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Practicing Excellence
****
How to Give Great Care and
Feel Better at the End of
Your Day
Jay Kaplan, MD, FACEP
Practicing Clinician and Director,
Service/Operational Excellence, CEP America
Member, Board of Directors,
American College of Emergency Physicians
Medical Director, Studer Group
“The future viability of our organization will
be dependent on our ability to deliver
Service Excellence.”
Mayo Clinic
“And importantly . . . A Commitment to
Excellence will not manifest without the
leadership, support and example set by
physicians.”
Caveat #1:
What Brought Us to this Dance . . .
Ain’t Going to Get Us to the
Next One . . . .
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©Jay Kaplan, M.D. 2013
Caveat #2 –
The Best Definition of Madness is
To keep doing things
the same way
and expect different
results . . .
Caveat #3
How Most of Us Approach Change
CHANGE
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©Jay Kaplan, M.D. 2013
Caveat #4: To Get “Quality” Anything
People
Systems
Process Outcomes
Staff
Patients
Physicians
Which Means . . .
Efficient Care/Flow
Staff Engagement
Patient Engagement
Office ED Inpatient
Transitions of Care
Alignment of
Behaviors
Caveat #5: It’s About The Team
While we give care seemingly individually,
The Patient and Family Experience is
dependent upon the coordinated actions
of all members of the team . . .
From the moment they walk in, to the
moment they walk out or on . . .
Success is never achieved alone.
If it’s not always . . . It’s not great . . .
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©Jay Kaplan, M.D. 2013
Where We Are
How We Need to Feel . . . What We Need to Do
“ER”
The Burning Platform
Declining Reimbursement
Workforce Shortage
Malpractice Risk
Transparency of Data
Pay for Performance – VBP
Quality and Service are Inseparabl3
4
©Jay Kaplan, M.D. 2013
Why is this important?
#1 - Reimbursement
“Here you
go…
thought you
might like this”
Attracting Patients Through Service
#2 Workforce Shortage - Nurses
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©Jay Kaplan, M.D. 2013
Workforce Shortage - Physicians
Reason #3 - Malpractice
Relationship between patient satisfaction,
complaints and lawsuits
Each one point decrement in patient satisfaction scores
is associated with a –
6% increase in complaints (RR 1.06, 95% CI 1.03 –
1.08;p<.0001)
5% increase in risk management episodes (RR 1.05,
95% CcI 1.01 – 1.09;p< .008)
Lower performing physicians were at greater risks for
lawsuits (RR = 2.10;p 95% CI 1.13 – 3.90; p<.019)
75% of complaints were related to communication issues
Stelfox HT, et al, The American Journal of Medicine 2005;
118: 1126 – 1133
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©Jay Kaplan, M.D. 2013
The Transparent Environment –
Quality On-Line
Patient Experience Measurement: CAHPS
During your hospital stay, how
often did doctors /nurses:
treat you with courtesy and
respect?
listen carefully to you?
explain things in a way you
could understand?
Never/Sometimes/Usually/Always
Pay for Performance for Hospitals is Here . . .
Core Measures
(45% Weight)
1.25% Base operating DRG payments
HCAHPS Composites
(30% Weight)
50th percentile or improved over the previous reporting period to “win” the $ back!
Outcomes
Note: Implementation FY 2014
(25% Weight)
Source: OPPS VBP Final rule 11.1.11
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©Jay Kaplan, M.D. 2013
Pay for Performance for Physicians
Coming Soon . . .
