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Leading Transformation Through Increased Patient Engagement in QI Emilie Buscaj, MPH, PCMH CCE Program Manager HealthTeamWorks and Christin Sutter Quality Improvement Coach, High Plains Research Network 2

Objectives By the end of this session participants will be able to: Explore the benefits of patient engagement in order to educate practice providers and staff. Summarize the role of the practice staff and providers in supporting patient engagement through their experiences in leadership roles and active participation. Recommend coaching strategies to implement patient engagement activities in practices.

Patient Engagement Three levels: Consultation - Inform patients how it will be different Involvement - Engage patients in health partnership Partnership and Shared Leadership - Activate patients to take action/change behaviors 4 © HealthTeamWorks. Reprint with permission only.

Carman KL, et al. Patient and Family Engagement: A Framework for Understanding the Elements and Developing Interventions and Policies. Health Affairs 32, No 2 (2013): 223 – 231.

Methods for Engaging Patients in Quality Improvement Patient Experience Surveys Focus Groups Patient Rounding in the Waiting Room Provider/Staff Recommendations Key Informant Interviews Patient Advisory Group Others Suggestion Box External Referrals for Practice Feedback Community Outreach Workers Community Organization and Support Group Leaders Community Health Education Classes

Patient Experience Surveys

Experience questions These reflect actual experience, aiming to avoid value judgments and the effects of existing expectations. For example: Were you able to get an appointment within two working days? How many minutes after your appointment time do you normally wait to be seen? Patient Satisfaction vs. Experience Surveys Satisfaction questions These are subjective and often non-specific. For example: How satisfied are you with the appointment system in your practice? How do you rate your doctor’s caring and concern for you? Are you happy with how long it took to be seen?

Options for Patient Experience Surveys Conduct a survey to evaluate experiences of at a minimum 4 topic areas Access Communication Coordination Whole-Person Care/SMS CAHPS Patient-Centered Medical Home Survey Tool Validated set of questions Vendor collects data Cost – per provider/per practice Develop your own internal survey that covers the topic areas Practice specific questions No more than 20 questions Cost – practice time in development and distribution

How do you coach practices to use surveys? Considerations in identifying practices to use surveys As a starting point to generates topics to work on and that are concerns for your patients Some practices see surveys as less time consuming Practices are nervous about brining in patients When you need a specific answer to something Generates ideas to bring to patient advisory boards To track consistent data over time Reasons to not do a survey When the practices need more information or more conversation around a topic area Is actually more time consuming – development of questions, administering the survey, collecting the data, entering the data, analyzing the data, reports, data is old, and want more information

Practice Example Quarterly surveys distributed to 50 patients of various payer sources Results are shared across the practice Bulletin board communicating back to the patients about outcomes Current Interventions Access and Continuity: Measures patient experience with same-day appointments Implemented new scheduling strategy, tests number of open appointment slots with various PCPs Began in July seen a 10% increase in overall continuity experience Communication Measures patient experience with phone hold time Office manager cross-trains all staff to answer phones Schedule ensures that wait-time is kept to a minimum 5% reduction in 1 year

Approaches to Developing and Sustaining Personal Relationships with Patient Advisors and the Community 12

The Journey to Engaging Patient Council

Purpose Serves as resource to administration and staff of the organization Promotes improved relationships Provides a vehicle for communication and to understand miscommunications Provides a venue for patients to provide input, recommendations, development of new projects, and help implement sustainable change Provides opportunities for staff to listen and a safe venue for patients to express needs and concerns Developed by Marlene Fondrick and Beverley H. Johnson, Institute for Patient- and Family-Centered Care, Bethesda, MD, Revised 2002.

Benefits Provides a mechanism for receiving and responding to input Results in more efficient planning Leads to increased understanding and cooperation Promotes respectful, effective partnerships Offers a forum for developing creative, cost-effective solutions to problems and challenges Supplies a link between the practice, its surrounding community, and community groups Provides increased emotional support and access to information Developed by Marlene Fondrick and Beverley H. Johnson, Institute for Patient- and Family-Centered Care, Bethesda, MD, Revised 2002.

Working successfully with others requires understanding of what we bring to the relationship… 16 Reprint with Permission Only ©HealthTeamWorks …and, the ability to develop an understanding of what the other person brings to the relationship as well.

Why do Patient Advisory Groups Matter? Identifying priority health topics or processes Vetting project ideas presented by clinic team Developing/editing surveys and questionnaires Developing/editing print materials for patients/community Regardless of project: Provide fresh ideas! Diverse perspectives and knowledge Credibility to work being done in region/at practice

Patient Advisory Council Boards or councils Intentional integration Combination of both Any of these options gives you proactive feedback about areas for improvement in your practice & potential solutions Considerations Cost Time/Energy

Implementation Strategies Practice champion Decide on your strategy Whether a Board or members of QI team: Create a recruitment strategy Interview patients Coach patients Plan how to facilitate meetings Provide a topics and/or allow them to develop projects

Starting a Patient Advisory Council Your first meeting – Orientation Introductions and the sharing of personal and family stories in the healthcare system Review the vision and goals of the organization Describe how the board its fits within the organization’s structure Develop roles and responsibilities of members Review HIPAA and expectations for honoring privacy and confidentiality Expectations for the board and attendance 2nd Meeting and Beyond

Focus Groups and Patient Rounding

Additional Options for Obtaining Feedback from Patients: Focus Groups and Patient Rounding/Interviews Timely feedback about a particular topic Diverse perspective Addresses language challenges Prepare and test your engagement strategies with patients before establishment of an advisory board or waiting for the next meeting for feedback Used to identify good patient advisory board participants

Do you have practice examples of using focus groups for an interviewing approach to patient engagement?

