Presentation on theme: "Measuring the Patient Experience in a Medical Home QI/PCMH Roundtable March 14, 2013, Seattle, WA."— Presentation transcript:
Measuring the Patient Experience in a Medical Home QI/PCMH Roundtable March 14, 2013, Seattle, WA
Radical Patient Centeredness (1) “The needs of the patient come first.” –Mayo Clinic (2) “Nothing about me without me.” –IHI (3) “Every patient is the only patient.” –Harvard Community Health Plan Hospital
Why Focus on Patient-Centered Interactions? Without a deliberate focus on integrating the patient’s perspective and the patient and families desires/goals, practice changes may create efficiency, but miss entirely the changes that would have come from patients’ experience of care. Without involving patients and family members in quality improvement, we are only guessing at what they want and need.
The “big ASK”: routinely asking patients about their experience of care to guide teams in the improvement and redesign aspects of achieving patient-centered medical home-ness Methods to capture our patients’ experiences Regularly host focus groups Have patient representatives on the improvement team Ask patients about their experience at the point of service Routinely conduct patient surveys and review the results immediately
Radical Patient Centeredness A never-ending inquiry to those we serve: “What do you want and need?” “What is your way?” “How am I doing at meeting your needs?” “How could I do that better?” “How can I help you?”
Patient-centered care as a quality dimension. Ask the following question at the end of most interactions: “Is there anything at all that could have gone better today from your point of view in the care you experienced?” And then, listen and learn. For quantitative ratings, ask patients to rate on a 1–5 scale disagreement to agreement with the assertion: “They gave me all the care I needed and wanted, exactly when and how I needed and wanted it.” Seek 5s and study the low raters. L. Gordon Moore, MD
Data for Improvement, Accountability, Research AspectImprovementAccountabilityResearch AimImprovement of care Comparison, choice, reassurance New knowledge Test Observability Test observationsEvaluate current performance; no test Test blinded Bias & Sample Size Consistent bias – just enough data Measure and adjust to reduce bias – 100% of data Design to eliminate bias – just in case data Flexibility of hypothesis Improvement of care No hypothesisFixed hypothesis Testing strategySequential testsNo tests1 test Is change an improvement? Run or control charts No change focusHypothesis tests (F- test, T-test, Chi- squared, P-value) Confidentiality of data Only used by those involved in improvement Available for public consumption Identities protected Tammy Fisher, MPH Director, Quality & Performance Improvement San Francisco Health Plan
Collecting Patient Experience Data PurposeData Collection Tools/strategies ImprovementPoint of service surveys Telephonic surveys Comment cards Patient exit surveys Focus groups Patient (and family) Walkabouts Kiosks, via web Accountability/ResearchMailed surveys Telephonic surveys
Common Reasons for Using an Existing Instrument So normative comparisons can be made (benchmarking) To replicate or maintain continuity with previous studies Existing measure is state-of-the-art The time and expense of developing new measure is prohibitive
Examples of Existing Patient Experience Surveys CAHPS (consumer assessments of health plans survey) –http://www.cahps.ahrq.gov PCAT (primary care assessment tool) –http://www.jhsph.edu/pcpc/pca_tools.html –Cassady CE et al., Pediatrics (J Ambul Pediatr Assoc) 2000;105: ACES (ambulatory care experience survey) –http:// /icrhps/resprog/thi/aces.asp –Safran DG et al., Medical Care (5): IPC (interpersonal processes of care): –Stewart et al., Health Serv Res June; 42(3 Pt 1): 1235–1256. PACIC (patient assessment of chronic illness care): –http://www.improvingchroniccare.org/index.php?p=PACIC_Survey&s=36http://www.improvingchroniccare.org/index.php?p=PACIC_Survey&s=36 –Glasgow RE, et al., Med Care 2005; 43(5):436-44
Approaches to measuring patient experience with care Patient surveysPatient surveys –Proprietary tools –Public domain instruments (CAHPS) Focus groups and interviewsFocus groups and interviews WalkthroughsWalkthroughs “Mystery shopping”: participant observation by trained informants“Mystery shopping”: participant observation by trained informants Web-based user-generated reviewsWeb-based user-generated reviews
Sampling Issues Patient populationPatient population –General population –Specific subgroups (e.g., chronic illness) TimeframeTimeframe –Visit-based –Over the prior 6 or 12 months FrequencyFrequency –Annual monitoring –Continuous sampling for improvement Sample sizeSample size –Internal use for improvement –External use for public reporting, P4P
Traditional Data Collection Modes Mail administrationMail administration –3 waves of mailing (initial mail, postcard reminder, second mail) Telephone administrationTelephone administration –At least 6 attempts across different days of the week and times of day Mixed mail and telephone administrationMixed mail and telephone administration –Boost mail survey response by adding telephone administration
Alternative Modes Internet/WebInternet/Web – distribution –Web response option Interactive Voice Response (IVR)Interactive Voice Response (IVR) –Touchtone IVR –Active Voice IVR In-office distributionIn-office distribution –Paper survey Mail returnMail return Internet returnsInternet returns Drop box on siteDrop box on site –Kiosk or other electronic modes
Comparison of Mail, Web, and IVR Modes MailWeb Web + Mail IVR IVR + Mail Response Rates 50.8%18.4%48.6%34.7%53.7% Respondent Characteristics* Younger More ed Healthier Less ed Less ethnic More use Survey Scores* (adjusted and unadjusted) SameSameLowerLower Total Costs (per completed response) $5.19$13.94$8.01$9.04$8.06 Rodriguez, et al. Evaluating Patients’ Experiences with Individual Physicians. Medical Care. Vol. 44, No. 2, February 2006.
