Measuring the Patient Experience in a Medical Home QI/PCMH Roundtable March 14, 2013, Seattle, WA.

Measuring the Patient Experience in a Medical Home

QI/PCMH Roundtable

March 14, 2013, Seattle, WA

Radical Patient Centeredness

• (1) “The needs of the patient come first.”– Mayo Clinic

• (2) “Nothing about me without me.”– IHI

• (3) “Every patient is the only patient.”– Harvard Community Health Plan Hospital

Why Focus on Patient-Centered Interactions?

• Without a deliberate focus on integrating the patient’s perspective and the patient and families desires/goals, practice changes may create efficiency, but miss entirely the changes that would have come from patients’ experience of care.

• Without involving patients and family members in quality improvement, we are only guessing at what they want and need.

The “big ASK”: routinely asking patients about their experience of care to guide teams in the improvement and redesign aspects of achieving patient-centered medical home-ness

Methods to capture our patients’ experiences

• Regularly host focus groups• Have patient representatives on the improvement team• Ask patients about their experience at the point of service• Routinely conduct patient surveys and review the results

immediately

Radical Patient Centeredness

A never-ending inquiry to those we serve:

• “What do you want and need?”

• “What is your way?”

• “How am I doing at meeting your needs?”

• “How could I do that better?”

• “How can I help you?”

Patient-centered care as a quality dimension.

• Ask the following question at the end of most interactions:

“Is there anything at all that could have gone better today from your point of view in the care you experienced?”

And then, listen and learn.

• For quantitative ratings, ask patients to rate on a 1–5 scale disagreement to agreement with the assertion:

“They gave me all the care I needed and wanted, exactly when and how I needed and wanted it.” Seek 5s and study the low raters.

L. Gordon Moore, MD

Data for Improvement, Accountability, Research

Aspect Improvement Accountability Research

Aim Improvement of care

Comparison, choice, reassurance

New knowledge

Test Observability

Test observations Evaluate current performance; no test

Test blinded

Bias & Sample Size

Consistent bias – just enough data

Measure and adjust to reduce bias – 100% of data

Design to eliminate bias – just in case data

Flexibility of hypothesis

Improvement of care

No hypothesis Fixed hypothesis

Testing strategy Sequential tests No tests 1 test

Is change an improvement?

Run or control charts

No change focus Hypothesis tests (F-test, T-test, Chi-squared, P-value)

Confidentiality of data

Only used by those involved in improvement

Available for public consumption

Identities protectedTammy Fisher, MPH

Director, Quality & Performance Improvement

San Francisco Health Plan

Collecting Patient Experience DataPurpose Data Collection

Tools/strategies

Improvement Point of service surveys

Telephonic surveys

Comment cards

Patient exit surveys

Focus groups

Patient (and family) Walkabouts

Kiosks, via web

Accountability/Research Mailed surveys

Telephonic surveys

Common Reasons for Using an Existing Instrument

• So normative comparisons can be made (benchmarking)

• To replicate or maintain continuity with previous studies

• Existing measure is state-of-the-art

• The time and expense of developing new measure is prohibitive

Examples of Existing Patient Experience Surveys

• CAHPS (consumer assessments of health plans survey)– http://www.cahps.ahrq.gov

• PCAT (primary care assessment tool)– http://www.jhsph.edu/pcpc/pca_tools.html– Cassady CE et al., Pediatrics (J Ambul Pediatr Assoc) 2000;105:998-

1003.• ACES (ambulatory care experience survey)

– http://160.109.101.132/icrhps/resprog/thi/aces.asp– Safran DG et al., Medical Care. 1998. 36 (5):728-739.

• IPC (interpersonal processes of care): – Stewart et al., Health Serv Res. 2007 June; 42(3 Pt 1): 1235–1256.