Quality
PQRS = Physician Quality Reporting System
PV = Physician Value-Based Payment Modifier
Electronic RX and EHR incentives
Payment is tied to quality and cost metrics
Cost and quality metrics are transparent via Physician Compare
Patient Experience
CG CAHPS is the patient experience component for outpatient/office
practice
HCAHPS is the patient experience component for inpatient
practice
ED CAHPS will become the patient experience component for
the ED
Clinician & Group CAHPS
Composites
Access to care
Getting needed care
Getting care quickly
Provider Communication
Follow up on test results
Global rating of doctor
Clerks and Receptionists
Pediatrics includes Development & Prevention
Clinician & Group CAHPS
Provider communication
Doctor explained things in a way that was easy to
understand
Doctor listened carefully to patient/[respondent]
Doctor gave easy to understand instructions about taking
care of health problems or concerns
Doctor knew important information about patient’s/[child’s]
medical history
Doctor respected patient’s/[respondent’s] comments
Doctor spent enough time with patient/[child]
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©Jay Kaplan, M.D. 2013
The Survey
14. In the last 12 months, how often
did this provider explain things in a
way that was easy to understand?
19. In the last 12 months, how often
did this doctor show respect for
what you had to say?
1 Never
1 Never
2 Sometimes
2 Sometimes
3 Usually
3 Usually
4 Always
4 Always
15. In the last 12 months, how often
did this provider listen carefully to
you?
20. In the last 12 months, how often
did this doctor spend enough time
with you?
1 Never
1 Never
2 Sometimes
2 Sometimes
3 Usually
3 Usually
4 Always
4 Always
23. Using any number from 0 to 10,
where 0 is the worst provider
possible and 10 is the best provider
possible, what number would you
use to rate this provider?
0 Worst provider possible
1
The Global Rating
Question
2
3
4
5
6
7
8
9
10 Best provider possible
Physician Value-Based Payment Modifier
(VBPM)
Statutory Timeline for VBM Implementation
Reporting Period
Value‐Modified Payment Adjustment
Eligible Professionals Included
2013
2015 payments
Groups ≥ 100
2014
2016 payments
Groups 10‐99
2015
2017 payments
ALL ELIGIBLE PROFESSIONALS
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©Jay Kaplan, M.D. 2013
Physician Compare
Public Reporting of PQRS and CGCAHPS
beginning Calendar Year 2014
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©Jay Kaplan, M.D. 2013
The Old Paradigm
Care
= Income
The New Paradigm
Outcome = Income
Clinical Quality
&
Service Excellence
=
$$$
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©Jay Kaplan, M.D. 2013
Reason #5 –
Some Would Say . . .
Clinical Quality is the real
deal, the “hard stuff.”
Service Excellence is the
fluff stuff.
Higher Patient Satisfaction =
Communication = Compliance = Quality
Communication correlates STRONGLY with
adherence rates by patients in acute and
chronic disease. There are now over 100
observational and 20+ experimental studies
published demonstrating the correlation of
communication (patient satisfaction) with
compliance. Compliance with treatment
regiments has significant influence on quality
measures in chronic disease and outcomes.
Medical Care: August 2009 - Volume 47 Issue 8 - pp 826
British Medical Journal 2013
http://dx.doi.org/10.1136/bmjopen-2012-00157
Patient experience is positively associated with
clinical effectiveness and patient safety.
Associations appear consistent across a range of
disease areas, study designs, settings,
population groups and outcome measures
Positive associations
No association
Negative association
429 studies (77.8%)
127 studies (22%)
1 study (0.2%)
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©Jay Kaplan, M.D. 2013
Academic Medicine - March 2011
Does a physician’s empathy impact a diabetic
patient’s treatment?
Hemoglobin A1c test results to measure the
adequacy of blood glucose control according to
national standards  lower = better control
LDL cholesterol level  lower = better control
“Empathic engagement in patient care can contribute
to patient satisfaction, trust, and compliance which
lead to more desirable clinical outcomes.”
30% of respondents had poor adherence to their
cardio-metabolic medication regimens
After adjusting for potential confounders, the
prevalence of poor refill adherence increased by
0.9% (95% CI, 0.2%-1.7%) (P = .01) for each 10point decrease in CAHPS score.
