Without federal support, hospitals and health systems in Texas are hampered in their efforts to help the uninsured enroll in health insurance exchanges.
Texas providers with large uninsured patient populations are hoping to have a hand in making enrollment in the health insurance exchanges (HIX) smoother, but for now, it's a waiting game.
Fort Worth, Texas–based JPS Health Network, which includes a 537-bed acute care safety-net hospital as well as 50 community health and specialty centers, illustrates the situation. The health system wants to help its patients understand what is happening with their health insurance, but it can't.
JPS, which applied to the federal government to become a certified entity so that some 60–65 of its staff could be HIX application counselors, says its efforts are stalled.
"We're still waiting to hear from the federal government," says Jill "J.R." Labbe, vice president of communications and community affairs for JPS.
Labbe says once the health system receives federal approval, counselors will be most likely placed in JPS community centers where patients are already enrolling in JPS Connection, a program that offers discounted health care services to patients who meet certain income requirements. It's possible that the JPS counselors could fan out to help patients in other venues, too.
"If we go beyond our own facilities, we will probably go to churches and senior centers," says Labbe.
JPS is not the only organization in Texas waiting on the feds. East Texas Behavioral Health Network (ETBHN), a consortium of 11 community organizations across 75 counties that serves chronic and severe mentally ill patients as well as people with developmental disabilities, received the state's second largest Navigator grant—$1.3 million. But, it still hasn't been able to fully staff its centers.
"We had a tough time filling positions," says Gary Bramlett, executive director at ETBHN.
Bramlett says he's been able to hire 16 navigators so far. He plans on hiring 24, which would put two navigators at each of the 11 centers, plus two lead navigators in different regions of the state to collect data and act as a resource for the other navigators.
Of the 16 who have been hired, a little over a handful are out in the community helping patients enroll.
"Seven are fully trained," he says. "The rest are in the process and almost finished with their training."
It's not where Bramlett wanted to be, but federal government approval of ETBHN's grant application didn't come until late August. The application was submitted in June.
Dallas-based Los Barrios Unidos Community Clinic, a federally funded health center serving the area's large, uninsured and underinsured Latino population, echoes the delays experienced by JPS and ETBHN. Unlike JPS, however, it has already received approval to certify some staff as application counselors.
"We just started enrolling this week," says Joleen Bagwell, director of development and marketing for Los Barrios Unidos, which received federal approval also in late August. "It took us that amount of time to [train]."
Hospitals and health systems like Los Barrios Unidos, JPS, and ETBHN, are eager to see HIXs succeed because it will impact the populations they serve.
Bagwell says about 14,000 of its patients are uninsured, and the Los Barrios Unidos staff who are certified application counselors are charged with reaching out to its own patients as well as the community at-large so that it can ultimately drive down costs.
"Right now, we can get our patients in for discounted or even free services," says Bagwell. "For example, we work with agencies on breast health. [Our patients] are tied into the healthcare system through Los Barrios, we have the resources and collaborations to allow women to have testing and treatment. If this same woman has insurance, the options open to her are greater. We have great options, but with health insurance exchanges, it will ease up on the system."
Both Parkland Health & Hospital System, the Dallas-based safety net system and the American Hospital Association have questioned the Centers for Medicare & Medicaid Services about whether hospitals can pay premiums for patients who enroll in the HIXs.
The answer remains murky, as does the road to Medicaid expansion in Texas. Governor Rick Perry has held the line at a firm "no," despite outspoken opposition from providers.
"[HIX]is going to help some more of our indigent population, but there's some that will be left in a hole without Medicaid expansion," says Bramlett. "I hope that Texas decides to expand Medicaid."
Without the expansion, the Texas Hospital Association says the exchanges' effectiveness will be muted.
"Hospitals and other community-based groups are working hard to get as many uninsured Texans as possible enrolled in the best coverage option," says Dan Stultz, MD, FACP, FACHE, CEO of THA.
"Unfortunately, the missing piece of Medicaid expansion means the impact of health reform to reduce the uninsured population will be blunted. The state's decision to sidestep Medicaid expansion is an acceptance of the status quo where large numbers of the working poor do not have access to employer-based coverage resulting in limited access to comprehensive, affordable health insurance options."
David Salsberry, CFO and executive vice president of JPS, says another roadblock in Texas will be the provider network. He says he initially anticipated a significant change in patient load because their options would be greater, but if there are a limited number of physicians taking HIX patients, the impact will also be limited.
I thought, 'We're going to have a lot of patients who we may lose because they'll have more choice,' but what physicians are going to be willing to take those patients?" he says. "We have the largest family practice residency in the country, so at first I thought [we'd] run the risk [of losing patients], but now I don't think it's going to be as great."
A study from the Society for Healthcare Strategy and Market Development shows that senior marketing professionals believe that evaluating the performance of an organization's communications strategy will be more important five years from now than it is today.
Diane Weber, SHSMD's executive director, released the results of its 2013 report that looked at the job tasks of its members at the group's annual conference in Chicago Sep. 29 – Oct. 2.
"This year we conducted a core competencies study, otherwise known as a job analysis, for strategic planners, marketers and communications/PR professionals," said Weber.