Activity: Identify a project at a practice that is currently being worked on. Answer the following questions; 1. What is the primary outcome of the project? 2. What aspect of the project would most benefit from hearing the patient experience? 3. How do you think interacting with a patient would change the potential project outcomes? 4. What strategy would you recommend to use to engage patients? 5. How would you advocate for your practice to use your suggestion? Report back to the group

Supporting Practices in Forming Relationships with Patients

What benefits should you as a coach share with practices about engaging patients in QI?

Why engage patients in QI? To build strong relationships with patient advisors and the community To explore ways to prepare patient and family advisors to participate in primary care redesign To identify strategies and key barriers to sustaining patient advisors and family advisory councils

How many participants and who is in an advisory group?

How do you identify successful members? See the big picture Have ability to listen and hear other view points Do not push personal, professional, or political agendas Have a sense of humor Have to ability to connect with people Can learn and will step outside of comfort zone Are willing to share their opinions and thoughts

What advice do you have regarding the Nuts and Bolts?

Sustaining Advisory Councils Meeting tips Enjoyable AND productive Agendas include time to Reconnect Review and report Work on task(s) of the meeting Reflect and decide next steps Someone facilitates, listens for the nuggets and summarizes at the end Next steps include: reading, thinking, collecting, asking, gathering, observing, talking

Patient Advisory Council and Intentional Integration Brainstorm what the patients want to focus on related to practice goals Clinically Important Condition Focused Resource center in waiting room Feedback on agenda setting and shared decision making QI team integration Practice Leaders: Nurse and Provider Patient Advisory Board & Chronic Pain Advisory Board Developed a charter, group norms and protocol for adding or removing members Practice Leaders: BH Providers Patient Advisory Board Theme: Communication Patients developed 3 yearly goals Practice Leaders: BH Provider, 3-4 Providers, Practice Manager, Medical Assistant, and Front Desk Lead Board and Council Examples

What activities do you recommend? Conduct a “walk-about”... take pictures and record comments. Ask advisors to envision the ideal experience in the hospital/clinic/practice. Include advisors in an assessment process of clinic/practice and its policies, programs, practices, and facilities. Invite advisors to review patient survey data and participate in the process of developing responsive changes and evaluating improvement. Involve advisors in a restructuring/rebuilding/rethinking project.

Tools for Practices to Use Handouts: The Magic Wand Exercise The Walk-About

Lessons Learned and Considerations Larger pool of patients Meeting time considerations Diversity based on practice population Establish goals Don’t generalize the agendas or ask patients for generalized feedback Future Needs: Recruitment of more members Strategic redesign to spread members onto ongoing meetings Bi-monthly PAC meetings Development of a charter

Improved Engagement Shared Experiences from the Field

High Plains Research Network Testing to Prevent Colon Cancer

Understanding Roles Respect natural delineation of roles and responsibilities Be sensitive to comfort levels Allow for growth

“Recruit the heart but train the mind.” Think about education Key to better engagement “Bootcamp” concept provides Background knowledge Common language, richer conversations A level playing field Together determine action steps

“Constant state of incomplete” Marking Progress Mark the little steps and intermediate goals Celebrate the conclusion of any project Recognize PAC alongside usual practice rituals— Luncheons, conferences, travel Special invitations or opportunities to step out of comfort level

“Experts in your community” Relationship with Community

Relationships with Practice Patient’s and Community Members Boots on the ground to Carry messaging Share philosophy Be your eyes and ears Recruit Be ambassadors Gather ideas and feedback

Potential Role Expansion and Sharing Patient Stories

Sharing Patient Stories Stories have a long term impact on the way someone views different circumstances. Help patients prepare to tell their story using the following questions; What am I willing to share? What do I feel is too private to share? What does my family not want me to talk about? What will my story teach those who are listening? Have I had negative experiences that are still bothering me and will be difficult to share in a constructive manner?

Expanded Patient Advisor Roles Recruitment of patients Trains patients as leaders Liaison between the board and the practice Assist patient advisors in group facilitation Schedules presenters with guidance from the board

Expanded Patient Advisor Role Act as a liaison to the rest of the practice, the health system and the community – sharing stories Involved in QI teams and projects Advisors as co-chairs (as a rotation or elected to a 6 month - 1 year membership) Develop meeting agendas Assist practice champion in facilitating meetings Take on the responsibility of meeting minutes and documenting action items Recruit, interview and orient new advisors

Questions

Resources and Additional Information Reprinted with permission from: Institute for Patient- and Family-Centered Care ( Arlington Road, Suite 309 Bethesda, MD Phone Fax Publications: Essential Allies Patient, Resident and Family Advisors: A Guide for Staff Liaisons Word of Advice: A Guide for Patient, Resident, and Family Advisors Tools/Checklists Research Articles How to Videos