Massachusetts General Hospital, Boston, MA; Physician Executive Council interviews and analysis.

UCLA has also invested in tools to Ronald Reagan UCLA Medical Center Patient Poster Initiative support the care team-patient connection. They recently created a “Getting to Know You” poster designed to humanize patients by “telling their story” on a single page. “Getting to Know You” Poster at UCLA The poster captures information about the patient’s family and his or her Designated fields personalize background, hobbies, and preferences, patient by capturing family, allowing the physician and other background, hobbies, preferences providers to know more about the patient as an individual. The poster is placed at the patient’s Prominent placement near patient bedside so that any caregiver can use bedside serves as conversation starter for caregivers it to engage the patient and his or her family in conversations tailored to their values, goals, and preferences. Poster travels with patient across inpatient stay, providing sense of continuity and comfort

Poster content informs plan of care by highlighting patient’s goals after hospitalization

Source: Ronald Reagan UCLA Medical Center, Los Angeles, CA; Physician Executive Council interviews and analysis.

Because these posters are so simple, they’ve been easy to implement and are now used with 95% of patients on the pilot units. They have dramatically Percentage of Patients with Completed Percentile Ranking for Patient increased patient trust in physicians. “Getting to Know You” Posters on ICU Confidence and Trust in ICU Nurses Patient confidence and trust in nurses on the units where the posters were 100 95% first deployed has increased by 80%. 99% 84% 75%

29% 19%

0 Nov. 2009 Mar. 2010 Oct. 2011 Q4 2008 Q3 2009 Q3 2011

Case in Brief: Ronald Reagan UCLA Medical Center • 520-bed academic medical center located in Los Angeles, California • Frontline caregiver introduced “Getting to Know You” posters on ICU in October 2008 as part of Advisory Board Talent Development’s “Frontline Impact” program; currently in place on three units • Posters distributed to all patients and families at admission; completed posters kept in Plexiglass frames at patient bedside and travel with patient across inpatient stay

Source: Ronald Reagan UCLA Medical Center, Los Angeles, CA; Physician Executive Council interviews and analysis.

Communication is the second core Train-the-Trainer Model Develops In-House Expertise, Fosters Ownership competency physicians must master to improve physician-patient interactions. Overview of Physician Facilitator Role A model for physician communication training is exemplified by both Mayo Clinic Florida and Mission Hospital in North Carolina. The Chief Quality Officer (CQO) had great success with this approach at Mayo and has since Role and Responsibilities Important Competencies Additional Criteria transitioned to Mission, which is in the Utilized in Selection process of implementing the program. At both organizations, it was not only • Facilitate peer training sessions • Respected by peers • Clinical background, an expectation that all physicians for eight hours every other month • Ability to facilitate group specialty participate in the patient experience • Serve as role model for best discussions • Tenure communication training, but also that practices in patient-provider • Ability to create a positive • Gender communication the training be physician led. Given tone for group sessions • Relationship with the rest that communication trainings address • Participate in additional skills • Ability to lead role play of the medical staff sensitive patient-physician relationship workshops for ongoing activities development issues, it was deemed critical that the • Ability to incorporate sessions be reserved for physicians • Compensated with hourly feedback effectively only. stipend for services Physician facilitators were selected to attend a four-day training program to prepare them for leading communication training for their peers, Case in Brief: Mayo Clinic in Florida Case in Brief: Mission Hospital and additional workshops were offered • 214-bed hospital located in • 750-bed hospital, located in Asheville, North for ongoing skill development. Jacksonville, Florida Carolina; part of Mission Health Physician facilitators were not only • Specially trained physician cohort • Specially trained physician cohort facilitated selected based on their reputation and facilitated patient experience patient experience communication training for leadership skills, but also to ensure communication training for all 350 one-third of medical staff in six months they represented a range of clinical physicians on the medical staff • Plan to train remaining medical staff over specialties, tenure, and genders. the next year

Source: Experia Health, “Improving Physician Communication,” http://www.experiahealth.com/HCStrategy2011.pdf; Mayo Clinic Florida, Jacksonville, Florida; Mission Health, Asheville, North Carolina; Physician Executive Council interviews and analysis.