Over two months, SHSMD, which is known as the premiere organization for healthcare marketers, collected 721 survey responses from strategic planners, marketing, communications, and PR professionals who were mostly in senior and mid-level positions.
The report's findings showed that strategic planning professionals spent 41% of their time on planning and analyzing data and research. They spent about 13% of their time on implementing strategies.
More than 50% of strategic planners said they expect evaluating performance will be more important in the next five years, than it is now. The finding falls in line with a new focus on marketing metrics, particularly from efforts on social media.
But Weber called out specific measures that planners indicated would also be important, and they go beyond typical financial ROI, particularly in relation to an organization's performance relative to its competition.
Strategic planning professionals said that in addition to ROI, it would become important to evaluate performance for quality, patient outcomes, and patient satisfaction.
"Interestingly, of all the research that will be important in the future, quality and outcomes research had the highest rating for being more important in five years," said Weber.
Leadership has had a renewed focus on quality and patient outcomes with the ongoing transition from volume to value. The fact that the emphasis on it is extending into other departments could signal that value-based reimbursement transitioning from buzz word to process.
The effect this will have on marketing professionals is significant. According to SHSMD's report, marketing professionals now spend about 43% of their time on planning, strategic development and management and leadership. The strategic planning part of their job is expected to grow in importance over the next five years, especially in the areas of improving patient experience.
There is a correlation and conclusions to be drawn from these shifts, but it's also important to point out that patient satisfaction and patient experience are not the same thing. [Incidentally, hospitals with high patient satisfaction scores, don't necessarily correlate with hospitals that offer high quality care, according to a study released this week.]
It is difficult to parse out the difference between them, and it is not just semantics. I've had some leading healthcare organizations tell me that patient satisfaction is a leading indicator of patient experience, but they are careful about not blurring the lines between the terms.
This is an important distinction for marketers and strategic planners to be aware of as the industry continues to move toward a more consumer conscious market place. In the 2013 HealthLeaders Media Industry Survey, patient experience and satisfaction topped the list of hospital executives' priorities. It is a strategic goal that is a natural fit for marketers, though with hospital leadership identifying it as a top priority, marketers will need to be ready to measure.
SHSMD's report indicates marketing professionals have honed in on the importance of metrics, placing more importance on them in the next five years. Currently, that task takes up about 11.3% of marketers' time. That's expected to increase, says Weber.
"We learned that research and evaluation tasks took up less of a marketer's time, and was not found to be as important as some of the other task categories," she said. "Well, that's about to change."
The findings show that marketing professionals placed increasing importance on managing physician relationship and customer relationship databases. Those two tools are scarce among hospital systems now, but can be powerful allies in helping manage an organization's message; however, it's unclear how a PRM or CRM can track a strategy aimed at improving patient experience or satisfaction.
Marketing, communications and strategic planning professionals have always been under pressure to perform. Until a full transition from volume to value occurs, they'll continue to straddle a divide between the past and the future, often without a lot of quantitative results to show the value of their contributions.
SHSMD's report on the future these professionals envision shows healthcare marketing pros are aware of the increasing need for metrics, and the tools to help them mine for that data.
"With changes in financial business models, and a push for efficiency and cost reduction, it will be even more important to understand what marketing efforts are working."
Instead of trying to teach senior healthcare executives marketing lingo in order to get them to understand the complexities of social media's ROI, a marketing expert suggests communicating with executives about outcomes rather than process.
While attending the Society for Healthcare Strategy and Market Development conference these past few days, I saw and heard some great examples of hospital and health system marketing campaigns with strong ROI.
Organizations picked to speak seem to be working harder than ever to tie value to their marketing efforts. In fact, figuring out the best way to measure marketing efforts was in such high demand from SHSMD members that Diane Weber, RN, executive director of the organization, said it added a marketing analytics track for the conference for first time this year.
"Marketing analytics was added because of the awareness of [the need for] data to find out who patients are," she said. "The types of data and analysis available to us is becoming more advanced. Research and evaluation is going to be more important."
But along with all of that information came one piece of sobering advice for marketers who are trying to teach the C-suite marketing lingo in order to get more understanding from them about the complexity of social media ROI.
Stop.
Instead, learn their language.
It's a simple statement that hushed a crowded room on Monday morning during a session on analyzing social media efforts. Linda Pophal, owner and CEO of Strategic Communications, had a captive audience when she pointed to a slide that seemed to resonate with many in the room judging by the murmurs and nodding heads.
There were two sentences on the teal and white slide; the first one said, "The most common demand the C-suite has about social media is 'What's the ROI?'" Directly beneath that sentence was the answer, "The problem is that's the wrong question." We all chuckled knowingly as Pophal asked for a show of hands of who had been asked that question about their social media efforts.
Next, Pophal said something that seemed to stun, or at least sting a little, "That's not the wrong question." Silence. Crickets.
Pophal then went on to explain that in order to get buy-in from the C-suite on social media efforts, marketers have to understand that outcome is what is most important to executives, not process measures, which is what likes, re-tweets, and followers represent.