Cultural Competence Missing from CAHPS Communication: –Use of complementary and alternative medicine –Respect for Patient Preferences/Shared Decision- making: Empathy and emotional support –Linguistic Competency: Access to language services; Health literacy aspects –Experiences Leading to Trust/Distrust: Level of trust, caring, truth-telling –Experiences of Discrimination: Due to race/ethnicity, insurance, language, etc.
Point of Service –Good for measuring the effect of changes tested –Focus on meaningful measures –Document collection methodology; train staff collecting information –Collect “just enough” data –Have at least 15 completed surveys –Easy to develop reports –Data collection is burdensome!
Sample Comment Card Comment Card We would like to know what you think about your visit with Doctor X. □ Yes, Definitely □ Yes, Somewhat, □ No Did Dr. X listen carefully to you? Did Dr. X explain things in a way that was easy to understand? Is there anything you would like to comment on further? Thank you. We are committed to improving the care and services we provide our patients.
Telephonic Surveys Good for measuring the effect of changes More rapid feedback than mailed surveys Typically less expensive Outside vendors do it and provide reports Easy to manipulate data for reporting Less frequent – monthly data at best
Patient Exit Interviews Rapid feedback on changes tested Not burdensome to collect data Uncover new issues which may go unreported in surveys Requires translation of information into actionable behaviors Providers “see” the feedback Include 3-5 questions, mix of specific measures and open ended questions Receptionist or non-clinic member obtains feedback (HP or IPA staff)
What is patient-centered care? “Health care that establishes a partnership among practitioners, patients, and their families…to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.” Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academy Press: 2001.
Self-management Support Steps to Build Skills and Confidence Adequate for majority of population Basic Skills Goal Setting Action Planning Problem Solving Advanced Skills & Techniques Motivational Interviewing Uncomplicated Depression Group Interactions Training others in Basics Expert Skills & Techniques Ex: Cognitive Behavioral Therapy Dialectical Behavioral Therapy Addresses special situations Necessary for special populations (Addictions, MH) Source: Connie Davis. RNP
The CareSouth Carolina Elements of SMS in the Stepped Model Care Teams with roles and responsibilities for SMS throughout the team Care Managers for higher levels of need Standardization of group and individual learning needs Patient focus groups for re-design
“The process of becoming an intelligent partner in the health process can be hard for people.” -- Toni M.
