Practicing Excellence
***
How to Make More $ and Feel
B tt att th
Better
the End
E d off Your
Y
Day
D
Jayy Kaplan,
p , MD,, FACEP
Medical Director, Studer Group
Practicing Clinician and Director,
S i /O
Service/Operational
ti
lE
Excellence,
ll
CEP A
America
i
“The future
“Th
f t
viability
i bilit off our organization
i ti will
ill
be dependent on our ability to deliver
Service Excellence
Excellence.”
Mayo Clinic
“And importantly . . . A Commitment to
Excellence will not manifest without the
leadership support and example set by
leadership,
physicians.”
How We Need to Feel
Why is this important?
#1 - Reimbursement
“Here you
go…
thought
g yyou
might like this”
Attracting Patients Through Service
#2 Workforce Shortage - Nurses
Workforce Shortage - Physicians
Reason #3 - Malpractice
Relationship between patient satisfaction,
complaints and lawsuits
Physicians with lower patient satisfaction results are more
likely to have patient complaints (RR 1.79;95% CI 1.38-2.33; p<.001)
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 11.05,
05 95% CcI
1.01 – 1.09;p< .008)
Lower performing physicians were at greater risks for lawsuits
(RR = 2
2.10;p
10;p 95% CI 1
1.13
13 – 3.90;
3 90; p<
p<.019)
019)
75% of complaints were related to communication issues
Stelfox HT, et al, The American Journal of Medicine 2005; 118: 1126 – 1133
Reason #4: The Transparent Environment –
Quality
Q
y On-Line
Patient Satisfaction Measurement
On-Line: HCAHPS
During your hospital stay,
how often did
doctors/nurses:
treat you with courtesy and
respect?
p
listen carefully to you?
explain things in a way you
could understand?
Never/Sometimes/
U
Usually/
ll / Always
Pay for Performance Coming to Your
Neighborhood Soon . . .
Value-Based Purchasing (VBP)
= a specified
ifi d percentage off h
hospital
i l payment would
ld
be conditional on performance
– Reimbursement currently: 100% public reporting
– Reimbursement FY 2013: 1% based on
performance (70% clinical quality/30% patient
experience)
i
)
– Reimbursement FY 2017: 2% (at least)
Calculating Reimbursement
– Will need to either be at 50%ile or show
improvement from previous score to earn points for
that dimension
Clinician & Group CAHPS
Composites
Access to care
Getting needed care
Getting care quickly
Provider Communication
Follow up on test results
Gl b l rating
Global
ti off d
doctor
t
Clerks and Receptionists
P di t i includes
Pediatrics
i l d D
Development
l
t&P
Prevention
ti
The Survey
14. In the last 12 months, how often
did this doctor explain
p
things
g in a
way that was easy to understand?
In the last 12 months, how often did
this doctor show respect
p
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 doctor 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
3U
Usually
ll
3U
Usually
ll
4 Always
4 Always
The (Draft) Supplemental Survey
15. Wait time includes time spent in
the waiting room and exam room.
During your most recent visit, did
you see this doctor within 15
minutes of your appointment time?
1 Yes
2 No
18. During your most recent visit,
did this doctor explain things in a
way that was easy to understand?
1 Yes, definitely
2 Yes, somewhat
3 No
19. During your most recent visit,
did this doctor listen carefully to
you?
1 Yes, definitely
2 Yes, somewhat
3 No
21. During your most recent visit,
did this doctor give you easy to
understand instructions about
taking care of these health
problems or concerns?
1 Yes, definitely
2 Yes, somewhat
3 No
23. During your most recent visit,
did this doctor show respect for
what you had to say?
1 Yes, definitely
2 Yes, somewhat
3 No
24. During your most recent visit,
did this doctor spend enough time
with you?
1 Yes, definitely
2 Yes, somewhat
3 No
23. Using any number from 0 to 10,
where 0 is the worst doctor possible and
10 is the best doctor possible, what
number would you use to rate this
doctor?
0 Worst doctor possible
1
Th Global
The
Gl b l Rating
R ti
Question
2
3
4
5
6
7
8
9
10 Best doctor possible
The New Paradigm
O t
Outcome
= Income
I
Reason #5 –
Some Would Say
y...
Clinical Quality is the real deal, the “hard
hard stuff.”
stuff.
Service Excellence is the fluff stuff.
Operational efficiency - “a great work
environment” - should be created for us so we
can do our job well.
Higher Patient Satisfaction =
Communication = Compliance
= Quality
p
Q
y
Physician
y
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
C
with treatment regiments
has significant influence on quality measures in
chronic disease and outcomes.
Medical Care: August 2009 - Volume 47 - Issue 8
- pp 826
Simple Truth #1:
We Live in a Service Economy
y
Key Words for Us
Satisfy
Satisf
to please, to be adequate to an end in view,
to meet an obligation
Astonish
tto strike
t ik with
ith sudden
dd and
d usually
ll greatt
wonder or surprise
Memorable
worth remembering
Simple Truth #2:
We All Believe We Give Great Service
We assume
=
Patient
Satisfaction
=
Employee
Satisfaction
Simple Truth #3:
It Just Isn’t So . . .
