The simplest, most effective patient experience strategy may be listening to the patient, directly through personal discussions and indirectly through survey data analysis.
This article appears in the July/August issue of HealthLeaders magazine.
"Real change begins to happen when physicians, nurses, and staff hear the voice of the customer, the voice of the patient."
"It's really about cultural change and maintaining that, which is probably twice as hard as getting to cultural change."
"Patient experience is not a campaign. It's an actual, critical part of culture."
"If anything makes physicians act, it's not being the best, and wanting to be."
"It was horrible. When I pressed the call button, I couldn't get anyone to answer. I could hear other patients crying in their room and the nurses weren't attending to them."
Those comments were part of a six-sentence paragraph described by a patient during a telephone survey after a three-week hospital stay in October 2012. It's something no hospital wants to believe is happening, but the reality is that scenes like the one above play out in patients' hospital rooms across the country.
That feedback is hard to read, but even harder to hear says Kevin Gwin, vice president of communications for Nashville-based Ardent Health Services, parent company of the hospital where the incident occurred. Gwin is providing new insight into how patient experience scores can be improved at Ardent Health and believes that the voice of the patient is the most effective change agent. The C-suite at each Ardent hospital is in charge of patient experience, but Gwin is in charge of getting patient experience scores up. That's why he asks nurses to read this patient's comments in full and out loud at staff meetings.
"Nurses become emotional when they hear a comment like this," says Gwin. "But that's how you change behavior. We're going to read it in a voice that makes the comment come alive."
Patient experience and satisfaction is the No. 1 priority for healthcare executives, according to the HealthLeaders Media Industry Survey 2013—above clinical quality, cost reduction, and many other burning issues. Yet there is little consensus about how to measure, improve, and incorporate patient experience into hospital processes.
One reason patient experience is ambiguous for hospitals is because it is a close relative of patient satisfaction, which is measured through HCAHPS, says Patrick T. Ryan, CEO of Press Ganey, a South Bend, Ind.–based company that works with healthcare organizations to measure and improve patient experience through surveys and consulting. In fact, according to this month's HealthLeaders Media Intelligence Report on Patient Experience, most respondents surveyed said the No. 1 goal of their patient experience efforts is to improve HCAHPS scores. Patient satisfaction and experience are closely tied together, but they are not the same, says Ryan.
"It's much more than patient satisfaction," he says. "The confusion that some folks come into the industry with is that patient satisfaction is about keeping people happy, but it couldn't be further from that because when people enter the health system, they're coming in at one of the most complex and stressful times in their life. And what they want most from the experience is communication and understanding of what their condition is, the path to the best possible health they can achieve, and a way in which to coordinate that with their clinicians and staff to ensure that they get there."
Measuring patient loyalty
How hospitals and health systems approach patient experience varies widely. Some are adopting measures from retailing, financial services, and other industries that depend heavily on loyal customers because, with growing healthcare consumerism, hospitals want to be seen as a reliable health partner throughout a patient's life instead of the place where patients go when they are sick. Ardent Health—a for-profit system that owns 13 hospitals, a multispecialty physician group, a health plan, and retail pharmacies in New Mexico, Oklahoma, and Texas—is using Net Promoter Score as it aggressively works to change its culture.
"Real change begins to happen when physicians, nurses, and staff hear the voice of the customer, the voice of the patient," says Gwin, who believes NPS gives a clearer view of how the patient perceives experience at the time and place of care.
NPS, developed by the Boston-based global strategy consulting firm Bain & Co. in 2003, has been catching on in the healthcare industry as a way to measure patient experience. Besides Ardent Health, St. Louis–based Ascension Health, which has operations in 21 states and reported $16.6 billion in total operating revenue in 2012, also uses NPS.
The key difference from HCAHPS is that NPS measures loyalty by asking customers to assign a number, on a scale of 0 to 10, to the question "How likely is it that you would recommend to a friend or colleague?" A patient who chooses 0–6 is labeled a detractor and is likely to negatively talk about the experience. Scores of 7 or 8 mean the patient is passive—satisfied but "unenthusiastic, and vulnerable" to competition. The jackpot is a 9 or 10. Either of those means the patient is loyal and is extremely likely to promote the organization to friends and family members.
To calculate the NPS, it's a simple math equation: Subtract the percentage of detractors from the percentage of promoters, and that is the score. The NPS recommendation question is similar to the HCAHPS survey, specifically question 22, but Gwin believes an NPS score is a better measurement of patient experience and loyalty because the data is raw, relevant, and returned quickly. Ardent uses an outside vendor to conduct an NPS survey with a representative sample of patients who are discharged weekly. When the surveys are returned, the scores are pushed out to each hospital's C-suite team.
