Case Study: Allina Health Giving the Patients a Voice through Patient Advisory Councils (PACs) Allina Health System, Minneapolis, MN

Transcription

1 In 2009, Allina Health embarked on a journey to foundationally change their patients experiences. Allina believes that an important part of making a difference for patients involves bringing forward patients voices in a multitude of formats. At the forefront of the improvement journey, were formed. These councils provide a vehicle and structure to obtain regular and focused feedback from patients. There are now 6+ in existence or development across various clinical service lines as well as an Allina-wide PAC which provide this input to the strategies and structures of improvements made. Whether it is quotes from the PACs or patient comments from the Avatar survey, there are several ways in which Allina utilizes the patient s input and brings their voice to bear: Starting meetings with patient comments positive and negative Incorporating patient comments into newsletters, bulletins, and other periodic communications Weaving patient comments into presentations and bringing them to life with representational stock photos and background stories since qualitative comments resonate more than the quantitative data from the surveys when speaking with physicians and caregivers Involving patients on the Patient Experience Steering teams and other steering bodies for the organization Allina Health A not-for-profit health care system serving the patients and families of 41 Minnesota and western Wisconsin communities 90+ multi-specialty medical clinics which provide primary care, specialty care and urgent care 11 hospitals from tertiary teaching facilities to critical access hospitals with more than 1,797 staffed beds and more than 105,057 Inpatient hospital admissions 15 pharmacies and other specialty medical services, including hospice care, oxygen and home medical equipment and emergency medical transportation. Nearly 24,000 employees, 5,000 associated and employed physicians, and 2,500 volunteers 3.9 million clinic visits and 1.2 million hospital outpatient admissions

2 Early on, Allina recognized the need for some focus on which composites to start with in improving their HCAHPS scores. Avatar performed an HCAHPS Diagnostic on their data to help identify key areas of focus for the organization. In addition to Pain Management and Environmental Cleanliness, Communication with Doctors was identified as an opportunity for Allina to create focused improvements. From Allina was consistently well below the 50 th percentile in this composite. initiative at Allina. Dr. Stephan oversees the majority of hospitalists that Allina employs. Since 50-80% of all patients admitted to Allina hospitals are seen by a hospitalist, the initial focus of these improvement efforts involved the hospitalists and later expanded to include all physician groups employed and independent. Assessment and Approach Within the realm of physician communication, Allina developed a specific focus on physician empathy and teach back. Recognizing that these are topics that physicians do not receive much training on in medical school, Dr. Stephan and the team developed tools and training based on physician input. Allina s approach and philosophy with physicians was this simple, The challenge is not having empathy but rather, demonstrating empathy in a way that patients can perceive. With this, they challenged physicians to: Setting up for Success provided the strategic direction for Allina s patient experience improvements. Led by Executive Sponsors and a Patient Experience Steering team, the work was supported by a Patient Experience team created at the corporate level to lead these efforts across the system. Each hospital has Patient Experience Site Leads who were designated (not dedicated) to shepherd these efforts at their site. Dr. Tierza Stephan serves as the executive sponsor for the Communication with Doctors Look for windows of opportunity to try different communication techniques with patients Try to use these with at least 1 patient each day Tap into the tools and resources that were created with physician input Exceed their patients expectations

3 Demonstrating Care & Communication A review of evidence-based best practices in physician communication was helpful but not as scientific as physicians were used to for clinical efficacy. Nevertheless, several sources led to the generation of a Top Ten list of key behaviors. Some groups of physicians wanted the Top Ten List; however, others wanted the Top 5 or less. Central to their philosophy, Allina took this back to the Patient Advisory Councils and asked them to identify the top 4 most important behaviors. The patients identified: 1. Sit down 2. Shake hands and introduce yourself to both patients and visitors 3. Draw out the patient s concerns with open-ended questions 4. Incorporate teach back to ensure that the patients truly understand Tools and Techniques In addition to the Top Ten list, there were several other tools that Allina created and made available to physicians. Some of these included: A monthly Communication with Doctors newsletter featuring topics like empathy and teach back as well as other tips for improving communication A variety of cards for physicians to use with their patients a photo business card or a What is a hospitalist? card with a picture, a description of the services provided, and a place for patients to jot notes A Physician and Patient Communication DVD with several modules based on these key topics of empathy, teach back, etc. These vignettes were short (3-5 minutes) and featured actors but were based on scenarios developed by physicians Monthly HOPE Awards certificates generated for physicians based on positive comments received on the patient experience surveys. There was a letter and recognition from the Vice President of Medical Affairs as well as the President of each hospital

