Patient Experience: One Person at a Time

How can an organization get its arms around something as massive and variable as the patient experience? By listening to the experts—the patients.

This article first appeared in the September 2016 issue of HealthLeaders magazine.

Carol Raimondi, RN, knows what it's like to be a patient. Born with congenital heart defects, the 40-year-old's life has been entwined with the healthcare system for decades. Raimondi had her first open-heart surgery when she was 6 years old, and has since had multiple surgeries and hospitalizations both at well-known academic medical centers and at her local community hospital, 259-bed Elmhurst (Illinois) Hospital.

In her time as a patient and a provider, Raimondi has noticed changes in the way healthcare is delivered. What was once a very patient-focused experience has morphed into something less personal and more procedural, she says.

"Over the years, everybody just became busier. There was more charting and more things to do," says Raimondi, who worked as a nurse for eight years, but stepped away from clinical practice in 2006 due to health issues. "Healthcare has become so big, with all these pharmaceutical and insurance companies and all these different regulations. Patient experience has become focused on HCAHPS scores, and what are we going to do to get our scores higher?"

For healthcare executives, attention to results of the Centers for Medicare & Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems survey— the organization's tool for measuring patients' perceptions of care—has become a necessity due to reimbursement changes, public reporting of scores, and the shift to value-based care. But a single-minded focus on HCAHPS scores is a missed opportunity to improve quality, safety, and patient engagement through a broader, more multifaceted approach to patient experience. The Beryl Institute, an independent nonprofit thought leadership organization focused on improving patient experience, defines this approach as "the sum of all interactions, shaped by an organization's culture, that influence patient perceptions across a continuum of care."

"Patient experience is about building a relationship-centered culture that delivers an exceptional experience every time," says Adrienne Boissy, MD, MA, chief experience officer at Cleveland Clinic. "Here at the Cleveland Clinic, we define it as safe care, high-quality care in the context of satisfaction and high value."

Cleveland Clinic is considered an early adopter in the realm of patient experience, with the organization creating its first Office of Patient Experience in 2008.

Today more hospitals and health systems across the country are following its lead and moving beyond the silo of patient satisfaction in an attempt to improve patient experience through a variety of ways.

Patient satisfaction vs. patient experience
While the terms patient satisfaction and patient experience are often used interchangeably, they are in fact different—albeit related—concepts.

"Patient satisfaction is just that: Are you satisfied or aren't you satisfied?" says Kristin Baird, RN, BSN, MHA, president and CEO of the consulting firm the Baird Group in Fort Atkinson, Wisconsin. "It's kind of a yes or no, and it's on a continuum where you can say how satisfied you are. It's pretty quantitative."

The HCAHPS survey is one tool to help organizations gauge patients' sentiments in this area.

"Satisfaction is really, are they happy?" says Shawn R. Smith, vice president of patient experience at Wilmington, Delaware–based Christiana Care Health System, a not-for-profit health system that had $1.6 billion in total patient revenue in fiscal year 2015. "To some degree, the CMS platform for HCAHPS is an indicator of how well they like you, how well they're into you as an organization."

Patient experience, on-the-other-hand, is all encompassing.

"It's clinical. It's operational. It's behavioral. It's cultural. It's everything," says Sandra Myerson, RN, BSN, MBA, MS, chief patient experience officer at New York's Mount Sinai Health System, an integrated system that sees 152,576 annual inpatient admissions. "It's every interaction patients have with anything within our healthcare system, whether it's someone on the telephone, whether it's a document they're reading, whether it's our website, whether it's the building—everything matters."

It is also personal.

"Patient experience gets into more of the qualitative, where you're saying what's important to you. It's all about the individual," Baird explains. "If you and I were both being admitted to the hospital right now, hopefully somebody would say, 'During your stay with us, what is going to be most important to you?' You're going to have an answer for that, and chances are it's not going to be the same as mine."

This variability in patient preferences can create a challenge in determining how to provide an excellent patient experience, Boissy says.

"If you asked every patient what the patient experience meant to them, they would say something different, just as if you were to ask clinicians, they would say something different," she says. "It's very difficult to get your arms around it if we can't agree on a definition."