Gwin says leaders in Ardent Health hospitals are empowered to manage their own NPS scores; the data is to help them make decisions, but there is a corporatewide standard of calling back a patient who was surveyed and turned out to be a detractor. He says hospital leaders are the ones who make the calls because he believes the most effective and meaningful way to change culture is to hear—really hear—from the patient what the experience was like.
"If our hospital leadership interacts with patients and they hear complaints, they act immediately, but for some reason, when it's on paper or it's on your computer screen, it becomes a little less real," says Gwin. "I just want our leaders, even our charge nurses and our department directors, to get used to hearing from our customers. Even the corporate CEO reads every patient comment every week and makes a few phone calls, because we just need to get into the practice of hearing from patients so we can better align our organization."
The frequency of measuring loyalty produces volumes of data on rooms that are consistently rated as noisy, dirty, clean, or quiet. The survey used is so specific that Gwin says he can tell who the nurse was and what room the patient was in, which helps identify patterns on floors among nurses and even among the cleaning crew. If he sees a room is starting to be consistently rated as noisy or dirty, he can use the data to drill down and find—and remedy—the problem. Likewise, if a room or nurse is getting praised by patients, he can find out what the nurse is doing and implement those homegrown care strategies among other nurses and at other hospitals.
Ardent Health does not dismiss HCAHPS, says Gwin, but he also adds that NPS "goes beyond HCAHPS"; the health system's third-party surveyor asks not only the HCAHPS questions but also the NPS recommendation question and another asking how the hospital can improve. It's the open-ended question where Ardent learns what went right and what went wrong, like the patient who heard others crying in their beds.
The strategy of frequently surveying patients and collecting and mining the data to find out how an Ardent Health hospital is proficient or deficient has helped its hospitals improve patient experience. At Ardent Health's Bailey Medical Center in Owasso, Okla., the 73-bed suburban hospital consistently receives a positive NPS of 95% or better, up from scores in the 50s and 60s when it opened in 2006. Its HCAHPS scores also are above both the state and national average on every single question. The increase in both scores indicates that there may be a correlation between patient satisfaction and patient experience, which means that healthcare executives may be right to rely on HCAHPS as a leading indicator of what a patient is experiencing.
"Amazing" is how Gwin describes Bailey Medical's journey. Pushing out the data regularly to pinpoint problems and quickly fix them helped the hospital's NPS climb steadily, and now its NPS score is an Ardent Health success story.
"That culture is up and running," says Gwin, who is also quick to say that implementing patient experience improvements using NPS is easier in a smaller environment. However, he is passionate that NPS data is the foundation for changing culture no matter the size.
"Sometimes, all of this is not the easiest thing to hear, but, when we act on this information, we're acting in the best interests of our patients and their families," says Gwin.
Creating sustainable cultural change
Hospitals are eager to improve a patient's experience during his or her stay, but one health system is focusing its patient experience efforts on its outpatient facilities.
"Healthcare will be delivered in a variety of settings and more and more often in outpatient locations. So ambulatory care is an important part of the future," says Chris Holt, chief experience officer and vice president of marketing and public affairs for Holy Redeemer, a Meadowbrook, Pa.–based health system with 2012 net patient service revenue of $336 million. Its system includes an acute care hospital, outpatient and diagnostic services, as well as multiple community and senior care facilities, together with a home care and hospice division.
Holy Redeemer's strategy of focusing on outpatient care is in line with what other health systems are doing or are planning on doing. According to the HealthLeaders Media Industry Survey 2013, healthcare executives said growing outpatient care is their top strategy for fueling financial growth over the next five years, so looking to patient experience beyond the inpatient setting becomes increasingly important.
Holt says Holy Redeemer's focus on improving patient experience came about two years ago from leadership wanting the brand to be associated with delivering an exceptional patient experience. The health system believes that its patient experience at outpatient facilities could be a market differentiator, potentially allowing for growth.
Holy Redeemer's C-suite turned to a consulting firm that encouraged them to abandon traditional methods of improving patient experience and instead approach it more creatively—a lot more creatively. Holt says it wasn't a hard sell because the leaders were interested in innovative techniques, but it was hard to understand how creative they would get.
"The hardest question is, 'If it's not HCAHPS scores or customer service on steroids … what are you talking about?' " says Holt.
