Despite some unique challenges, safety-net hospitals are achieving strong patient satisfaction results by focusing on compassionate care and quality outcomes.
This article appears in the June issue of HealthLeaders magazine.
Do hospitals that treat more low-income, ethnically diverse patients with multiple comorbidities have a tougher time getting good patient experience scores than other hospitals, as some organizations contend?
And if so, should those hospitals merit an adjustment for socioeconomic status or payer mix, especially when millions in value-based purchasing incentive pay is now at stake?
Safety-net advocacy groups say the Hospital Consumer Assessment of Healthcare Providers and Systems surveys should be adjusted for race, ethnicity, income, and health literacy as well as insurance status because HCAHPS misses a measure of hospital cultural competence.
But to date, the Centers for Medicare & Medicaid Services has disagreed, arguing that existing adjustments—such as for age, education, and the patient's primary language—are adequate.
Besides, CMS said in its 2013 payment rule, one-fourth of hospitals with large safety-net populations show they do just fine on patient experience.
Executives of several hospitals that treat larger shares of these populations have grappled with this issue, and they, too, think it can be done. Although it can be tough. One of those is 520-bed Ronald Reagan UCLA Medical Center in Los Angeles, which acknowledges an uphill climb in a "melting pot" of patients.
"We do more organ transplants than any other hospital in the United States. We invented the PET scan, diagnosed the first case of AIDS, and we're about to do a face transplant," says David Feinberg, MD, MBA, president of the UCLA Health System and CEO of the UCLA Hospital System. "We're world famous."
"But five years ago, if you asked patients to rate UCLA on a patient experience score of 1 to 10, we were in the 30th percentile, and our emergency department was in the 17th. Basically, we could save your life, but two out of three people would never come back."
After a few months of sitting near patients' beds listening to their experiences, Feinberg says, he got an earful. "It was very clear: No one knew who was in charge of their care. The place was dirty. The hot food was never hot. The cold food was never cold."
And providers were arrogant, conveying the attitude, " 'We're UCLA. Aren't you lucky you get to see us.' That came across in how we treated ourselves and certainly how we treated our patients and their families," Feinberg says.
When he was named system CEO in 2007, Feinberg says, "I told the organization, 'We are really going to change this. We're going to treat patients with compassion.' "
Feinberg says he began spending "a couple hours a day" walking hallways, knocking on doors, and asking patients about their care. "I say, 'Here's my cell phone number. Call me 24 hours a day if you or your family ever need anything.' " He still does this with 10 patients a day.
Now, "the whole management team does this. We have structured rounds, with 250 people who go out two or three times a week." Even the CFO.
The hospital draws from what Feinberg calls "a melting pot" of uncountable ethnicities around Los Angeles, and where nearly one in five patients is self-pay or Medicaid.
Ronald Reagan UCLA Medical Center also launched a talent program developed by Ritz Carlton to ensure the hiring of service-minded people. There are training programs that guide the way providers enter a room and interact with patients to convey their engagement.
Staff use current events to start conversations like, "Did you know it's the 70th anniversary of Little League?" and housekeepers ask, "Is there an area you want me to clean?"
And there are movie tickets, cafeteria coupons, or $10 gas cards if something goes wrong, "like you're waiting a half hour for your MRI because there was an emergency. It's a small token of appreciation for the hassle we put patients through," Feinberg says.
Some of this strategy has worked. According to Hospital Compare, 80% of patients give Ronald Reagan UCLA a 9 or 10 on a scale of 0 to 10, compared with the California average of 67% and the national average of 69%. And 83% would definitely recommend the hospital, compared with 69% statewide and 70% national.
Ronald Reagan's NRC Picker surveys indicate favorable responses to the "Would you recommend" question are getting better, with 93% as of June, 2012.
But responses to other questions still trail—for example, those about nurse and physician communication.
"Yes, our scores are much, much better than they were before, but my honest opinion is that they're still terrible," Feinberg says. "The next patient who comes in really doesn't care about the Nobel Prize winner on our staff or that we published this paper. All they care is that the people standing around them with badges are explaining what's going on. Are they listening? Are they engaging the families?"
Staff still give excuses: "We can't be as good as other hospitals because we don't have a new building. Or because we have residents and trainees. Or because we take care of really old, very sick patients. There are hundreds of excuses."
Feinberg tries to make staff understand what patients go through. One hospitalized cancer patient whose pain wasn't well controlled told him how it kept her awake. Finally, the staff got her medication adjusted, and Feinberg asked her to speak to managers to tell them what intractable insomnia was like. She spoke to 400 members of the team "about when the care was great, and how compassionate we were, but at the same time, how we screwed up on her pain. And it will be our goal to make sure her issue doesn't happen to another patient in our care."
"We definitely get more right now than we used to. But we have such a long way to go. And when you have cancer, I don't care if you're a safety-net hospital or the Taj Mahal."
The National Association of Public Hospitals and Health Systems suggests the road for these safety-net hospitals is too steep. Xiaoyi Huang, the assistant vice president of policy for the Washington-based organization, which lobbies on behalf of safety-nets, says the HCAHPS survey "lacks measures of cultural competence, and therefore fails to capture key aspects of healthcare quality" important to minorities. This "flaw" she says, "unfairly disadvantages hospitals" with minority and non-English-language patients.
Other factors that should adjust the scores include "sex, race, ethnicity, income, health literacy, insurance status … disease and functional status," she says.