Those metrics, while important to a marketing team because it gauges how well (or not) a particular campaign message is resonating, do not give enough information about how that activity is contributing to the bottom line. And that, really, is what your CEO wants to know.
The shift in thinking is subtle, but can be a powerful tool that elevates the credibility of marketing activities. Suzanne Sawyer, chief medical officer for the Philadelphia-based Penn Medicine, put an even finer point on the topic saying, "It begs the question about the role of social media… unless it sits in a larger, strategic framework, we are at risk for being criticized by the C-suite."
Sawyer uses a robust CRM system to calculate Penn Medicine's digital/social/traditional media ROI for each campaign. She credits the system with giving her and her team a 360° view of all the audiences being touched by one of Penn Medicine's marketing campaigns. The CRM system took two years to build and is enterprise-wide.
It's a significant investment that allows Sawyer to integrate analyze marketing activity, online behavior, and engagement as well as pull patient data, billing, and insurance information together to show true ROI. It also pinpoints what doesn't work. For example, efforts to engage on Twitter were not as successful as Pinterest for a recent Penn Medicine bariatrics campaign.
But, knowing that not all systems have those robust resources at their fingertips, both Sawyer and Pophal gave practical tips to gaining credibility in in the C-suite with meaningful metrics for social media.
The first thing both suggested was knowing your organization's strategic plan in order to align marketing campaigns to those goals. It makes sense, but it is also easy to lose track of that big picture when you're constantly monitoring the number of likes a post gets on Facebook or the number of views a video gets on YouTube.
Get out of weeds and look at the landscape. It'll give you a different view – the same one your leadership most likely has.
Pophal broke down into three categories what the C-suite is looking for in terms of social media ROI:
Increased revenue
Reduced expenses
Improved service
To show increased revenue from a campaign, potential patients have to be tracked somehow. Whether it is capturing email addresses at an event, such as a health fair, or tracking the number of new patients to a particular service line that was recently marketed on social media channels, patients must be tracked.
There are several ways to track volume increases, and it tends to be easier when executing a service line campaign, but the key is tying it to the strategic plan of your organization.
If your hospital wants to increase colonoscopies by 10% over six months, giving your CEO the percentage increase in Facebook fans doesn't address the ROI question. Instead, frame it by noting how Facebook contributed to engaging patients who came in for colonoscopies.
One opportunity social media is great at exposing is the bang for your buck. Traditional media spends are so high, comparatively, and simply figuring out what you didn't spend on another billboard because you reached more people with a pay-per-click, is an easy calculation that shows, in real dollars, the impact social media can have.
Improving service is a little trickier to measure, but keeping a physician happy, i.e. improving physician relations, is something hospital and health system CEOs are paying attention to. Contributing to an effort to help increase patient satisfaction, experience, and employee relations also fall under this category and those are also buzzwords that leadership is keen on improving in this transition from volume to value.
The tips for tying ROI to social media are not meant to be tricks you can pull out to impress the C-suite when need be. None of them are meaningful without knowing your organization's strategy.
For example, at Penn Medicine, Sawyer says the system's business strategy is aimed at growing its advanced medicine volume, the "super sub-specialties." Her job is to deliver profitable volume, and everything she reports back to the C-suite is tied to that.
Telling your organization's social media story through the lens of what its contribution is in terms of increasing revenue, service, or reducing cost, may require another set of tools and a different mindset, but it may be the best way to get you and your marketing department closer to being viewed as a valuable, strategic partner.
With HIX set to debut in less than a week, some insurers are marketing the benefits of enrollment to younger, healthier people. One PA insurer is using social media and a roving truck to pitch its "Live Fearless" campaign.
With the debut of health insurance exchanges less than a week away, some health insurance plans are ramping up their marketing efforts to convince the younger, healthier population to enroll.
That demographic is significant to HIX success. According the Congressional Budget Office, 2.7 million people aged 18–34 need to enroll to make the exchanges affordable. Nearly every player involved in exchanges has been laser-focused on attracting a younger consumer since marketing began earlier this year.
Oregon, Minnesota, and other states have already rolled out television ads that are clearly aimed at the young, hip, and healthy with fun music and eye-catching mascots, like Paul Bunyan and Babe the Blue Ox . California's commercials for its Covered California HIX feature young families, as does Nevada's advertising campaign for its Silver State HIX.
The federal government is buoying efforts to reach this population with its Healthy Young America video contest, in which budding filmmakers could enter a video that shows the benefits of having health insurance when they're "young and invincible." The winning entries are picked by popular vote; not incidentally, voting begins on Oct. 1, the same day exchanges begin enrolling.
Of course, Oregon, Minnesota, and California are among just 17 states that opted to establish a state-based exchange. For the 27 states that defaulted to a federally based insurance exchange, encouraging enrollment in exchanges will be harder. But some insurers are picking up where the state government can't or won't.
For example, Philadelphia-based insurer Independence Blue Cross (IBX), which is participating in Pennsylvania's federally run HIX, began an advertising campaign in July called "Live Fearless," aimed at engaging the younger crowd.
"We need to align our brand with consumers in ways that we never have done before," says John McClung, vice president of advertising and creative services for IBX. "We did a study of consumers, and the older the consumer was, the more willing they were to pay for Blue Cross Blue Shield coverage. As you get younger, that margin gets smaller."