Archives Internal Medicine 12/31/12
Simple Truth #1:
We Live in a Service Economy
Our entire staff is
committed to your
complete
satisfaction and
empowered to
deliver
personalized
service to take care
of your needs.
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©Jay Kaplan, M.D. 2013
Key Words for Us
Satisfy
to please, to be adequate to an end in view,
to meet an obligation
Astonish
to strike with sudden and usually great
wonder or surprise
Memorable
worth remembering
Simple Truth #2:
We All Believe We Give Great Service
We assume
=
Patient
Satisfaction
=
Employee
Satisfaction
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©Jay Kaplan, M.D. 2013
Simple Truth #3: We think we’re doing
better than we actually are . . .
Wall Street Journal April 8, 2013
Doctors need to work on their people skills . . .
It’s something patients have grumbled about for a long
time . . . Doctors don’t listen. Doctors have no time . . .
What is Excellent Physician Communication?
The physician listened (RR 1.8; 95% CI 1.0 – 2.5; p< .001)
The patient got as much medical information as they
wanted (RR 1.6;95% CI 1.1 – 1.9; p< .001)
The patient was told what to do if symptoms continued,
worsened or returned (RR 1.4; 95% CI 1.2 – 1.5; p<.001)
The patient spent as much time as they wanted with their
physician (RR 1.8; 95% CI 1.3-2.2;p<.001)
Keating NL, et al, Annals of Internal Medicine 2004; 164: 1016 – 1020
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©Jay Kaplan, M.D. 2013
Provider Communication . . . Really?
Physician Communication When Prescribing
(Arch of Internal Med, 2006)
Medications:
26% failed to mention the name of a new medication
13% failed to mention the purpose of the medication
65% failed to review adverse effects
66% failed to tell the patient duration of treatment
The Golden 2 Minutes
74% of patients are interrupted by providers when giving
their initial history in an average of 16.5 seconds
(J Gen Int Med, 2005)
Physician Communication . . . Really?
Physician Communication When Prescribing
Medications:
26% failed to mention the name of a new
medication
13% failed to mention the purpose of the
medication
65% failed to review adverse effects
66% failed to tell the patient duration of
treatment
Arch of Internal Med, 2006
Simple Truth #4:
No Rest For The . . .
“If the other guy’s getting better,
then you’d better be getting
better faster than that other
guy’s getting better . . . or
you’re getting worse.”
-- Tom Peters
The Circle of Innovation
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©Jay Kaplan, M.D. 2013
What Does All This Mean For Us?
There’s a lot of work to do.
We have to assure engagement before we
can expect alignment.
You can’t get Quality as a group if
everyone is not on board, which means . . .
We all need to recommit and understand
“No more reserved seats on the bus.”
With the measurement feedback you get
(ask for it!!), if you personally are not at the
mean or above, get going.
The Big Question
How can you, as medical practice, create a
consistent high quality compassionate experience
for your patients, despite your:
Varied backgrounds
Diversity
Different years of experience
Different and rotating personnel
Especially given the fact that any patient may see
3-5 different members of your medical staff during
one hospital stay or one office visit????
Some Upfront Learnings
Blame Nobody, Expect Nothing,
Do Something. (Bill Parcells, NY Post 1999)
Change starts at home – first me,
then thee. (Leadership)
It’s not the ideas, it’s the
implementation. (Accountability)
Perception is all there is. (Almost)
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©Jay Kaplan, M.D. 2013
A Plain Fact
Physicians are not trained for many of
the roles they are being asked to play in
today’s healthcare environment.
And even the role for which they were
trained . . . has changed.
The Different Roles We Have
Craftsman: caring for the individual patient.
Team player: being a part of the team which
delivers that care in a coordinated and supportive
manner.
Manager: managing the process by which that
care is delivered.
Leader: creating the vision – getting everyone on
board.
For which role(s) did you receive training?
Definitions
“A person who guides on a way especially by
going in advance, who directs on a course.”