Once the physician facilitators were Multifaceted Program Trains Entire Medical Staff trained on key communication competencies, they led skills-based trainings for the entire medical staff. Comprehensive Training Rolled Out to All Physicians These trainings included two, four-hour Physician Education Tools sessions of 25 to 30 physicians and Communication Training several facilitators. Facilitators utilized a variety of teaching mediums, Presentations on including didactic presentations, videos communication skills demonstrating physician-patient interactions, and role-play activities. • Training consists of two, At Mayo, it took two years for all 350 Videos illustrating four-hour group sessions physician-patient physicians on the medical staff to of 25-30 physicians interactions receive the training. At Mission, a third • All medical staff members of their 450 physicians have been required to participate as trained in just six months. outlined in credentialing Role-play activities After the program was implemented, standards Mayo achieved great gains in physicians’ overall scores. Based on Peer-Led Communication Training Yields Impressive Results the program’s success, it became the model for training all clinical and non- Mayo Clinic Florida Press Ganey clinical staff. Further endorsement of Physician Percentile Rank the program came when non-affiliated Expansion of Peer Coaching Model hospitals participating in a regional 90% health care collaborative with Mayo Based on success of the program: decided to adopt this same physician 75% • Training rolled out to rest of training model. the clinical and non-clinical staff at Mayo • Training adopted by non-affiliated hospitals participating in regional Florida collaborative

2009 2011 Source: Experia Health, “Improving Physician Communication,” http://www.experiahealth.com/HCStrategy2011.pdf; Mayo Clinic Florida, Jacksonville, Florida; Mission Health, Asheville, North Carolina; Physician Executive Council interviews and analysis.

While group trainings like those at Full-Time Coach Offers Dedicated Support Mayo and Mission have proven successful, other organizations have Dedicated Physician Service Excellence Coach at Prevea elected to implement one-on-one coaching models. Prevea, a multispecialty medical group based in Wisconsin, has dedicated a Coach Hired by Service full-time role to providing physicians Excellence Department with ongoing coaching and support. In addition to managing all physician- level satisfaction data, the coach conducts 80 to 100 training sessions Conducts 80-100 Collects and monitors per year with all new physicians as well coaching sessions physician level as established doctors. The coach also per year satisfaction data shadows select high-performing physicians each month to identify best Provides coaching, Shadows select high- practices. shadowing for performing physicians Prevea’s program has been so physicians, including each month to identify all new hires best practices effective due in part to the structured shadowing and follow-up support from the coach. Overview of Prevea’s Patient Experience Shadowing Process Beyond one-on-one sessions, the coach shadows physicians across several patient visits. The physicians Coach shadows physician Coach sends physician observation in office for three to four report outlining next steps, physician receive real-time feedback after the patient encounters1 satisfaction data shadowing session is complete and the coach follows-up with a written letter summarizing her observations, recommendations, and an overview of opportunities to improve. Additionally, Coach meets with Coach follows-up with physician at 3, 6, continued support is provided by the physician to give brief 9, and 12 months to monitor progress coach at regular intervals across the real-time feedback and provide continued guidance year to discuss progress and provide additional guidance as needed. 1) All patients informed about observation visit by coach; provided Source: Prevea Health, Green Bay, Wisconsin; with option to decline coach attendance during visit. Physician Executive Council interviews and analysis.

Coaching Model Delivers Results

Prevea’s investments to support the patient experience have resulted in significant improvement. Overall physician percentile rank and communication rank have increased Prevea Health Patient Experience Scores significantly. Individual success stories have also been striking. One physician participating in the coaching improved Press Ganey Press Ganey from the 15th percentile to the 80th Overall Patient Experience Physician Communication 1 percentile within six months. Percentile Rank Percentile Rank

75% 76%

44% 48%

2008 2011 2008 2011

Case in Brief: Prevea Health

• 200-physician multispecialty medical group based in Green Bay, Wisconsin • Began coaching program in 2009 with a pilot group consisting of department chairs • Pilot coaching program became model for broader adoption and was first offered to lower scoring physicians, but eventually expanded to all physicians • National ranking on Press Ganey surveys increased by 10 points within one year following implementation of physician service excellence program

Source: Prevea Health, Green Bay, Wisconsin; Physician Executive Council interviews and analysis.