Which is why Boissy suggests organizational leaders ask individual business units or service lines to develop their own vision and measurements to assess patient experience.

"HCAHPS can be one of the metrics but not the metric," she says. "We've gone through an exercise over the last year or so … to drive every department, every unit within the office of patient experience to articulate what their own goals are for patient experience and then, to come up with goals and metrics around those."

For example, volunteer services and the center for excellence for healthcare communications are both part of Cleveland Clinic's office of patient experience. Boissy says each group asked questions such as ...

• How do they feel they've touched patient experience?
• What are they expecting out of themselves for the next year?
• What would success look like?

Different groups may come up with different answers, but teasing out those variables is essential to understanding how to affect patient experience.

"We believe that listening to patients is not only the right thing to do, but it's absolutely one of the best ways we can spend time."

"I think HCAHPS is one of what can be a more richly defined experience and metrics to track whether or not we're moving the needle," Boissy says. "But that's individualized."

A multipronged approach
Christiana Care's Smith agrees that there is a richness to patient experience that can't be measured just through HCAHPS scores.

"Patient experience created a conversation to broaden the context of how we connect with people," he says. "If you start looking at what health systems are really focused on, it's really about the quality of communication."

Smith points out that communication isn't just pushing information out to patients; it's actively listening to feedback from them as well.

"Whether we're rounding virtually from a phone call, calling and connecting with the patient postcare, or we're in the moment having a conversation about safety and quality and about their overall healthcare experience, we're collecting that data in real time to look at matters that we can address."

"We believe that listening to patients is not only the right thing to do, but it's absolutely one of the best ways we can spend time," he says.

Christiana Care takes a multipronged approach to patient experience. In addition to HCAHPS scores, the organization uses feedback from patient advisors along with real-time information gathered through conversations with patients to improve patient experience.

"Whether we're rounding virtually from a phone call, calling and connecting with the patient postcare, or we're in the moment having a conversation about safety and quality and about their overall healthcare experience, we're collecting that data in real time to look at matters that we can address," Smith says.

Another way the organization is trying to understand the patient experience is through sentiment analysis. "You have two different ways—qualitatively and quantitatively—to get data out of a survey," he explains.

"You actually get your metrics, but you also get a great story when you start looking at the feedback. We take the sentiment from all of our surveys, and we take all of our sentiment from our mobile applications, all the sentiment inside social media chatter—think #ChristianaCare or Facebook—and we actually push that into an engine that does natural language processing on that." This allows Christiana Care to notice themes in that information.

"Those themes can be as simple as, 'Close the door on the unit for quiet,' or something more significant like as a concern about the medication side effects," Smith says.

Smith stresses that just focusing on one data set, whether it be HCAHPS or patient sentiment, isn't enough to fully comprehend that patient experience.

"It's not necessarily a true indicator of quality," he says. "You really need to look at the quality, safety—those outcomes—as well as experience."

Providers' discomfort zone
Because they are involved in direct patient care, the two groups most visibly involved in a patient's experience are nurses and physicians. They're specifically called out on the HCAHPS survey where patients are asked to rate the degree to which they think these providers showed them courtesy and respect, listened to them, and responded to their needs during their hospital stay.

And it's no secret that feedback to such questions has caused discomfort for some providers.

"I've been a nurse for 24 years, and more than any time in my career, we are asking providers to do more with less. In addition, they're being judged almost every day on how they're doing, whether it's a point-of-care survey or patient satisfaction. I would imagine it's very hard for them not to take it personally," says Jennifer Strickland, RN, BAN, customer experience director at Lakewood Health System, an independent, integrated, rural healthcare system based in Staples, Minnesota, with a 25-staffed-bed critical access hospital and primary care clinics.

Strickland saw this uneasiness occur when the organization began sharing scores of provider's Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS)—CMS' standardized survey tool to measure perception of physician's care in an office setting. Originally, the providers said they were on board with—even looking forward to—this transparency of scores.