• PACIC (patient assessment of chronic illness care):– http://www.improvingchroniccare.org/index.php?p=PACIC_Survey&s=36– Glasgow RE, et al., Med Care  2005; 43(5):436-44

Approaches to measuring patient experience with care

• Patient surveysPatient surveys– Proprietary toolsProprietary tools– Public domain instruments (CAHPS)Public domain instruments (CAHPS)

• Focus groups and interviewsFocus groups and interviews

• WalkthroughsWalkthroughs

• ““Mystery shopping”: participant Mystery shopping”: participant observation by trained informantsobservation by trained informants

• Web-based user-generated reviewsWeb-based user-generated reviews

Sampling Issues• Patient populationPatient population

– General population General population – Specific subgroups (e.g., chronic illness)Specific subgroups (e.g., chronic illness)

• TimeframeTimeframe– Visit-basedVisit-based– Over the prior 6 or 12 monthsOver the prior 6 or 12 months

• FrequencyFrequency– Annual monitoringAnnual monitoring– Continuous sampling for improvementContinuous sampling for improvement

• Sample sizeSample size– Internal use for improvementInternal use for improvement– External use for public reporting, P4PExternal use for public reporting, P4P

Traditional Data Collection Modes

• Mail administrationMail administration– 3 waves of mailing (initial mail, postcard 3 waves of mailing (initial mail, postcard

reminder, second mail)reminder, second mail)

• Telephone administrationTelephone administration– At least 6 attempts across different days of At least 6 attempts across different days of

the week and times of daythe week and times of day

• Mixed mail and telephone administrationMixed mail and telephone administration– Boost mail survey response by adding Boost mail survey response by adding

telephone administrationtelephone administration

Alternative Modes• Internet/WebInternet/Web

– Email distributionEmail distribution– Web response optionWeb response option

• Interactive Voice Response (IVR)Interactive Voice Response (IVR)– Touchtone IVRTouchtone IVR– Active Voice IVRActive Voice IVR

• In-office distributionIn-office distribution– Paper surveyPaper survey

• Mail returnMail return• Internet returnsInternet returns• Drop box on siteDrop box on site

– Kiosk or other electronic modesKiosk or other electronic modes

Comparison of Mail, Web, and IVR ModesMailMail WebWeb Web + Web +

MailMailIVRIVR IVR + IVR +

MailMail

Response RatesResponse Rates 50.8%50.8% 18.4%18.4% 48.6%48.6% 34.7%34.7% 53.7%53.7%

Respondent Respondent Characteristics*Characteristics*

YoungerYounger

More edMore ed

HealthierHealthier

Less edLess ed

Less Less ethnicethnic

More useMore use

Survey Scores*Survey Scores*

(adjusted and (adjusted and unadjusted)unadjusted)

SameSame SameSame LowerLower LowerLower

Total CostsTotal Costs

(per completed (per completed response)response)

$5.19$5.19 $13.94$13.94 $8.01$8.01 $9.04$9.04 $8.06$8.06

Rodriguez, et al. Evaluating Patients’ Experiences with Individual Physicians. Medical Care. Vol. 44, No. 2, February 2006.

Cultural Competence Missing from CAHPS

• Communication: – Use of complementary and alternative medicine – Respect for Patient Preferences/Shared Decision-

making: Empathy and emotional support– Linguistic Competency: Access to language services;

Health literacy aspects – Experiences Leading to Trust/Distrust: Level of trust,

caring, truth-telling– Experiences of Discrimination: Due to race/ethnicity,

insurance, language, etc.

Point of Service – Good for measuring the effect of changes

tested– Focus on meaningful measures – Document collection methodology; train staff

collecting information– Collect “just enough” data – Have at least 15 completed surveys – Easy to develop reports – Data collection is burdensome!

Sample Comment Card

Comment Card

We would like to know what you think about your visit with Doctor X. □ Yes, Definitely □ Yes, Somewhat, □ No

Did Dr. X listen carefully to you?

Did Dr. X explain things in a way that was easy to understand?

Is there anything you would like to comment on further?

Thank you.

We are committed to improving the care and services we provide our patients.