Individual coaching and shadowing is Who Is the Physician Coach? clearly one of the most high-impact opportunities for inflecting patient experience performance. The success of this tactic hinges on the person selected to serve as the coach.

Interestingly, physician executives are uniformly divided on whether or not the ” coach must be a physician. Ultimately, the best coach is someone who can truly reflect the patient perspective, and Key Characteristics of the Physician Coach often that person is a non-physician. A “We have been doing physician good coach must be credible and be coaching for over a year now. The docs were initially skeptical, but now they love comfortable providing feedback to Holds credibility with hospital’s 1 it. We have a great emeritus physician physicians. Indeed, physicians physicians; possibly a retired who shadows docs who are having a physician themselves may prefer a non-physician hard time. He has credibility among the for communication coaching, because physicians and is also widely recognized they don’t feel like that person will also as a leader in the “soft-skills” be judging their clinical skills. 2 Excellent understanding of both department. He just really “gets it,” both Depending on the culture of an physician role and patient the patients and physicians. It’s working organization, a physician may be experience in the hospital really well for us.” required. Chief Medical Officer 3 Excellent teacher; track record as effective teacher with physicians

Source: Physician Executive Council interviews and analysis.

Case Study: Cone Health

Throughout this publication, numerous Implements System-Wide Hospitalist Training to Improve Performance strategies and tactics for engaging physicians in transforming patient Cone Health Moves to Transform Patient Experience experience have been identified. Starting in 2010, Cone Health, located in Greensboro, North Carolina, System-Wide Cultural Transformation New Identity as “Patient Centered” underwent a cultural transformation System initiates a cultural System aims to move employee centered on becoming more patient- transformation focused on transforming perception of organization from centric in which they deployed many of health care and creating measurably financially driven to patient centered these strategies. Their story is superior triple aim performance reproduced across the following pages, with particular attention paid to the Leaders Selected Across System Cultural Transformation Ambassadors work done with their hospitalists, where targeted interventions drove a dramatic Application process selects 19 “Breakthrough Masters” serve as “Breakthrough Masters,” leaders focused cultural transformation ambassadors, turnaround in patient experience on breakthrough unprecedented results make two-year commitment and performance. across the system dedicate 10%-15% of time Cone Health began its patient experience overhaul by addressing culture. Executives spent a year engaging the entire system in a Case in Brief: Cone Health and Triad Hospitalists deliberate cultural transformation, • Six-hospital system located in Greensboro, North Carolina; over 11,500 employees; more than 1,000 physicians targeting superior clinical performance with an emphasis on patient • In June 2010, system initiated a cultural transformation focused on transforming health care and creating experience. At the time, Cone measurably superior triple aim performance employees characterized the • In June 2011, developed a system-wide patient experience project for system’s 45 hospitalists organization as “financially-driven,” as • Program involved development of a service excellence committee, broad-based messaging at department opposed to “patient-centered.” meetings, shared reading, one-on-one rounding, and a half-day training comprised of focus group discussions and skills- based simulation training • After training, patient satisfaction data individually shared with each hospitalist; high performers acknowledged and praised, while low performers targeted for coaching • In one year, system-wide hospitalist patient satisfaction scores moved from the 4th to 31st percentile, 89th percentile for a specific site

Source: Cone Health, Greensboro, NC; Cone Health “Code U” Newsletter, April 2013, http://www.conehealth.com/app/files/public/1149/Code-U---April-2013.pdf; Physician Executive Council interviews and analysis. ©2014 The Advisory Board Company • 28986 60 advisory.com Broaching Issues in Hospitalist Performance