McClung says their research showed that once consumers reach their 20s, they view picking health insurance akin to picking airfares, with the cheapest price winning.
To capture the attention of young invincibles, IBX is reaching out to them where they live, physically and digitally. The insurer has built out a tractor-trailer with exchange info and Internet capabilities that is driving to neighborhoods where their targeted demographic lives. Dubbed the "Independence Express," the truck goes to community events such as the Kennett Square Mushroom Festival and Greenfest Philly, to be an educational tool that helps consumers learn about HIX as well as promote the brand with IBX materials and interaction.
The Independence Express
"The younger demographic isn't necessarily willing to pay more for Blue Cross coverage, so we need to position our brand as providing [a] different value," says McClung.
IBX is also cross-promoting HIX with local sports teams, the Philadelphia Phillies, 76ers, and Flyers. And it's using social media for a major push of the "Live Fearless" campaign.
IBX's newest social media push is a photo contest called #IBXLiveFearless that encourages residents to post pictures on its contest site showing the embodiment of what it means to live fearlessly.
"The 'Live Fearless' theme is not to live your life in a bubble wrap, but to have confidence to live your life with the security and stability of the Blue brand behind you," says McClung.
Contest participants can enter their photos by signing up through Facebook or Instagram, either via a PC or mobile device. The contest began on Sept. 9 and will run through Dec. 1. Winning photos are being chosen by community votes each month. The strategy is clever because photos are one of the most popular things posted on social media. By encouraging voting by friends and family, who have to register with an email address to vote, IBX is growing its raw engagement numbers exponentially. Who doesn't want to vote for a friend's picture?
The contest and campaign enter into IBX's social media goals. McClung says IBX has been actively engaging consumers on those channels for years, and its effort to garner attention for HIX fits perfectly with its Facebook, Twitter, Pinterest, and Instagram efforts. He says IBX wants to see its Facebook fan base increase by 1,000 per month, as well as develop deeper customer connections and, most importantly, grow its customer base through the insurance exchanges.
"They [the federal government] are banking on the fact that they need to get the younger demographic into the exchange to make everything work from a cost perspective," he says. "We're looking at it the same way. We're interested in that younger demographic who really doesn't have the brand allegiance to us. Contests like this make them feel like they can identify with this brand."
Physicians and nurse practitioners will conduct tele-consultations for high-risk pregnancies, strokes, and mental health, with an emphasis on rural areas and small towns.
BlueCross Blue Shield of South Carolina and BlueChoice HealthPlan of South Carolina will use telemedicine to increase access to some specialty services for its members in rural areas.
In mid-August, the insurer announced it will cover consultations for high-risk pregnancies, strokes, and mental health. An unspecified number of specialty providers within each network will be available for telemedicine consultations to any traditional network provider in the state.
"Our intent is to improve access for our members in rural areas and small towns to specialty care and mental health providers, who tend to be in the state's metropolitan areas," said Laura Long, MD, chief medical officer and vice president for BlueCross BlueShield of South Carolina. "We also expect this to increase cost efficiency, reduce transportation barriers, improve quality of care and communication among providers and our members, and in some cases to save lives."
Telemedicine consultations for stroke, commonly referred to as telestroke, have grown to be a covered service. Many states' Medicaid programs, including South Carolina's, already cover telestroke care. "It's a pretty common starting point," says Gary Capistrant, senior director of public policy for the American Telemedicine Association. "Stroke diagnosis is a very common covered situation. High-risk pregnancies are not as common, but are increasingly being looked at."
South Carolina's Medicaid program also already covers some mental health services. "That's a big area for growth in telehealth," says Capistrant. What's unique about South Carolina's Medicaid rules is that the telemedicine visits are covered with a licensed physician and/or nurse practitioner. It is more common for states to limit the telemedicine visit to be handled by a physician only.
South Carolina's telemedicine network for mental health is also well established. The University of South Carolina School of Medicine's partnership with the state's mental health department has helped build a network of 18 emergency departments that use telemedicine for its patients' mental health needs.
The range of covered mental health services through South Carolina's Medicaid program include office or outpatient visits, pharmacologic management, psychiatric diagnostic interview exam, and other diagnostic exams.
Capistrant says a major reason for the growth in mental telehealth services is that the visits are less intimidating for patients. "The person is able to open up a little bit more," he says. "If you have severe depression, you're not likely to put up the shades in your house, much less go to a mental health provider."
State Medicaid programs, in general, have been quicker to cover telemedicine services than commercial payers. In fact, 39 states offer some mental health coverage using telemedicine through Medicaid. By contrast, 19 states require commercial health insurers to do the same.
South Carolina's legislature was considering a bill this year that would have required commercial payers to reimburse for telemedicine services. A Senate health committee approved the proposal, which would have also set up a Telemedicine Advisory Council, but the bill lost support in the state House.
Using shared, secure video connections to pair patient and specialist has been seen as a pathway to help residents in rural areas gain greater access to healthcare, but reimbursement remains a big challenge, says Jee-Young Kim, a healthcare attorney in the California offices of Philadelphia–based law firm Pepper Hamilton LLP.