Such arguments miss the point, because proper focus and attention to each patient is what's important, advises David P. McQuaid, FACHE, president of 969-bed Thomas Jefferson University Hospital in Philadelphia, which gets 20% of its volume from Medicaid and uninsured patients.
"Don't waste your time debating data and targets," he says. "Your focus should be on the best possible outcome, and if you're doing the kinds of things that need to be done in a patient-centered model, your outcomes will follow."
At Jefferson, the trick has been getting providers to see how their certain behaviors—terse or quick answers or rushed visits—may seem insensitive and uncaring when viewed from the perspective of the patient.
So Jefferson created a training and educational video that plays during physician meetings to sensitize providers to the patient's perspective. To get the point across, it begins with patients expressing negative views of their experience.
Says one man, "I remember when my doctor first came in to see me after my procedure. He looked at his watch three times in the two minutes he was there." Says another, "I feel I could have used a little more honest communication, certainly with me, but also with my family."
In 2010, McQuaid instituted a task force within each department to take responsibility for patient experience. There are teams for the ambulatory and emergency departments as well as inpatient areas. When he took over in 2007 as COO, he says, "there was one centralized team, but they obviously weren't effective because the scores weren't good. Now our scores are improving because we've taken this different structural approach."
After tweaking the culture with targeted campaigns, both Press Ganey and HCAHPS survey scores improved.
For the period April 2011 to March 2012, Medicare's Hospital Compare shows Jefferson's HCAHPS were better than both national and state averages in six of 10 questions and were similar in a seventh. In response to the last question—would patients definitely recommend the hospital?—76% said yes, compared with 68% in Pennsylvania and 70% in the nation.
One area in which the organization still struggles is physician communication with the patient; scores lag a few points behind state and national average, although more recent surveys show improvement, says Jennifer Jasmine Arfaa, PhD, Jefferson's chief patient experience officer. "Many of our physicians were not aware that patients were being surveyed about their entire patient experience at Jefferson, let alone the fact that there is a section in the survey where patients can rate their physicians and the whole hospital can see that in a comment report," she says.
Arfaa cites several campaigns—under the leadership of Elisabeth Kunkel, MD, vice chair for clinical affairs, department of psychiatry and human behavior, and chair of the MD Care Task Force, and Susan Krekun, MD, director of thedivision of hospital medicine and cochair of the MD Care Task Force—that have helped improve patients' perception of their experience related to their physicians:
- Chairs are placed in patient rooms with a directive to physicians and other staff to sit down and make eye contact with their patients as they speak with them.
- Staff and doctors wear lapel buttons that ask "What questions do you have for me?" and notepads and pens are placed in each patient's room so they may jot down questions that occur to them.
- White boards are available for patients to list their three most important things. "It might be something as simple as, 'I want to see my husband every day.' Then the housekeeper comes in, looks at the board, and can have a positive interaction. 'Oh, Mrs. Smith, did your husband come in today?' " Arfaa says.
Arfaa and McQuaid say Jefferson hospitals don't try harder with safety-net patients. "Our patients are our No. 1 priority, and every patient is treated the same, with dignity, respect, and integrity," Arfaa says.
At University of Kansas Hospital in Kansas City, a safety-net hospital where more than one in five patients is on Medicaid or self-pay, patient experience scores are higher than the state and the national levels for six questions, including "Would you recommend ..."
There was a time that the organization's patient experience scores put them in the bottom 5% of the nation's hospitals. The turnaround was brought about through a focused effort toward the patient experience for more than a dozen years, says Terry Rusconi, the 751-bed organization's vice president for performance improvement. The key to success, he says, was in developing special customer-service training classes that begin with new-employee orientation, and a focus on hiring people with customer-service attitudes.
"We keep the instructor pool small to ensure consistency and maintain people who have a history with the organization," he says. "They listen to concerns and challenge people who want to say there are certain patient populations who just can't be made happy. We nip that in the bud because it's just not true."
One technique that Rusconi says has brought up scores in struggling units is having nursing staff spend five minutes "not giving medications, not checking vitals, but literally sitting at the bedside talking with the patient to get to know them better and understand what makes the patient tick from a personal perspective. They make a personal connection."
Executive-level attention to those HCAHPS scores, delivered weekly from Press Ganey, is at the root of their good results, says COO and CNO Tammy Peterman.
"This transparency sets the stage for this part of our culture," she says, and even helps with those departments that may be struggling.
"We believe every unit in the hospital has some best practices to share. One of our approaches has been to pair a unit having consistently favorable patient satisfaction with a unit whose performance has been less consistent. In the process, we have seen both units improve," she says.
"The unit with less consistent patient satisfaction has learned new approaches to earn higher satisfaction ratings. And the unit with consistent patient satisfaction performance has picked up ideas on improving safety, such as reducing falls. All teach and all learn. In the end, patient care and service are better."
Another element is regular reward and recognition for those units that score well on patient experience.
If special ethnic or low-income populations do have certain needs that can affect their comfort level while they're hospitalized, they're addressed in interdisciplinary huddles—daily meetings with the pharmacist, social worker, physician, nurse, or anyone else involved in that patient's care.
A financial services group helps identify patients very early in their stay who might not be able to afford to pay "and figures out resources we or they might tap into to help and support their healing," Peterman says.
The bottom line, these leaders say, is that patient experience improvement for the sickest and the poorest patients is possible. It just takes a hospitalwide effort.
This article appears in the June issue of HealthLeaders magazine.