Telephonic Surveys

Good for measuring the effect of changes • More rapid feedback than mailed surveys• Typically less expensive• Outside vendors do it and provide reports • Easy to manipulate data for reporting • Less frequent – monthly data at best

Patient Exit Interviews

• Rapid feedback on changes tested• Not burdensome to collect data• Uncover new issues which may go unreported in

surveys• Requires translation of information into

actionable behaviors • Providers “see” the feedback • Include 3-5 questions, mix of specific measures

and open ended questions• Receptionist or non-clinic member obtains

feedback (HP or IPA staff)

What is patient-centered care?““Health care that establishes a Health care that establishes a

partnership among practitioners, partnership among practitioners, patients, and their familiespatients, and their families…to ensure …to ensure that decisions that decisions respect patients’ wants, respect patients’ wants,

needs, and preferencesneeds, and preferences and that and that patients have the patients have the education and education and

supportsupport they need to they need to make decisions make decisions and participateand participate in their own care.”in their own care.”

Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academy Press: 2001.

Self-management Support Stepsto Build Skills and Confidence

Adequate for majority of population

Basic Skills

Goal SettingAction PlanningProblem Solving

Advanced Skills & Techniques

Motivational Interviewing

Uncomplicated Depression

Group Interactions

Training others in Basics

Expert Skills & Techniques

Ex: Cognitive Behavioral Therapy

Dialectical Behavioral Therapy

Addresses special situations

Necessary for special populations (Addictions, MH)

Source: Connie Davis. RNP

The CareSouth Carolina Elements of SMS in the Stepped Model

• Care Teams with roles and responsibilities for SMS throughout the team

• Care Managers for higher levels of need

• Standardization of group and individual learning needs

• Patient focus groups for re-design

Reliability Data for SMG Set

0102030405060708090

100

Jan

Feb

Mar

ch AprM

ayJu

ne

% SMG Set

THE PATIENT PARTNER PROJECTBetsy Stapleton, FNP & Jessica

Osborne-Stafsnes

“The process of becoming an intelligent partner in the health process can be hard for people.”

-- Toni M.

• Humboldt County AF4Q Alliance; Part of RWJF’s “Aligning Forces for Quality”

• Humboldt Focus: to generate meaningful opportunities for patient engagement in healthcare improvement, delivery, and design.

About Aligning Forces Humboldt

www.aligningforceshumboldt.org

Patient Engagement in Humboldt County, Ca

HDNIPA participates in the IHI

“Quality Allies” Project

2005-2006

2007AF4Q initiative begins,

citing patient engagement

as a key driver of quality improvement

Implementation of the Chronic

Disease Self-Management Program (CDSMP)

2008

2009HDNIPA adopts collaborative

model to improve

primary care called:

Primary Care Renewal (PCR);

10 PCP practices participate

CDSMP leaders act as faculty at PCR

meeting to discuss the patient

perspective of living with a

chronic health condition

2009

2011PCR 2.0 launches with an emphasis

on PCMH.Recruitment of a “patient partner” team member is a

requirement of participation.

Significant infrastructure is built to support

this effort.

PCR 3.0 kicks-off.Practices must

recruit two patient partners to participate.

Patients participate in

collaborative and office

improvement meetings.

2012

Patient Core Function Levels

Recommended Patient Role

Key Patient Characteristics

Necessary Support Practice Readiness

1. Help individual patients better manage their own health

Partner in care • Willing to develop self-awareness about personal role in managing health•Receptivity to initiate better health care behaviors• The ability to communicate with care team

Offer peer-support resources, such as referrals to community-based chronic disease self-management programs (often available both in-person or online), group visits, etc.

Starting to engage in viewing patients as partners in chronic condition management. Beginning practice redesign efforts. Willingness to explore new models of care. Leadership support

2. Becoming a leader beyond personal health. Support others in better managing their own health.

Partner in care •Desire to become peer leader and provide support to others.•Able to work cooperatively and effectively with others

Access to training for peer leader roles.

Starting to implement internal self-management support. Practice open and receptive to chronic disease peer leaders. Leadership support

3. Assist individuals to weigh in on patient experience (resulting in weighing in on quality improvement efforts, office workflows, and patient experience).