"One of the big challenges is how are you going to get paid for doing it," says Kim. "There seems to be a trend among states to leave a certain amount of discussion and decision-making up to the market."
Besides BlueCross BlueShield of South Carolina, UnitedHealth and Carolina Care Plan also cover some telemedicine claims in the state. And though South Carolina's telemedicine coverage law didn't make it into statute this year, Capistrant says support for telemedicine is building among states.
"There is a lot of state activity, state interest" in telemedicine, he says. "This was the biggest year for bills introduced, bills being approved. There's clearly momentum; we expect a bigger year for 2014."
Organizations that believe marketing campaigns must boil down to ROI may be missing important qualitative data that could help inform leaders. Hearing from real people is invaluable, and inexpensive.
For every academic center with a robust marketing department tracking the value of each patient that touches the system, there is a hospital cobbling together a marketing campaign with nearly non-existent resources.
For these hospitals and health systems, proving the value in marketing to the C-suite can be especially hard because a barely-there budget typically means enough money to execute, but not enough to track results. Marketers fighting to have a bigger voice in hospital strategy are doubly hamstringed: there's not enough money to truly compete and no way to prove if whatever they can execute on is effective.
At Franklin, TN-based Capella Healthcare, which operates hospitals in six states, the marketing department is small but resourceful when it comes to tracking its campaigns. Beth Wright, vice president of corporate communications and strategic marketing, emphasizes the importance of being prepared to give meaningful metrics to the CEO by "going beyond the standard tracking" of patients.
"Fiddle with consumer perception question surveys, with specific questions," says Wright. "Don't be afraid of asking questions that measure softer things."
To her point, organizations that believe boiling marketing campaigns down to ROI may be missing the important qualitative aspects that could help inform leaders. Hearing from real people, in their own words, how they perceive a hospital or health system is an invaluable piece of information that numbers miss.
Reach Out
For small hospitals or systems without large marketing budgets, qualitative data is relatively easy to get. It's not the only thing to rely on, but when combined with figures on whether patient volumes increased after a recent marketing push, it can become a meaningful data point.
For example, Dignity Health Hospitals of the Central Coast (DHHCC), a three-hospital system that is also part of San Francisco-based Dignity Health, recently recorded its highest turnout of walkers at this year's National Walking Day.
The annual event is part of DHHCC's community partnership with American Heart Association (AHA). But the bigger number doesn't give the complete picture of the system's relationship to the community it serves, says Lisa Dosch, AHA's executive director for the central coast division in Santa Barbara and San Luis Obispo counties who works closely with DHHCC.
"The Rotary Club of San Luis Obispo de Tolosa held their meeting at French Hospital that day (National Walking Day) and went for a walk with the entire community," says Dosch. "It's bringing people to their hospitals to enjoy the walk around the campus. They had so much fun. The president of the Rotary came to me and said, 'Hands down, we are doing this again next year.' "
Engage With the Community
The sentiment is a win for the AHA and for DHHCC, which is tying its community partnership to specific marketing strategies. It's a smart tactic that smaller hospitals can learn from because chances are that partnerships are an untapped source for marketing that isn't being leveraged strategically.
Megan Maloney, marketing director for DHHCC, knows marketing budget challenges, but is blazing a new trail at the small system by tying its AHA partnership to cardio service lines at two of DHHCC's hospitals: French Hospital Medical Center and Marian Regional Medical Center. Together, both hospitals have 60% of the market share; Maloney is aiming to grow that by 3% next year.
"We've always tracked the community engagement activities with our disproportionate population, but the marketing… we've never tracked because we're a small community hospital," says Maloney. "We lacked the funds, the focus. Now things are changing so much in healthcare. I need to make sure we're very strategic in what we're doing. I need to make sure we are putting efforts toward programs and spending marketing dollars that are going to help and effect the population."
Mine the Waiting Room for Patient Feedback
Wright believes that service lines offer a tailor-made route to track marketing activities. And she's right. The message is usually aimed at a specific audience, and counting appointments made for a specific period of time after the campaign begins is a standard, effective measure of volume growth.
There are more sophisticated metrics and systems that will dig deeper, but if the organization isn't giving the marketing department money to do that, it doesn't mean marketing can't do anything. This is just one place to start building marketing's value as a strategic business partner.
Kim Fox, vice president at Nashville-based Jarrard Phillips Cate & Hancock, says to get at the softer, qualitative information that will net information about patients' perception, head to the lobby or waiting room.
"Having a volunteer in lobby asking questions… some branding and image type [questions]… gives you a snapshot of what people are thinking, says Fox. "CFOs want numbers; CEOs like perception."
Finding the right balance of metrics to prove marketing's value to an organization and metrics that show marketing messages are resonating in the community is tricky. It's even trickier when budgets are tight, as they usually are. Smart hospitals already see marketing as a strategic partner. Smart marketing departments are resourcefully fighting their way up the ladder to stake that position.
Beth Wright, vice president of corporate communications and strategic marketing at Capella Healthcare, and Kim Fox, vice president at Jarrard Phillips & Cate will participate in a HealthLeaders Media webcast, Metrics and Marketing: Proving Value in Healthcare Marketing, September 25.