"The first time, we put their scores up during a provider meeting, we listed each provider from best to worst, with those at or above the practice average listed in green and those below in red. There was immediate silence, and literally no discussion. No one wanted to see their name on that list, unless they were one of the top-ranking providers. They immediately asked us to change the process," she recalls. One provider even came to Strickland following the meeting, visibly upset about being ranked in the red zone.

"I explained, 'Well, you are actually doing fairly well; the red just means you're slightly below the practice average,' " Strickland says. "The provider replied, 'I can't be below average. If there's something red, it means there is something I haven't done or haven't done right.' "

While listening to clinicians' concerns is essential, the key to making progress in providers delivering a positive patient experience is support, says Craig Wolhowe, vice president of clinics and hospital services at Lakewood.

"We see the providers' side of the story, but they also have to understand our side. This is important. This is how we get reimbursed," he says. "We need to make sure we're all working together and ask providers, how can we make you better? How can we make you successful?"

The power of thank-you
Finding ways to help providers improve patient experience, including one-to-one work if needed, is a major part of Strickland's role. This philosophy of support was successful with a physician who was unhappy about having some of the practice's lower CG-CAHPS top box scores regarding the CG-CAHPS question "Would you recommend this provider's office?" and in the provider communication domain.

Strickland acknowledged that by virtue of being new to the practice and therefore seeing patients who couldn't get appointments with their usual providers, this provider was "already behind the eight ball" when it came to patient satisfaction. So Strickland created an assignment. For the next 30 days, the provider simply was to look each patient in the eye at some point during the visit and thank him or her for coming.

"A genuine 'Thank you so much for seeing me today. Thank you for coming in,' " Strickland says. "That was the only thing, the eye contact and that genuine thank-you."

Next she asked the provider, and the rest of the practice, to intentionally open the patient's visit with the thank-you.

"I said, 'Think about where the patients are coming from. They have higher deductibles than they have ever had. People are paying a lot more out of pocket. So, where people used to just go to the doctor without much thought, you need to know that the mom of that small child or that gentleman who is already missing work, they're wondering if they even made the right choice to come to the doctor," says Strickland.

And questions like, "Am I wasting the physician's time? Am I wasting my time? Am I wasting my money?" are likely running through most patients' heads.

"Many patients are having those thoughts. So what if you started the visit with, 'Thank you so much for coming in today.' They're going to take a deep breath. They're going to relax. You're affirming that they made the right choice in seeing you, and you're connecting with them," Strickland says.

Since the one-on-one work with Strickland, the provider's top box scores on the "would you recommend" question improved by 20 percentage points, and the provider communication scores improved by 16 percentage points.

First impressions matter
Just as it's wise to expand the concept of patient experience beyond patient satisfaction or CG-CAHPS and HCAHPS scores, it's also important to recognize physicians and nurses are not the only individuals who can influence patient experience.

"What if you started the visit with, 'Thank you so much for coming in today.' They're going to take a deep breath. They're going to relax. You're affirming that they made the right choice in seeing you and you're connecting with them."

"You could talk about how the nurses impact experience and miss the phlebotomist, miss the physical therapist that comes into the room, miss the dietitian, miss the environmental services. The industry created that broad context of patient experience to cover everybody for it to be an inclusive measure," Smith says.

Detroit's Henry Ford Health System is one organization that recognizes improving the patient experience means including employees beyond physicians and nurses.

"I think it's been helpful to break down the workforce into different components and take different approaches to each of the components," says William Conway, MD, executive vice president at Henry Ford Health System and CEO for Henry Ford Medical Group. "Our receptionists operated around 65% to 68% of positive comments" just three years ago.

As of March 2016, the receptionists were ranking at 95% on the CG-CAHPS question "How often did the clerks and receptionists treat you with courtesy and respect?"

The results are impressive, but as Conway points out, it did not happen easily.

"There has been an intense education," he explains. "That component of the workforce, they're entry-level jobs. I think in the past we didn't pay a lot of attention to it. We inservice that group about as intensively as we do anybody in this organization right now."