Cone Health’s cultural transformation had been underway for over a year when the Executive Director of Patient Experience created a new Service Early Steps in Hospitalist Patient Experience Transformation, June 2011 Excellence Committee composed of five physicians and the administrative director of the system’s hospitalist group. Collectively, participants decided that hospitalists should be the System-Wide Patient Experience Performance primary focus area for patient New Service Excellence experience improvement. 76% 1 Committee selects hospitalist As a first step, the system began performance as focus area sharing hospitalist patient experience data at hospitalist department meetings with the goal of galvanizing 4% the group around the need for change. All Physicians Hospitalists With patient experience scores in the Share patient experience 2 first and fourth percentile, the Service data at hospitalist Excellence Committee was able to department meetings create a strong burning platform for change. They then proposed the Hospitalist Patient Experience Performance creation of a hospitalist-specific training 24% program. Propose hospitalist-specific 3 training program

4% 1% 1% System A1 B1 C1

1) A, B, C representative of campuses in the Cone Health system. Source: Cone Health, Greensboro, NC; Cone Health “Code U” Newsletter, April Percentile achievement in Press Ganey survey. 2013, http://www.conehealth.com/app/files/public/1149/Code-U---April-2013.pdf; Physician Executive Council interviews and analysis. ©2014 The Advisory Board Company • 28986 61 advisory.com Hospitalists Play Critical Role in Patient Experience

Cone Health’s decision to choose hospitalists was strategic and effective. For many systems, hospitalists are a lynchpin of the care team. They admit approximately 50% of patients and are uniquely positioned to influence the Factors Making Hospitalists a Crucial Group for Improvement Support care team given their knowledge of the patient’s condition, care plan, and relationships with other participating specialists. Admit about 50% of HCAHPS scores often lower than hospital’s patients—more any other subset of physicians Further, hospitalists often have lower than any other specialty

HCAHPS scores than other physician groups. While this is partially due to the fact that hospitalists are practicing in an environment with many structural barriers to securing high HCAHPS scores, it also creates an opportunity Hospitalist Challenges in Patient Experience for a quick win. This is precisely the logic Cone Health employed when opting to focus their Autonomy reduced by structural No relationship to patient efforts on their hospitalists. barriers, environmental factors prior to admission

Source: Physician Executive Council interviews and analysis.

The Executive Director of Patient Experience kicked off the hospitalist- specific campaign by rounding with each of the hospitalists to understand Investigation Deepens Understanding of Problem their specific patient experience challenges. September, 2011-December, 2011 In addition to observing and coaching hospitalists on their performance, he also asked questions about their day- to-day experiences, such as “What is 1-1 Rounding the most difficult conversation you have had with a patient?” These insights were then leveraged by the Executive Director, Office of Patient Research from rounding drives future Service Excellence Committee to Experience, does 1-1 rounding with of program, incorporated into future hospitalists in order to observe, skills training and development of develop the next phase of the program. discuss, and coach on most difficult simulation lab Throughout this process, patient conversations and challenges experience became a topic discussed continuously among hospitalists, both informally and at organized events like department meetings. The hospitalists collectively decided to read the book Laying Foundation for Group Accountability “Practicing Excellence” to better “Practicing Excellence: A Physician’s Manual to understand some of the issues they Exceptional Health Care” –Stephen Beeson, MD faced and to create a conceptual In addition to discussing patient experience common ground for driving performance at department meetings, all 45 improvement. hospitalists read and discussed Beeson’s “Practicing Excellence,” focused on leadership, conduct, and physician performance

Source: Cone Health, Greensboro, NC; Cone Health “Code U” Newsletter, April 2013, http://www.conehealth.com/app/files/public/1149/Code-U---April-2013.pdf; Physician Executive Council interviews and analysis. ©2014 The Advisory Board Company • 28986 63 advisory.com Step 4: Investing in Hospitalist Training Training Elevates Hospitalist-Patient Interaction