An ambitious rebranding plan creatively brings together a hospital system, medical school, health science colleges, research institutes, and physician practices.
Timing an internal campaign to win over the hearts and minds of employees before a major rebranding effort is key to the campaign's success, especially if the system that is getting rebranded is large. That's because employees' reach in the community is vast.
The old UF&Shands Logo
Timing the internal outreach is also tricky. UF Health, formerly UF&Shands, not only timed its internal campaign perfectly, but the academic health center and system in Florida also worked carefully to prepare the more than 22,000 employees to be ready and willing to go along with the system's new name and tagline.
Laying the foundation
The beginnings of a new path for the University of Florida Health Science Center and its partnership with Shands HealthCare actually began three years ago, in 2010, when David Guzick, MD, Ph.D., senior vice president for health affairs and president of UF Health announced the system's strategic plan called "Forward Together."
The plan was ambitious in that it aimed to bring together the hospital system, the medical school, the other health science colleges, research institutes, as well as physician practices.
At the time of the strategic plan, Shands employees and UF employees were functionally separate even though they often worked side by side. The two organizations were and remain legally separate entities, but their work and mission became a shared vision under Guzick's leadership.
To reinforce the singular mission of two organizations, the hospital introduced a new brand name, UF&Shands, and tagline: "The University of Florida Academic Health Center." The UF was blue, as was Shands, and the ampersand was a bright orange. The color scheme mimicked the university's colors, but it was the ampersand that quickly came to symbolize the partnership, says Guzick.
UF Health's new logo after the rebrand
"The ampersand began to represent this process of coming together as a functioning single unit," says Guzick. "Everyone came together and the ampersand became representative of that."
Moving slowly
Transitioning three years ago to UF&Shands was a major undertaking, and it's likely that employees thought that brand change was permanent. Melanie Ross, chief communications officer for the system, says the strategic plan to pull all the separate healthcare units under the umbrella of UF&Shands worked.
"All the employees saw themselves reflected in that brand," says Ross.
Even Guzick, who still has an orange ampersand fabricated out of metal in his office, says it was hard to let the symbol go when it had been such a successful tool for bridging a gap internally. "We were basically saying goodbye to the ampersand," says Guzick." It sits in my office. It's an important piece of history."
However, the work that went into bring the university employees together with Shands employees paid off when it was time to announced its newest brand, University of Florida Health, or UF Health.
"We were building momentum," says Ross. "Because that groundwork was laid and people saw themselves working together and working toward a shared vision and shared goal. I think they understood we had gotten to a point as an organization that it was time to really assess… 'How do we go to the next level?' "
Readying the staff
To prepare employees for another shift in branding, UF Health launched a four-week internal campaign called The Big Picture. Ross says the point of the campaign was not to announce the new name, but rather, to plant the seed that the employees were a part of a bigger vision for the health system.
"What we wanted to do was get employees into the proper mindset, so that when they heard the announcement they were already thinking more as one, and also that their role across our large, complex, and often complicated system was recognized," says Ross.
To that end, Ross says a photographer was sent out to UF Health locations in Gainesville and Jacksonville to take pictures of employees.
"We encouraged people to actually represent the organization by pulling a partner from the other organization to go along with them," says Ross. "It was a way to get people engaged and excited in their little neck of the woods and to reflect that visually and graphically. Some people held up little chalkboards that had UF&Shands written on them. One [arrow] would be pointing to a UF employee and one [arrow] would be pointing to a Shands employee."
More than 250 pictures were taken and posted on a website specifically developed for The Big Picture campaign, where employees were asked to vote on their favorite picture. A contest was also held asking employees to name the location of various health system landmarks. The photos were the big draw, but the site also had blog post-style messages from leadership and videos featuring employees.
All of it was aimed at setting employees up for the big announcement of the name change to UF Health on May 20.
Announcing the change
Having successfully kept the name change from UF&Shands to UF Health a secret from employees (key leadership groups were informed) and the media, Ross says the announcement was made on the three-year anniversary of the "Forward Together" strategic plan. The coincidence was pure luck, says Ross.
"The planets aligned… so, we invited all employees to celebrate the anniversary of that (strategic plan), and share in their vision for the future. A sort of a 'State of the Union' address for the hospital, so to speak."
Ross says that in the three months since the rebrand, employees have embraced the change. Anecdotally, they're ramping up requests for new business cards and requesting to use the new logo. The numbers back up the anecdotes, says Lindsay Wessel, senior account planner at Raleigh, NC-based Capstrat, an agency that UF Health worked with to develop the internal and external campaigns.
"We were able to easily measure because it (The Big Picture campaign) all lived online," says Wessel. "There are more than 22,000 employees at UF Health. The metrics showed us that more than 11,000 employees visited and engaged with the site, which is impressive. We got more than half the employees to visit."
What impressed Wessel more than the high rate of participation was that more than one-third of employees did not have access to the website during their workday, meaning they had to go to the site after hours or during their lunch breaks.