Merriam Webster
“Leaders are visionaries with a poorly developed
sense of fear and no concepts of the odds against
them.”
Robert Jarvik, M.D.
“A leader is a dealer in hope”
Napoleon
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©Jay Kaplan, M.D. 2013
Where To Start:
Define a Common Destination
“If you don’t know where you are going, you might
wind up someplace else.”
What Do You Want to Be Known For?
1.
I am known for (1-2 items); by next year at this
time, I plan also to be known for (1 additional
item):
2.
We (My practice) is known for (1-2 items); by
next year at this time, we plan also to be known
for (1 additional item):
3.
The first step I (we) need to take in order to
make that happen is . . .
4.
The single biggest obstacle we have to
overcome is . . .
Have the Conversation:
What Do We Want To Be Known For?
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©Jay Kaplan, M.D. 2013
My Current Practice
Exceptional Care, Extraordinary Service
in a Safe & Efficient Environment
Please Note . . . A Great Patient Experience
It is not about our Intent . . . .
It is about our patients’
Perception . . .
And it is an outcome of
Great Teamwork.
People - For Our Patients
Think Bakery
Think Baseball – Touching All the Bases
Rounding on Patients
Discharge Follow Up Phone Calls
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©Jay Kaplan, M.D. 2013
Think Bakery
What Do Our Patients See?
Is There A Difference?
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©Jay Kaplan, M.D. 2013
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©Jay Kaplan, M.D. 2013
Take a Fresh Look – Change the Signs
A s your physician, I am committed to:
•Putting your needs first.
•Treating you and your family with
courtesy, respect, and compassion.
•Working collaboratively with you,
staff and colleagues.
•Basing your evaluation and
treatment on the best medical
evidence.
•Earning your trust through my
actions and service
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©Jay Kaplan, M.D. 2013
What Do Our Patients Feel?
Sit Down
To Sit or Not to Sit?
(Annals Emerg Med 2007))
Sitting: time
overestimated 15%
Standing: time
underestimated 7%
Key Point: No one will
sit if there is not a chair
to sit in.
What Do Our Patients Hear?
People (Patients)
will not hear all of
your words . . .
Use Key Words
or Phrases to
express your
caring.
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©Jay Kaplan, M.D. 2013
Use Key Words
“For your safety”
“For your privacy”
“For your comfort”
“To keep you informed”
“Does this all make sense to you?”
What questions do you have? “Is there
anything you would like for me to go over
again?”
Do Not Assume Our Patients Know . . .
Who we are;
How good we are;
How much we care
How long some process takes;
What the process will involve;
What will follow.
Communication Strategy: Think Baseball Touching All the Bases
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©Jay Kaplan, M.D. 2013
I
Introduce self with title, Service recovery
if needed, Inspire confidence
C
Connect - with the patient & family,
Contact – Verbal/Physical/Non-Medical
A
Acknowledge what the patient has said,
Articulate what you have found and what
you think is going on - Use Key Words
R
Review the plan of care, what tests and
treatments are to be accomplished, and
Remember to say how long it is going to
take  Under-Promise and Over-Deliver
E
Educate What to Expect/Home Care,
Ensure Understanding-Ask “What
questions do you have? Is there anything
else I can do for you?”, Express Gratitude
A
I
Acknowledge patient and family, use a
greeting, smile, make contact with all.
Introduce self with title, Manage Up,
service recovery if needed
D
Duration - Explain how long evaluation
E
Explain the plan of care, what tests and
treatments are to be accomplished, and
what you feel is going on, Use Key Words
T
Thank - Say Good-bye to the patient
and diagnostic work-up will take,
Under-Promise and Over-Deliver
Closure
Key Strategy #3: Collaborative Rounding
“Is there anything you want to tell me
about the patient?”
“Do you have any questions about
his/her illness?”
“Would you like to round with me?”