The cornerstone of the hospitalist campaign was the creation of a system patient experience simulation training day. The four-hour training was mandatory for all 45 hospitalists. First Annual Hospitalist Simulation Training For the first two hours of the training, the hospitalists broke into small March 2012 discussion groups led by a physician member of the Service Excellence Four-Hour Mandatory Training Committee. Physicians were prompted All 45 system hospitalists participate in to share stories about their toughest half-day skills-focused training challenges and patient conversations. During the second two hours, the hospitalists participated in a communication skills training in the system’s simulation lab. Group Story Sharing Simulation-Based Skills Training (Two Hours) (Two Hours) Issues that had been uncovered during rounding were built into practice • Hospitalists broken into groups of 6-8 • Issues surfaced during 1-1 rounding revisited in simulation lab exercises. After each exercise, the • Service Excellence Committee physician groups debriefed and offered coaching member serves as facilitator for each group • All 45 hospitalists participate in to one another about what could be • Groups discuss most difficult conversations simulation exercises designed to improved upon or how they might they have had with patients and toughest improve patient communication skills practice differently. challenges they have faced • Groups debrief each simulation and coached post simulation

Source: Cone Health, Greensboro, NC; Cone Health “Code U” Newsletter, April 2013, http://www.conehealth.com/app/files/public/1149/Code-U---April-2013.pdf; Physician Executive Council interviews and analysis. ©2014 The Advisory Board Company • 28986 64 advisory.com Follow-up Cements Hospitalist Performance Gains

In the weeks following the hospitalist- wide training, Cone continued to push aggressively on more transparency around patient experience performance. They began sharing unblinded hospitalist performance Post-simulation Training Follow-Up scores at the individual level, investing significant resources in ensuring data was as current as possible. They also included patient verbatims collected After simulation training, during discharge calls to make the data hospitalist patient experience more actionable. To ensure they could performance scores shared, Pre-simulation unblinded, at individual level maintain gains in improvement, Training Performance physicians who continued to struggle were provided with additional support, and those who excelled were publicly acknowledged for their top Physicians receive rolling performance. Before simulation training, reports on their patient hospitalists’ patient experience performance; experience performance verbatims from discharge calls reported at group level included in reports

Administrative hospitalist director acknowledges hospitalists who are excelling and follows up with those who are having difficulty

Source: Cone Health, Greensboro, NC; Cone Health “Code U” Newsletter, April 2013, http://www.conehealth.com/app/files/public/1149/Code-U---April-2013.pdf; Physician Executive Council interviews and analysis. ©2014 The Advisory Board Company • 28986 65 advisory.com Hospitalist and System Performance Improve Together

Cone’s performance on patient experience improved quickly and dramatically. Nine months after the simulation training, hospitalist patient experience scores had moved to the 31st percentile system-wide. Inpatient satisfaction scores bumped to the 73rd Hospitalist and System Performance Improvements in Patient Experience percentile, and the system’s mean March 2012-December 2012 patient experience performance score saw a corresponding improvement. Ideally, every physician within an Hospitalist Patient System-Wide Inpatient System-Wide Patient organization would receive this level of Experience Performance Satisfaction Scores Experience Performance support and training, but that simply is Mean Score not feasible. By focusing on targeted 73% 87.4 groups with significant performance 31% gaps, hospitals can realize dramatic improvements and build momentum for broader change. 84.4 27% It is important to emphasize that Cone’s hospitalist campaign was part 4% of a broader cultural transformation focused on becoming more patient- Before After Before After Before After centered. They could not have achieved this level of improvement with their hospitalists absent the broader organization-wide investments in cultural transformation.

Source: Cone Health, Greensboro, NC; Cone Health “Code U” Newsletter, April 2013, http://www.conehealth.com/app/files/public/1149/Code-U---April-2013.pdf; Physician Executive Council interviews and analysis. ©2014 The Advisory Board Company • 28986 66 advisory.com ©2014 The Advisory Board Company • 28986 67 advisory.com ©2014 The Advisory Board Company • 28986 68 advisory.com