The hospital system also held multiple employee forums across its system to explain the purpose behind the rebrand and the vision. The thought put into getting employees on board so far in advance—three years—shows that leadership truly values its workforce. Authenticity like that can go a long way in changing the loyalty of an employee who is resistant to a name or brand change.
Guzick knows that longtime employees can be hard to convince, but he says he is seeing signs that the vision of a single, functioning organization from two legally separate entities is working.
"When folks who've been here a long time and didn't think anything would ever change, either stop me in the hall or send me a note saying, 'This is really an exciting place to be,' it hits home, in terms of how the brand is functionally becoming operative in the organization," says Guzick.
"This is more than employee engagement. They're all working improving patient care, our research efforts, and they all understand their role in the bigger picture."
Doing consumer research before a major rebranding campaign is worth the expense. A year after focus group testing prior to launching its campaign, one Philadelphia health system is tracking double-digit increases in call volume and website traffic.
Catholic Health East's Mercy Health System in Philadelphia is reporting success with the revamped brand the four-hospital system launched in 2012. A closer look at the preparation and execution of Mercy Health's strategic marketing plan illustrates how key research can be to positive end results.
Before a major rebranding campaign, quantitative consumer research is usually one of the first boxes checked off on the to-do list. It makes perfect sense to find out reach, audience, and preference data those surveys can provide. Mercy Health took this step with approximately 800 participants in a telephone survey that used the same questions from the previous surveys in years 2007 and 2010.
The results revealed an increase in market share and awareness, but a decrease in preference, which was troubling since Mercy Health's service area is the Delaware Valley. Patients who live in this area have access to highly acclaimed hospitals and health systems in Pennsylvania, New Jersey, Delaware, and Maryland.
Gabrielle DeTora, principal of DeTora Consulting, who was acting interim chief marketing officer for Mercy Health during the development of the campaign, says that in addition to market pressures, the hospital was faced with launching a campaign on a thin budget.
"Mercy probably has a marketing budget for all four hospitals equal to one competing hospital," she says, noting that the competition includes academic medical centers, such as Penn Medicine, who have monster marketing budgets, and as such, big campaigns.
Knowing that, DeTora focused on Mercy Health's target market of households with income $50,000–$100,000, to find out what they wanted from a hospital.
"In this campaign, we really tried to understand what was more important to the consumer first," says DeTora, who says the hospital held focus groups with consumers in the fact-finding phase of the rebranding and also in the test marketing phase.
What emerged from the consumer focus groups was surprising, says DeTora. There was a gap between the consumer's and hospital's definition of a top doctor. Leadership believed that consumers identified a top doctor as someone affiliated with one of the nearby academic medical centers. But focus group research revealed that its target audience defined a top doctor differently.
"They defined top doctors as someone who is going to take the time to listen to them, to understand their medical issue, which was totally different than how the administration defined a top doctor," she says. "That changed the language associated with the campaign."
DeTora says she shared some of the quotes from consumers to convince leadership that the branding needed to be on point with what patients wanted. Without having that kind of insight, Mercy Health might have been on a completely different brand trajectory that would have no chance of resonating with their audience.
Consumer focus groups are not totally uncommon in rebranding research, but they are also not used as much as they could be, particularly when it comes to test marketing the campaign an organization is launching.
DeTora says Mercy Health took the extra step and test marketed four ideas developed by ad agency Swanson Russell, and tested on a group that mirrored the demographic and geographic make up of the previous focus groups. It was above and beyond the marketing budget she was given, but fighting for the extra resources was important to the success or failure of the brand messaging.
"In the past, they launched campaigns, funded them, and then after the fact, we reported that it didn't work," says DeTora. "We now have the opportunity to see evidence that a campaign will or will not work before we even go to launch. It was not in the budget, and I did sell it as the opportunity cost of not doing this research."
The message that consumers responded to the most was one that identified Mercy Health as a hospital system that would take the time to get to know patients and their individual issues. DeTora notes a key component of the campaign even came from its focus group research with consumers.
"The idea that the consumer defined a top doctor as somebody who would spend time with them, not treated like a number, became the tag line, "You Deserve More," she says.
The revitalized brand was rolled out during subsequent service line campaigns, the first being cardiology in 2012. In year-over-year results, call volume is up 40%, its website traffic has increased 50%, and all areas of cardio services have increased in volume by 10%, which makes leadership happy.
"We are very pleased with the campaign," says Daniel Bair, FACHE, administrative director, cardiovascular and radiology services for Mercy Health System. "Even with our limited resources and a highly competitive market, the results have been within expectation on most fronts and exceeding expectations on many others."
Going beyond the standard consumer preference survey may mean extra money upfront, but as DeTora points out, for systems with limited resources, it pays off because the organization knows the consumer better and can craft a meaningful message instead of just a catchy one.
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."
Reprint HLR070813-2
This article appears in the July/August issue of HealthLeaders magazine.
Some early adopters in the surgical suite are pushing ahead with efforts to capitalize on the promise of Google's revolutionary hands-free tool.
When new technology is still in its infancy, years can pass before it is widely accepted among health systems and hospitals, and even longer before the technology is a component of an organization's marketing strategy. A perfect example is the iPad.