The consultants were talking about stories, dreams, and experience guides, which are metaphors for a component of patient experience. Stories equate to why a patient is coming in to see the doctor; dreams describe the process that Holy Redeemer went through to develop how a patient interacts with staff and the environment; and experience guides are the receptionists or assistants who make sure a patient gets to the correct room.
Health system leaders were inspired by the imaginative methodology and jumped in with both feet, establishing six teams of 12 people who worked for six months starting in mid-2011 on recommendations for improving patient experience. Holt says the extended time period actually helped to develop the culture required to implement and maintain its patient experience improvements.
"You have incremental improvement that turns into transformational change," she says. "It's really about cultural change and maintaining that, which is probably twice as hard as getting to cultural change."
One of the first things the groups did was develop a definition for patient experience. It was tricky, says Holt, because the term isn't explicitly defined in the healthcare industry. Holy Redeemer describes patient experience as:
"Intentionally crafted interactions that are personal and individual in nature, require participation, and meet unrecognized needs, resulting in a relationship that provides unique value to customer and the organization."
Establishing a formal definition gave Holy Redeemer the foundation it needed to develop the kind of patient experience it wanted to deliver. Leadership decided to go for the wow approach—they wanted to dazzle patients, families, and employees. This is where the creative thinking comes in.
Holt says the health system developed what is called a story structure to communicate to patients Holy Redeemer's story, which is "a rich, interconnected set of stories from the heritage of our founders to the stories of those we serve and serve with every day." The story element is meant to connect with patients on a level that is more human and also communicate that Holy Redeemer is a patient's partner in health.
"Every one of us has a life story we're writing," says Holt. "I really think this is about changing the nature of the relationship that we have with people. The basis that we have right now as an industry is based on, 'What healthcare do you need, and how can I serve that up to you?' I think where all the reform and the trends in the industry are moving us toward is really about helping people be well and live their life to the fullest."
Delivering on a brand promise
To help employees understand how they were supposed to interact with patients, Holy Redeemer developed five categories of behavior types that are tied to the system's brand promise, "Caring for you and about you." For example, "Offering a warm, calming, and welcoming presence" is part of the healing presence category. Another category, expert care, describes employees as "Assuring, qualified staff with excellent skills and a quest for continuous learning." There are three more categories, each with behavior and communication goals for employees when interacting with patients, families, and each other.
Holt says the work also included dreamscaping—think of it as very creative brainstorming—which is a term that describes how Holy Redeemer designed patient experience scenes, so to speak, around how they want patients to feel. "Patient experience can't be just about building new environments. The dreamscaping isn't just about the space; it's about what happens in the space."
The culmination of dreamscaping and storytelling was built out in Holy Redeemer HealthCare at Bensalem, a 22,000-square-foot outpatient clinic devoted to delivering the ultimate patient experience. The facility opened in October 2012 and includes primary care, obstetrics and gynecology, and breast surgeons as well as lab and imaging services.
At Bensalem, winding hallways are called boulevards, waiting rooms are called living rooms, and an experience guide meets you in the center of the lobby at a table designed to look like a tree trunk. A green canopy of hand-blown glass leaves hangs from the ceiling giving the illusion of an abstract tree. The natural theme extends throughout the building, from a six-foot-long fireplace built into a wood-slatted wall to the artwork to the calming paint colors.
According to Holt, the theme was a way to turn a physical space into a story structure, which is meant to prompt patients to think about their own health story. A coffee bar, Kindles loaded with the most recent magazines, and a choice of music in the exam room all are extras meant to help ease patient anxiety that comes with going to a doctor, and also enrich the patient experience. Once in the exam room, patients have 12 music channels to listen to, and nurses record patient preferences for their next visit.
Anecdotally, Holt says this environment is improving the experience patients have, noting the example of a special-needs patient who frequently has to have his blood drawn. "In the history of this patient's experience, he had always been very upset and always exhibited anxiety at a high level," she says. But that changed with '70s music playing in the background during his visit. "With the music we put into the exam rooms, he calmed down for the first time ever and let us draw his blood without any kind of anxiety. Those kinds of stories are not things we're going to capture in a survey, but those are the real impacts."
There is also a real impact that surveys are capturing. Holt says it hired a mystery shopper company to visit Holy Redeemer's other similar outpatient facilities. The mystery shoppers acted like patients and were then surveyed about their experience to get a baseline assessment. On average, Holt says, other, similar practices to Bensalem averaged a 76% satisfaction rate, while Bensalem averaged a 98% satisfaction rate.