Humboldt County AF4Q Alliance; Part of RWJF’s “Aligning Forces for Quality” Humboldt Focus: to generate meaningful opportunities for patient engagement in healthcare improvement, delivery, and design. About Aligning Forces Humboldt
Patient Engagement in Humboldt County, Ca HDNIPA participates in the IHI “Quality Allies” Project AF4Q initiative begins, citing patient engagement as a key driver of quality improvement Implementation of the Chronic Disease Self-Management Program (CDSMP) HDNIPA adopts collaborative model to improve primary care called: Primary Care Renewal (PCR); 10 PCP practices participate CDSMP leaders act as faculty at PCR meeting to discuss the patient perspective of living with a chronic health condition PCR 2.0 launches with an emphasis on PCMH. Recruitment of a “patient partner” team member is a requirement of participation. Significant infrastructure is built to support this effort. PCR 3.0 kicks-off. Practices must recruit two patient partners to participate. Patients participate in collaborative and office improvement meetings. 2012
Patient Core Function Levels Recommended Patient Role Key Patient Characteristics Necessary SupportPractice Readiness 1. Help individual patients better manage their own health Partner in care Willing to develop self- awareness about personal role in managing health Receptivity to initiate better health care behaviors The ability to communicate with care team Offer peer-support resources, such as referrals to community- based chronic disease self-management programs (often available both in-person or online), group visits, etc. Starting to engage in viewing patients as partners in chronic condition management. Beginning practice redesign efforts. Willingness to explore new models of care. Leadership support 2. Becoming a leader beyond personal health. Support others in better managing their own health. Partner in careDesire to become peer leader and provide support to others. Able to work cooperatively and effectively with others Access to training for peer leader roles. Starting to implement internal self- management support. Practice open and receptive to chronic disease peer leaders. Leadership support 3. Assist individuals to weigh in on patient experience (resulting in weighing in on quality improvement efforts, office workflows, and patient experience). Advisor Communication skills Can collaborate with diverse individuals Desire to increase knowledge Can contribute and provide collective pt. perspective comfortably Focused on improving care related to the team goals Offer information and training on key focus areas. Ask specific questions. Create a culture that values patient insight. Significant investment in resources. Link into external support that will aid your practice in working with patients in a quality improvement setting. Leadership support. 4. Foster and support champion patients as equal core members of committees that drive redesign efforts at the highest levels Advisor and ChampionSkills listed above and: Can articulate pt. insight and bring pt. feedback to the forefront Functions in a fast- paced and technical setting Problem-solves in inclusive ways Create roles for a patient/patient advocate on committees. Solicit patient feedback. Offer educational and training opportunities. Significant investment in resources. Link into external support that will aid your practice in working with patients in a quality improvement setting. Leadership support. (Stapleton & Osborne-Stafsnes, 2011)
CDSMP Shared Decision- Making AFH Patient Engagement Model Patient Partners Focus Groups Surveying Surgical Rate Project Leadership Team CDSMP Leader Training Community Health- Campaign Engageme nt in personal health Engageme nt beyond personal health Patient Engageme nt in Patient Experience Fostering Patient Champions at policy levels Osborne-Stafsnes & Stapleton, 2013
The Patient Partner Project “Practices often struggle with the 'fires' of the day, making it difficult to focus on larger constructs such as patient-centered care. The participation of Patient Partners on practice improvement teams keeps the importance of improving patient care at the forefront of discussion.”– Rosemary DenOuden, Chief Operating Officer, HDNIPA
Primary Care Renewal QI collaborative 10 Practices/20 Patient Partners Collaborative meetings every two months Practice meetings 2X/month Each team is assigned a practice coach Patient Partners receive training and support Ambassadors and advocates Share insights and feedback explicitly focused on collaborative topics
Conceptual Framework Patient Partner Collaborative Meetings Team Meetings Patient Partner Meetings Stapleton & Osborne-Stafsnes for AFH, 2013
Collaborative Coaching Model Stapleton & Osborne-Stafsnes for AFH, 2013 Practice Coaches Patient Partner Project Managers Practice TeamPatient Partners Effective QI Team
Collaborative Meetings Techniques Standing agenda item that starts meeting and sets tone Prep patient for presentation Vary presentation mode to keep interest Evaluate
Patient Partner Meetings Introduce meeting topics and curriculum Practice updates, brainstorming, and problem-solving Sharing of “best-practices” Capture patient recommendations and perspective on meeting subjects.
Team Meetings Patients attend one “practice improvement” meeting at their office each month. Some offices have standing agenda items specifically for their patient partners. Patients offer insight and work on projects specific to the practice. Sample Projects: Practice brochure Patient-friendly language Practice ombudsman Testing patient portals Process development
Challenges “As a consumer we are often treated like we don't know anything or the staff doesn’t want us involved. They feel that staff can represent the consumer instead of us consumers.” Osborne-Stafsnes & Stapleton, 2013
Addressing Challenges Recruitment Transformation Outside Opportunities Unbalanced Engagement Initiate with a project in mind Clarity and intent with requests Sharing of ideas/best- practices In-office Engagement Patient training and support Creative solutions to meeting coordination barriers Clinical Culture
Whose Home Is It? Providing Medical Care Patient Experience Practice Home Doing Business QI Practice Redesign Medical Home (Stapleton, 2012) Patient’s Home Patient-centered Staff uses comprehensible language Ultimately, patient is in control Provider/Staff home Office-centered Patient Partners learned “Medicalese” Ultimately, Provider/Staff are in control
Recognizing Success “They keep our focus centered where it should be: on the patients.” -- Participating Clinician
Recognizing Success Focus Groups Surgical Rate Project Empanelment Process Development Backlog reduction “They keep our focus centered where it should be: on the patients.” -- Participating Clinician
Foundational Engagement Elements 1.Didactic orientation and training 2.Clear role expectations and focus 3.Structured solicitation of input 4.Transparent and continuing feedback loop An Observation: Success occurs more often when patient activation level, staff activation level, and complexity of the project align.
Tools in PCI Implementation Guide transformation/implementation-guides Thank you!