4 Discussing Data with Docs With each group of physicians, the HCAHPS data discussions took a similar trajectory. Often the first time that physicians heard of Value Based Purchasing, HCAHPS, or actually saw the questions they were being judged upon, there was a lot of push back. They often had to discuss it for a while and air their frustrations over the public transparency of measures that they believed did not truly reflect their total performance and value as a physician. Physicians also claimed certain exemptions as they sought to learn and understand more about the national apples-to-apples comparisons now available for these non-clinical measures similar to the clinical core measures. Frequent questions included: Does this include my chronic pain patients? What about the drug seekers? Is this case-mix adjusted for the higher acuity of my patients? Once they were able to move beyond these concerns, they would then ask What do the patients say? This is where the power and the wealth of information from the PACs really came through. Literature, sparse as it was, was vetted and validated by patients. When patient comments were shared with the physicians, it helped to bring the issues to light. Fiercely and naturally independent and competitive, the physicians wanted to see their data! This was a bit of a challenge but proved to be an important component of culture change. HCAHPS data is not intended to be reported at the physician-level; the items read How often did doctors (plural) listen carefully etc. However, with the creation of an Enterprise Data Warehouse (EDW) and partnering with Avatar to provide data-feeds, Allina was able to build physician and group-level data. This was done by attributing the results based on attending physician data. No attribution model is perfect; but this was one that, over time, the physicians were willing to accept. There was a stepped process for sharing group and individual-level data with physicians which evolved over a series of group meetings. This involved first sharing hospital-level data, then hospitalist group-level data comparative to other hospitalist groups across the system, and then, at the next physician group meeting, blinded individual physician-level data with the physicians with the leads of each group receiving the unblinded data. Finally, after groups were comfortable with this, the unblinded data at the individual physicianlevel was shared with everyone in the group. The results of this effort were that each group realized 3-7% top box improvement in the Physician Communication composite in As a result of this pilot with the hospitalists, Allina s Clinical Leadership Team authorized the full transparency of physician-level data for all physicians across the system. This information was made available in Allina s Enterprise Data Warehouse. The specific reports were still pushed to the physicians and their groups.

5 Physician Shadowing A Powerful Tool In October of 2011, Dr. Atul Gawande wrote an article which was published in the New Yorker and it posed the question Why don t physicians have coaches? Top athletes and executives have identified the value of a personal coach but rarely do physicians receive any coaching after moving on from their residency program. This article coincided nicely with a new service offering from Allina s Patient Experience Team for physicians. Patient Experience team members were available to coach physicians on their communication. As non-clinicians, team member evaluators were viewing the encounter purely from the patient s eyes. A checklist of key communication behaviors was developed and the coaches used this in shadowing the physician through several patient encounters. Then, the coach and the physician would debrief the experience and discuss key physician communication strengths as well as areas of opportunity. The interaction and feedback was held in confidence between the coach and the physician. The approach was positive and affirming. The physicians volunteered to participate in this program and a variety of levels of performers participated. The observers were able to learn and identify best practices and then pass these on to other physicians. Physician feedback on the shadowing program included: Feedback -- which we almost never get as physicians. Hearing what we do well is helpful; hearing what we could do better is really helpful. The one-on-one learning/teaching experience is very helpful, especially the practical advice based on direct observation. The reviewer was very skilled, professional, and respectful. The feedback on teach back is very helpful also, the exercise of periodic self-examination. I evaluated myself for several days before the shadowing exercise to check whether I was implementing all of the best practices that I know I should be using. Additionally, when asked What will I add to my everyday practice? physicians indicated: More teach-back, more sitting down, and requesting questions from patients (e.g., What questions do you have for me? ) rather than asking if they have them (e.g., Do you have any questions? ) Yes, I will try to be clearer about specific points that need to be met before discharge. I had used teach back infrequently and now recognize I need to use the techniques more consistently.

6 The impact of the physician shadowing was striking. An analysis of the first cohort of physicians attributed data (1,369 surveys before shadowing and 1,783 surveys after shadowing) showed significant improvement in the Physician Communication composite and in the questions that make up the composite. Composite: 5.1% improvement Explained things in a way I could understand: 8.7% improvement Listened Carefully: 4.2% improvement Demonstrated Courtesy & Respect: 3.7% improvement Results To date, Allina has noted significant and sustained improvement in the Physician Communication composite. Beginning the impetus in 2010, Allina has increased 4% top box representing 30 percentiles of improvement. Lessons Learned Despite this success, much work continues to try to hardwire a few key elements which are affectionately referred to as the 4 Cs: Chairs a reminder to physicians to sit down when meeting with patients. Much work has gone into ensuring that a chair or a stool is available in each of the patient rooms for this purpose. Care Board this is such an important communication tool in the patient s room and Allina has encouraged physicians to ensure their name is listed and updated on this each day. Cards the distribution of either a photo business card or a What is a hospitalist? card have been identified as important and consistent communication tools. Connect this means connecting with the patient on a social and non-clinical level in order to establish a deeper relationship. It also includes connecting with the nurse for the patient every day either before, during, or after the patient encounter.