The popular tablet computer debuted three years ago and is widely used by consumers, small businesses, and other organizations, such as schools. Hospitals are not on the bandwagon, yet, though. Safety and quality concerns rightly outweigh promoting something that isn't fully vetted for the healthcare industry. So healthcare has some catching up to do before the iPad is widely adopted.
But Ohio State University Wexner Medical Center has found a way to boost its reputation as a technology pioneer with Google Glass, without endorsing Silicon Valley's hottest tech gadget, which isn't even available for distribution yet.
The wearable and interactive computer, browser, and camera (still and video) promises to revolutionize the way information is sent and shared. The video function, which is hands-free, has implications for academic medical centers like Ohio State's Wexner Medical Center because it means giving more medical students a precise line of sight during surgery.
When Ismail Nabeel, MD, assistant professor of general internal medicine at Ohio State's Medical Center, was chosen to test-run Google Glass this year, he went to the marketing department to help plan a live surgery event that would emphasize the hospital's willingness to try out new technology.
"We talk a lot here about creating the future of medicine," says Julie Scott, senior director of public relations for Ohio State's Medical Center. "From a media standpoint, and building our reputation, we felt like it was a great opportunity to highlight the innovative work that goes on here in improving healthcare and education."
On August 21, orthopedic surgeon Christopher Kaeding, MD, repaired 47-year old Paula Kobalka's torn ACL at the Columbus, Ohio-based hospital while wearing Google Glass to record and broadcast the surgery.
Kobalka says Kaeding assured her that her knee would be the only body part students would see. She says agreeing to be the guinea pig Kaeding operated on using Google Glass was easy.
"I'm a dental hygienist," she says. "I am already in the healthcare industry, and I'm all for anything to help. It's nice because 50 medical students can look at a knee in surgery. This is going to be another piece of technology. To me, at 47, l I think it's pretty awesome."
Another surgeon collaborated with Kaeding during the surgery in a second location, and a handful of medical students watched the surgery at OSU's main campus. Live images of the surgery, as well as Kaeding's commentary, were streamed to the remote laptop screens.
Kaeding, who is also executive director of OSU Sports Medicine, is partnering with Nabeel to find out the practical applications for Google Glass. In news release, he said he "appreciated the connectivity" of the technology.
Kaeding is not the first U.S. surgeon to use the glasses to transmit live surgery. In June, Rafael Grossman, MD, FACS, an employed surgeon at Brewer, Maine–based Eastern Maine Healthcare Systems (EMHS), used Google Glass during an endoscopic PEG tube procedure.
Both procedures that Kaeding and Grossman performed were fairly routine, making for an easier test run for future, more complicated surgeries. Both surgeons said the video quality of Google Glass needs to improve. Both used Google Hangout to stream their surgeries. But only one surgeon was on the receiving end of their hospital's marketing machine—Ohio State's Wexner Medical Center.
In terms of showcasing the live surgery event using one of the most talked about tech devices, the hospitals could not be more different.
While Ohio State's Wexner Medical Center promoted the event to its local news outlets and across the country, EMHS did not mention Grossman's surgery at all. There's no evidence of it on their website; in fact the only mention of it is on Grossman's personal blog.
Tricia Denham, manager of community relations at Easter Maine Medical Center, which is part of EMHS, says the hospital system took a wait-and-see approach.
"We've been asked how we view this," says Denham. "While we support technology, you have to take into consideration with patient privacy and patient safety."
The reticent approach to promotion by EMHS is safe and understandable. Denham says the hospital system is known as being an early tech adopter, so there was no rush to emphasize a new tech tool that may not be around in the long-term.
"It's very preliminary," she says. "It's just too early."
Besides, says Denham, Grossman is an active blogger about medical technology and was contacted directly about the procedure, which he tweeted about, as well.
Conversely, Ohio State's Wexner Medical Center used Kaeding's surgery with Google Glass to reinforce its marketing message that the hospital is at the forefront of technology that could be used to improve healthcare.
"As an academic medical center, that's important to us," says Scott. Kaeding and the hospital were featured in a nearly two-minute news segment on CBS This Morning, and Scott says the hospital is reaching out to other media across the country as well.
"It really was a test of this technology, not an endorsement," she says. "We don't know that this will be a technology that we will end up using, but as an academic medical center, it's that kind of innovation that we're comfortable with."
The publicity generated by Kaeding's use of Google Glass will likely have a halo effect on Ohio State's Wexner Medical Center because the hospital actively promoted the event. In its first few hours, the hospital's promoted post on Facebook garnered 74 shares. Scott is happy with the response to the story so far.
"What we're really looking for is that spike in social media and that spike to the website," she says, adding they didn't set "hard and fast numbers," because they're curious to see how social media users react, and what other sites pick up the news.
Meanwhile, at EMHS, Grossman continues to try practical applications with Google Glass, and documents them on his blog, which is a really useful step-by-step guide on how to use the device. EMHS isn't ruling out promoting the glasses, but for now it's staying out of the spotlight.
There hasn't been a lot of interest in the organization," says Denham. "My sense is that boost to publicity will come later, once Google Glass is more mainstream."