So far, this is the primary metric Holy Redeemer looks to for assurance that its patient experience work is having an effect because the Bensalem site is relatively new, as are the recommendations from the six working groups that presented their ideas in early 2012. However, Holt says Holy Redeemer is expecting a bump in HCAHPS scores, patient volume, and brand awareness, which Holt plans on studying over the next 18 months.
Right now, Holy Redeemer is moving ahead with another experience-derived environment at a second freestanding outpatient center as well as the entry lobby at its 242-bed acute care hospital. A dining and living room are also being dreamscaped for one its senior living communities.
To maintain the momentum for the system's ambitious patient experience trajectory, the health system has launched what it calls Holy Redeemer University, a sort of training program that will eventually educate all 4,000 employees over the next couple of years.
"Holy Redeemer University is really about aligning everyone's thinking and their work, i.e., giving them that foundation in what we expect them to do, what we want them to deliver on," says Holt.
The first group of "students" to go through the university will be managers and supervisors, approximately 250 people. Holt says they'll go through two days of classes.
First comes what Holt calls Experience U 101, which is one day and something every employee will eventually attend as well, to give a baseline of mission and expectations.
"Day one is about individual change because change starts with the individual and then it moves to the organizational level then to the community," says Holt.
Day two of class is called Experience U 201, and will be specifically for managers.
"That second day is really about addressing questions such as: How do you manage people who are delivering an experience? How do you behave as a manager in that kind of environment? We're going to try to build in accountability pieces so they'll walk out of there with a kit that provides them with guidelines on how to work with people when they return from the training and start asking questions or have ideas."
Holt says everyone who completes Experience U 101 will have an assignment to reinforce the patient experience Holy Redeemer wants its patient to have.
Holt admits that measuring its grand experiment with patient experience is going to be challenging, but she's convinced that the stories, the dreamscaping, and the behavior categories are making a difference. She says the experience has made her more adept at being a culture change champion.
"For me, the brand lived on a page or brand was a concept," she says. "To actually be able to help people act on it has been very fulfilling. It's really changed the way I approach my work, and also understanding more about who we are and connecting to that on an everyday basis."
Delving deeper into analytics
Unsure that a hefty investment in patient experience programs will net a big enough ROI, some hospitals and health systems take small steps, believing that improving food or getting the lighting and noise levels right in the room will be a short-term solution until the industry finds the right algorithm to solve the ambiguity that exists when trying to measure patient experience.
That's a mistake, says Press Ganey's Ryan.
"Patient experience is not a campaign. It's an actual, critical part of culture," he says.
From delivering patient care in an environment designed to cater to any need a patient may have, like at Holy Redeemer's Bensalem site, to the data mining at Ardent Health, organizations have a lot of choices for improving patient experience, but the common denominator must be true cultural change that involves hearing "the patient's voice and understanding what they're experiencing," Ryan says.
Ryan does not equate patient experience and HCAHPS scores, which isn't surprising. Press Ganey was built 28 years ago on the idea that a patient's voice is critical to care and outcomes, two decades before the Centers for Medicare & Medicaid Services started collecting HCAHPS data.
Ryan says HCAHPS renewed hospitals' focus on the significance of providing a positive patient experience. A 2011 white paper from Baptist Leadership Group, the consulting arm of Pensacola, Fla.–based Baptist Healthcare Group, said CMS put "a stake in the ground" with HCAHPS. But, Ryan says, healthcare organizations are focused on patient experience more than ever because of the transformation from a fee-based to a value-based healthcare system.
"The challenge that we face in the next five years is to reduce the cost of healthcare," says Ryan. "The only way in which we're going to do that and improve quality is by incorporating the patient's voice and the patient's experience into their care and understanding how we can improve their care."
Deirdre Mylod, Press Ganey's senior vice president of decision analytics and research, and executive director of the Institute for Innovation, a nonprofit organization that Press Ganey is launching and supporting, goes farther, saying that organizations need "a combination of culture and rigor" to improve patient experience.
"You need that culture where, yes, they understand why patient centeredness is important. But if they're not using the patient voice data as the operating data, if they're not incorporating that with clinical and safety data, then they are well intentioned but they are not executing on what their promise is," says Mylod. "Conversely if you have all the rigor of 'You must do this,' but you don't listen to employees and engage them, then you get people who are disenchanted with the mission, so you need that combination to really make things move."