Advisor • Communication skills• Can collaborate with diverse individuals • Desire to increase knowledge • Can contribute and provide collective pt. perspective comfortably• Focused on improving care related to the team goals

Offer information and training on key focus areas. Ask specific questions. Create a culture that values patient insight. Significant investment in resources.

Link into external support that will aid your practice in working with patients in a quality improvement setting. Leadership support.

4. Foster and support champion patients as equal core members of committees that drive redesign efforts at the highest levels

Advisor and Champion •Skills listed above and:•Can articulate pt. insight and bring pt. feedback to the forefront • Functions in a fast-paced and technical setting• Problem-solves in inclusive ways

Create roles for a patient/patient advocate on committees. Solicit patient feedback. Offer educational and training opportunities. Significant investment in resources.

Link into external support that will aid your practice in working with patients in a quality improvement setting.Leadership support.

(Stapleton & Osborne-Stafsnes, 2011)

CDSMPShared Decision- Making

AFH Patient Engagement Model

Patient Partners

Focus GroupsSurveying

Surgical RateProjectLeadership Team

CDSMP Leader Training

Community Health- Campaign

Osborne-Stafsnes & Stapleton, 2013

The Patient Partner Project

“Practices often struggle with the 'fires' of the day , making it difficult to focus on larger constructs such as patient-centered care. The participation of Patient Partners on practice improvement teams keeps the importance of improving patient care at the forefront of discussion.”– Rosemary DenOuden, Chief Operating Officer, HDNIPA

Primary Care Renewal

QI collaborative •10 Practices/20 Patient Partners •Collaborative meetings every two months•Practice meetings 2X/month•Each team is assigned a practice coach

•Patient Partners receive

training and support

• Ambassadors and

advocates Share insights and feedback

explicitly

focused on collaborative topics

Conceptual Framework

Stapleton & Osborne-Stafsnes for AFH, 2013

Collaborative Coaching Model

Stapleton & Osborne-Stafsnes for AFH, 2013

Practice CoachesPatient Partner Project Managers

Practice TeamPatient Partners

Effective QI Team

Collaborative Meetings

Techniques

• Standing agenda item

that starts meeting and

sets tone

• Prep patient for

presentation

• Vary presentation mode

to keep interest

• Evaluate

Patient Partner Meetings

• Introduce meeting topics and curriculum• Practice updates, brainstorming, and problem-solving• Sharing of “best-practices”• Capture patient recommendations and perspective on meeting subjects.

Team Meetings• Patients attend one “practice improvement” meeting at their office each month.

• Some offices have standing agenda items specifically for their patient partners.

• Patients offer insight and work on projects specific to the practice.Sample Projects:

•Practice brochure

• Patient-friendly

language

• Practice ombudsman

• Testing patient portals

• Process development

Challenges“As a consumer

we are often treated like we

don't know anything or the

staff

doesn’t want us involved.

They feel that staff can

represent the consumer

instead of us consumers.”

Osborne-Stafsnes & Stapleton, 2013

Addressing Challenges

Whose Home Is It?

Providing Medical Care Patient Experience

Practice

HomeDoing BusinessQI

Practice Redesign

Medical

Home

(Stapleton, 2012)

•Patient’s Home•Patient-centered

• Staff uses comprehensible

language•Ultimately, patient is in

control

• Provider/Staff home

• Office-centered• Patient

Partners learned “Medicalese”•Ultimately,

Provider/Staff are in control

Recognizing Success

“They keep our focus centered where it should be: on the patients.”

-- Participating Clinician

Recognizing Success

• Focus Groups

• Surgical Rate Project

• Empanelment

• Process Development

• Backlog reduction

“They keep our focus centered where it should be: on the patients.”

-- Participating Clinician

Foundational Engagement Elements

1. Didactic orientation and

training

2. Clear role expectations and

focus

3. Structured solicitation of

input

4. Transparent and continuing

feedback loop

An Observation: Success occurs more often when patient activation level, staff activation level, and complexity of the project align.

Tools in PCI Implementation Guidehttp://www.safetynetmedicalhome.org/practice-

transformation/implementation-guides

Thank you!