Providing continuous and consistent feedback has played a role in improvement as well. Each week, the clinic service representatives get reports on their performance measures, and the organization has put more resources into supervising this group than it did in the past, says Conway.

"I meet with the managers of the clinic services representatives across the medical group, and we review how well behavior standards and clinic appearance standards are being applied," says Kelley Dillon, director of care experience at Henry Ford Hospital and Health Network.

Henry Ford's behavior standards are based on AIDET, the Studer Group consulting firm's acronym for its five fundamentals of patient communication. It stands for acknowledge, introduce, duration, explanation, and thank-you. These, along with clinic standards like cleanliness and noise levels, are measured through CG-CAHPS scores, Press Ganey surveys, and mystery shopping feedback.

In addition to the managers, with whom she meets monthly, Dillon meets quarterly with clinic service representatives, whom she refers to as chief first impression officers, to provide feedback and recognition. From Dillon's perspective, continued follow-up with and development of this group of employees is necessary to improving patient experience.

Helping this group understand the importance of their interactions and recognizing them for a job well done is also important.

"It's finding ways to constantly talk about it that make them feel proud, too."

Dillon is now using some of the same techniques, including the AIDET model of communication, with medical assistants at the organization. "For example, the A is acknowledge. Instead of just acknowledging someone as mister-or-miss-last-name, we also want to find an opportunity to ask or to say some things that acknowledge their backstory as a human being," Dillon explains. "And then making notes in our electronic medical record that remind us of things that are important to the patient.

"Any time we teach any audience—nurses, doctors, medical assistants, clinic service representatives—we focus on this model so that way we're not reinventing a bunch of new behaviors," she says. "It's not that this is the be-all and end-all, but my strong opinion is, you've got to get consistent and decide what are the main behaviors of your organization's behavioral model and keep centering around that."

Listen to the experts
For all of the experts, tools, and solutions available to assess and improve the patient experience, sometimes it's easy to overlook the people whose opinions matter most—the patients. For this reason, many hospitals and health systems have created patient advisory boards to help ensure actions and interventions are on target.

"We can try to anticipate the patients' needs, but what we realized is—while we might get it 80% or 90% correct—how much more important it is to bring the patient's voice in earlier in those decisions," Strickland says. "If we have X number of dollars to spend on a certain area, how best do we use those dollars? We can come up with a good plan, but by asking patients to give their input earlier in the process, we can come up with a great plan."

Patients have insights on everything, both large and small. "We might think that our patient experience is about what the building looks like or that it's about the care that the doctor's giving," she points out. "But sometimes, it's as simple as, 'I'm on hold for too long when I'm trying to call,' or it might be, 'I really think waiting an X number of minutes is way too long.'"

At Lakewood, there are a variety of ways for patients to become involved in shaping the patient experience. There's an experience council that consists of 20 different people including Lakewood's CEO, a number of vice presidents including Wolhowe, directors, managers, frontline staff, a board member, and two patients who have used Lakewood's services. Strickland says the group's mission is to be proactive in looking at the patient experience from the first time patients call to access the health system to the moment they get their final bill.

The experience council discusses trends in patient complaints or concerns and develops action plans for areas across the system it would like to improve. For example, the group wanted patient experience scores to be easily available to all employees, Strickland says. To do this, it held a contest where the various business units created a themed dashboard where the scores could be posted. One of the assisted living facilities designed theirs as a bowl of popcorn in a nod to the movie nights they have with their residents. The higher the satisfaction scores, the more popcorn in the bowl. And if scores drop, so does the number of popcorn pieces, she says.

There is also a patient and family advisory council made up of 11 patients and one Lakewood staff member who takes minutes. These are patients who have used Lakewood's services, including primary care, acute care, and critical care. Members have come to the council in a variety of ways, including recommendations from their physicians, and, in one case, a recommendation from the financial services department, says Strickland.

In addition, there is an online patient advisory group of 88 patients, which Strickland hopes to grow to 100 patients by the end of the year, called VOICE—Valuable Opinions Innovating Customer Experience. Through this program, patients, family members, employees, and community members share their thoughts and opinions about Lakewood Health System through anonymous online surveys. This group will be giving feedback on changes that have been made to the organization's care coordination call tree, Strickland says.