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©Jay Kaplan, M.D. 2013
Patient Perception  Quality
Key Strategy #4:
Follow Up Phone Calls - Quality
Type of Adverse Events
“Nearly 1 in 5
patients”*
Other
400 patients surveyed
76 (19%) had adverse
events after discharge
Fall
13%
4%
Nosocomial
Infection
5%
Procedure
Related
16%
62%
Adverse
Drug
Event
* 81 events occurred in 76 patients
* “Adverse Events After Discharge from Hospital”, Annals of Internal Medicine, February 2003
Follow Up Phone Calls
Engel K, Heisler M, Smith D, Robinson C, Forman J,
Ubel P, “Patient Comprehension of Emergency
Department Care and Instructions: Are Patients
Aware When They Do Not Understand?,” Annals of
Emergency Medicine. July 11, 2008
•78% did not have full understanding
•80% of that 78% did not understand that they did
not understand
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©Jay Kaplan, M.D. 2013
Post Visit Calls
Likelihood of Recommending – Inpatient
Percentile Rank
Likelihood of Recommending ‐ Inpatient
100
90
80
70
60
50
40
30
20
10
0
98
99
98
98
98
98
76
75
97
93
92
95
94
85
73
60
62
59
56
65
62
54
44
24
3Q
4Q
1Q
2Q
3Q
4Q
1Q
No Call
2Q
3Q
4Q
1Q
2Q
Call
Source: New Jersey Hospital, Total beds = 775; 3Q2007 – 2Q2010
Post Visit Calls
Likelihood of Recommending - ED
Likelihood of Recommending ‐ ED
Percentile Rank
100
90
80
70
60
50
40
30
20
10
0
95
88
93
87
1Q
76
96
95
77
70
63
62
51
47
47
44
38
32
27
97
88
83
77
76
62
99
93
38
25
2Q
3Q
4Q
1Q
2Q
3Q
No Call
4Q
1Q
2Q
3Q
4Q
1Q
2Q
Call
Source: New Jersey Hospital, Total beds = 775; 3Q2007 – 2Q2010
Summary – For Our Patients
Sit Down/ before you get up, use a
key phrase
Think Touching All the Bases –
ICARE/AIDET
Rounding on Patients
Follow up Phone Calls
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©Jay Kaplan, M.D. 2013
Self –Test for Physicians
Self –Test for Physicians
Our Most Difficult Task
Our:
Philosophy
Goals
Passion
Commitment
must be shared by
everyone . . .
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©Jay Kaplan, M.D. 2013
Learning How To Communicate
Colleague as Customer
“What can I do to help you have a great day in
working with me today?”
How to Implement
Pick a person, group of people or department: ____________
If I considered this person/group/department to be one of my most
important customers, I would do the following differently in
order to better serve them:
1. __________________________________________________
2. __________________________________________________
3. __________________________________________________
If this person/group/department considered me to be one of their
most important customers, I would ask them the following
differently in order to better serve me:
1. __________________________________________________
2. __________________________________________________
3. __________________________________________________
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©Jay Kaplan, M.D. 2013
What Can I Do For You?
The Work Environment
Compliment to Criticism Ratio
3 to 1
3
1
Positive!
2 to 1
2
1
Neutral
1 to 1
1
1
Negative
Source: Tom Connellan, “Inside the Magic Kingdom”, pages 91-95
Say Thank You More
The Simplest Recognition:
Saying “Thank you” at the
end of the day (shift)
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©Jay Kaplan, M.D. 2013
What Can We Do?
Everyone has to
get on board
If you permit it
you promote it
Summary
We live in an experience economy.
“Satisfy” is not enough.
If the other guy’s getting better . . .
Quality gets you in the game.
Service helps you win.
32
©Jay Kaplan, M.D. 2013
No one said it was
going to be easy . . .
Thank you.
Jay Kaplan MD, FACEP
[email protected]
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©Jay Kaplan, M.D. 2013