Press Ganey has started to dive deeper into hospital data for its clients, moving toward a census-based survey of all of a hospital's patients rather than a survey based on a sample size of some patients.
"That allows us to get a greater sense for what's taking place and actually segment that data in the place of care so we can be very specific with regard to what's happening in the different departments within the hospital, i.e., floor one versus floor two, doctor versus doctor," says Ryan.
The census-based survey aims to study 100% of a hospital's patients. They don't always get a 100% response rate, but the strategy drives home the same point Ardent Health is trying to make: More data gives you more insight into what is specifically upsetting patients.
"What we've actually found is that organizations that take that fuller level of data and use analytic techniques to understand the effects actually perform better and are improving faster because they are capturing the patient voice, responding to it, and making changes that are improving healthcare," says Ryan.
And the need for organizations to move faster is here with the consolidation of health systems and value-based models of care.
Counting on competitive spirit
In the fifth annual HealthLeaders Media Intelligence Report on patient experience, which will be released August 15 and highlights of which appear starting on page 29, healthcare executives indicate, by far, that changing the organizational culture is their biggest stumbling block to creating an effective patient experience program.
With the emergence and acceleration of both Medicare-approved and commercial accountable care organizations, there is a new sense of urgency for some health systems to improve their patient experience, particularly because it is one of 33 benchmarks Medicare-approved ACOs have to meet in order to qualify for the incentive payment.
Lahey Health, the Burlington, Mass.–based nonprofit integrated health system formed in 2012 when Lahey Clinic and Northeast Health System merged, relies on the competitive nature of physicians to drive up the quality of a patient's experience in physician offices. Similar to what's done at Ardent Health and other systems, comments about physicians are read aloud at staff meetings. Many organizations take this approach because it's effective, says Mary Anna Sullivan, MD, chief quality and safety officer for Lahey Health.
"If anything makes physicians act, it's not being the best and wanting to be," she says.
Sullivan oversees performance improvement for patient experience. She says with the merger, Northeast Health brought over the discipline of surveying its outpatient providers with Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), which is similar to the HCAHPS, but in an office setting.
Greg Bazylewicz, MD, chief network development officer for Lahey Health and founding member and president of the Northeast Physician Hospital Organization, says at Northeast Health, he eased physicians into the idea of getting graded by patients. First, he says, Lahey surveyed only patients of primary care physicians before later including specialists' patients. The process involved giving individual doctors their own score but blinding everyone else's name for three months.
Since the merger, Lahey surveys its physicians' patients 30 times per year, says Sullivan, though she wants the frequency to increase to "cut a broader swath of patients to make sure we're really hearing what our patients think."
Using CG-CAHPS in a regular outpatient setting, even though it isn't required, is giving Lahey Health a foundation for its ACO, the Lahey Clinical Performance Network, which was approved by CMS in January as a Medicare Shared Savings Program. CMS is collecting CG-CAHPS data, which will be incorporated in the ACO's overall quality score, thus influencing shared savings and loss percentages.
Both Bazylewicz and Sullivan believe that patient experience should be better in an ACO. For Sullivan, it will lead to patients being more invested in their care.
"An engaged patient has better outcomes, does better, takes better care of his or her diabetes, communicates better with his or her doctor. It may be hard for us to continue on this journey, but I think it's going to mean better care for patients, and happier physicians and nurses," says Sullivan.
Bazylewicz, who leads the efforts of Lahey's ACO, believes care partners in an ACO start talking about patient experience on the front end.
"That's really the benefit … because you have to pay attention to how it's done, how well it's done, and where you're not living up to as full a detailed and communicated care system that you could have in place," he says. "It makes you search for areas to improve in a more active way."
Using CG-CAHPs to measure doctors in their offices is catching on. HealthStream, a Nashville-based third-party provider of survey instruments to help organizations improve patient experience, reported at its first quarter call with investors in April that more than half of its 13% increase in its Patient Insights survey was from new CG-CAHPS contracts. It expects that trajectory to continue with the growth of models of care that take a longitudinal view of patient care with other partners.
At Lahey Health, whether talking about its ACO or its integrated health system, Sullivan is quick to point out that patient experience is not patient satisfaction.
"My belief, for a long time, is that we're relieving anxiety and meeting our patients where they are and trying to give them a good experience because that's going to help them heal," she says. "It's about our patients knowing that we care for them. It's not a business transaction but a long-term relationship."
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This article appears in the July/August issue of HealthLeaders magazine.
Jacqueline Fellows is a contributing writer at HealthLeaders Media.