There also are what Strickland describes as "flash mob" groups, which, much like a focus group, meet in person one time for one hour to discuss a specific topic or issue on which Lakewood is seeking feedback.

"It's just myself and one person taking minutes and asking really open-ended questions, making sure they know we're not really looking for a right or wrong answer and not leading them in any way," Strickland says about the flash mobs.

This approach was used when developing new resources for patients with memory care issues. Strickland placed an ad in the local paper inviting caregivers of patients with dementia, Alzheimer's, or other memory care issues to share their ideas during a flash mob session. Though the group was small—there were about nine people in the room, representing four patients—what they had to say was very powerful.

While they expressed a need for a support group for their loved ones, Strickland noticed that the caregivers developed a bond with each other during the hour-long session.

This feedback led Lakewood to not only launch a new support system for patients with dementia, Alzheimer's disease, and memory issues, but also to create a separate support group for the caregivers.

"We started a support group for people with memory issues but simultaneously acknowledged the need to develop a support group for caregivers as well," Strickland says. "In that hour they can have coffee. They can share. It is very unstructured, and it works great because it's one time they can let their guard down."

Embracing the processes
At Elmhurst Hospital, patient experience is a driving factor in how the organization functions. At the hospital, which received Planetree designation in 2012, processes are designed to support patient-centered care and deliver high-quality patient experience.

"It's really about patient-centered care, or the patient experience, and making sure all of your policies and processes, et cetera, are really from the patient perspective," says Pamela L. Dunley, RN, MS, MBA, CENP, chief nursing officer and chief operating officer at Elmhurst Hospital, about the Planetree philosophy. "You think about the patient when you're developing anything. It's about demystifying the healthcare experience for patients and involving the patient in their care and taking into account the patient's cultural values, the patient's choices, how they learn, making sure that they and their families are part of the experience."

Even before it received the Planetree designation, Elmhurst had been listening to patients.

In 2009, it created its approximately 15-member patient advisory committee and asked Raimondi, who is now the volunteer co-chair, to join the group.

"I was instantly all over it. I really felt like I could be that voice for myself, for my family, and for my community because I have so many different hospital stays in different facilities," she says. "I felt like I could survive those experiences to give a lot of feedback, both negative and positive, what works and what doesn't work."

This includes the feedback the group gave when the organization was developing a new hospital building that opened in 2011.

"Everything was thought of from the patient perspective, which is really what patient experience is about," says Dunley. "We have a patient family advisory council that is very, very active, and they helped us design everything, and continue to help us."

During the design of the new building, the advisory committee helped develop expectations for what an acceptable response time should be if a patient needed pain medications or assistance to the restroom, says Raimondi. But the group's pride and joy is the glass communication boards in each patient room. The boards in the previous hospital were not very aesthetically pleasing, so the organization considered getting rid of them completely.

"Everybody on the patient advisory committee said, 'No, we want to keep those. We want to know who our nurse is and how to reach them or what we have scheduled for the day.' It was a unanimous decision," Raimondi says.

When the new building opened, what was included in every patient room?

"They came up with these beautiful glass boards that are etched and have your nurse, your caretaker, any scheduled tests—it's all written on there," says Raimondi. "So they kept it based on our response."

Another important point that Dunley makes is that to provide an excellent patient experience, processes also need to support staff members. For nurses, this means following what Dunley calls the 90-5 rule.

"Ninety percent of what you need is within 5 seconds of you," she says. "If for whatever reason something wasn't stocked right or they didn't have the right mix at that moment, then it starts getting stressful. As long as the nurses have what they need to do their job, then they want to make sure the patient has the best experience."

The 90-5 rule was put to the test after a merger with Edward Hospital in 2013, which created the current Edward-Elmhurst Health system of three hospitals and more than 50 outpatient locations that reports total revenues of more than $1 billion annually.

"I started hearing from the nurses that we didn't have enough staff," says Dunley, who knew that staffing numbers had not changed. While trying to uncover what had caused this shift in the nurses' perceptions of their workload, she discovered there had been a change, of which Elmhurst executives were unaware, in the way the stock room was maintained.

"The nurses only know that it's harder to do their work, so they're just assuming it's staffing, but we tracked it down to they didn't have the supplies they needed when they needed it. Once we fixed that, which took a while to get to, it went right back to, 'We are fine again,' " Dunley says. "It's a matter of really making sure you understand everything that competes for the nurses' time so that they can focus on taking care of that patient the way the patient needs to be taken care of."

Solving the mystery
Another way to evaluate the patient experience is through the use of mystery shoppers. A mystery shopper is someone who poses as a patient or patient's family member to assess what type of patient experience an organization provides.

"One of the toughest things for an organization to do is to look at the absolute truth," says Dwight W. McBee, RN, BSN, MBA, director of customer experience at AtlantiCare, a member of Geisinger Health System, in Egg Harbor Township, New Jersey. "Mystery shopping, in my eyes, is looking at the absolute truth. It's a truly unique and innovative way to assess whether the tactics that you put into play are really working. So we're engaging with our mystery shoppers to get a completely neutral assessment of the work that we provide."

A mystery shopping evaluation can be done by phone or in person. McBee says mystery shoppers were used in late 2015 to assess patients' experiences with various access points throughout the organization.

"We wanted to make sure that when people were reaching out to AtlantiCare for service, we truly understood what they were experiencing," he says. "Everything from the way they were greeted on the phone to the way that the interaction flowed from the person who asked them for their insurance information."

To understand the patient experience from soup to nuts, McBee says the organization used mystery shoppers in three different ways—by phone, by posing as patients, and by shadowing actual patients.

"Those three different methods really helped us get a perspective that we would not have gotten any other way," he says. "Sometimes you can start this patient experience work and think that you've trained a group and they understand the concepts that you're training and they're all doing it consistently everywhere that you provide service. But with the randomness that comes with mystery shopping … it was really an authentic assessment of our organization and we learned quite a bit."

One thing that came to light was the need for some standardization in communication.

"Some of the things that we say and the ways that we respond to our patients, or essentially our future patients or future customers in various care locations, we need to get that right in order for them to effectively access care. So we needed to standardize the way we were holding those conversations," McBee says.

This ensures that all patients have the basic information they need to make informed decisions about their care.

"We really want to make sure that it's easy, seamless, and things work in concert when you've made that very difficult decision to choose a healthcare provider. We want to make the process easy for you once you've made that decision," he says.

Standardization may sound counterintuitive because providing an excellent patient experience is so personal and variable. To understand this, it helps to remember something taught to most healthcare professionals—Maslow's Hierarchy of Needs. In order for people to reach their highest potential, they must first have the basic needs of food, water, warmth, and rest met; similarly, to have an outstanding experience with a healthcare organization, the patient must first have basic needs—appointment times, insurance coverage, test locations—met.

Healthcare providers can then build off this solid base to customize a patient's experience and make it meaningful to him or her and create what McBee calls, "a starfish experience."

The concept is based loosely on the short story "The Star Thrower" by Loren Eiseley. In it, a man sees a young man on the beach throwing starfish into the ocean. When he asks why, the young man explains that if he does not throw the starfish back into the water, they will die. The man tells him that with miles of beach and starfish, the young man surely won't be able to make a difference. After hearing this, the young man picks up another starfish, throws it into the ocean and replies, "It made a difference for that one."

"It's the story of making a difference one person at a time," McBee says. "Everything that we do focuses on everything working together to build an exceptional patient experience. So when we say 'starfish experience,' we're really talking about making the human connection at every moment during a patient's journey."

Feeling like the focus is on you is what takes a patient's experience from good to great. This is why Raimondi says she would receive all her care at Elmhurst, rather than a big academic medical facility if she could.

"I feel like when I'm there at Elmhurst, they really focus on you," she says. "Everything that they're doing is putting you first. I see that it's getting back to where the patient is a priority, despite whatever might be going on outside that room. That nurse is focusing on me when she's there."