How Is It Really, With Our Patients?
74% of patients are interrupted by
physicians
p
y
g
giving
g the initial history,
y
average time of interruption: 16.5
seconds
The Effect of Physician Solicitation Approaches on Ability
to Identify Patient Concerns. J Gen Intern Med. 2005
March;
a c ; 20(3):
0(3) 267–270
6
0
How Is It Really, With Our Patients?
In clinical encounters that lasted on
average 16.5
16 5 minutes,
i t
patients
ti t spentt an
average of 8 seconds asking questions of
their physicians
physicians. Although physicians
believed they spent on average 9 minutes
providing
p
g information to p
patients,, in fact,,
they spent less than 40 seconds.
Howard Waitzkin,
Waitzkin At The Front Lines of Medicine,
Medicine
Rowman & Littlefield, 2001
Simple Truth #4:
No Rest For The . . .
“If th
the other
th guy’s
’ getting
tti better,
b tt
then you’d better be getting
better faster than that other
guy’s
guy
s getting better . . . or
you’re getting worse.”
-- Tom
T
Peters
P t
The Circle of Innovation
It’s Getting Harder to be Great . . .
Press, Ganey Associates Hospital Pulse Report 2009
The Same Is True In the Office Setting . . .
“Physicians’ offices must continue to improve the patient
care experience if they are to remain competitive.”
Simple Truth #5:
The Best Definition of Madness is
To keep doing things
the same way
and expect different
results . . .
The Different Roles We Have
Craftsman: caring for the individual patient
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
g the vision – g
getting
g everyone
y
on
board.
For which role(s) did you receive training?
The Role of Manager
“Where’s There’s No Gardener,, There’s No Garden”
No one is going to
create a great
place for us to
work or for our
patients to
receive care
unless we
participate . . .
Help Your Hospital Help Your Practice
1 What are the 3 things which
1.
hich you
o most lo
love
e
about practicing medicine in this
environment?
2. What are the 3 things which you most
dislike about your current practice?
3. What suggestions/solutions do you have
for those issues mentioned in #2?
Here’s What’s In It for You . . .
Focus/Fix/Follow Up
Focus/Fix/Follow-Up
The Role of Craftsman/Healer:
Think Bakery
What Do Our Patients See?
What Do Our Patients Feel?
Sit Down
To Sit or Not to Sit?
(Annals Emerg Med 2007))
Sitting:
g time
overestimated 15%
Standing: time
underestimated 7%
Providers
overestimated
ti t d titime 6%
What Do Our Patients Hear?
People (Patients)
will not hear all of
your words . . .
Use Key Words
or Phrases
Ph
to
t
express your
caring.
Use Key Words
“We’re
We re going to do our best to keep you
comfortable and informed.”
“We’ve
We ve got more pain medicine than you
have pain.”
“You
You will be involved in the decisions made
about your treatment.”
“Do
Do you have any questions? Is there
anything I can do for you right now ?”
“Does
Does this all make sense to you?”
you?
Do Not Assume Our Patients Know . . .
Who we are;
How g
good we are;;
How much we care
How long some process takes;
What the process will involve;
What will follow.
Five Fundamentals of Communication
Think Baseball - Touching
g All the Bases
A
Acknowledge
I
Introduce
D
Duration
E
Explanation
T
Th k You
Thank
Y
A
Acknowledge patient and family, use a
greeting, adjust covers, smile, eye contact
Contact
Contact
I
Introduce self with title, Manage Up,
service
i recovery if needed
d d
(Thank/Apologize and Commit)
D
Explain how long evaluation and diagnostic
work--up will take, use key words for
work
keeping patient informed,
Under--Promise and Over
Under
Over--Deliver
E
Explain the plan of care, what tests and
treatments are to be accomplished,
accomplished and
what you feel is going on,
Use Key
y Words
T
Say GoodGood-bye to the patient
Closure
What is Managing Up?
Your Self
Your Team
Your Hospital
The Construct of the Physician/Patient Visit
The Beginning (A/I)- The first
impression
The Middle (D/E)- Gathering and
explaining information, and the creation
of a collaborative plan
The End (T)- Review of information and
ending
di strong
t
Incorporating the computer
The Exam Room-The Beginning
Know what you are doing prior to entering the exam room
Knock, pause 2 seconds prior to entry
ACKNOWLEDGE
smile
il and
d establish
t bli h eye contact
t t
Use the patient’s name
If you shake hand do it after hand hygene “for
for your safety
safety” or
comment that you have just washed your hands
INTRODUCE
IIntroduce
t d
self-role
lf l iin care and
d experience
i
Sit at eye level, facing the patient
Non-medical query
q y
The Exam Room-The Middle
DURATION (Do your
o r thing)
Let the patient agenda/concerns drive the visit
Let the patient speak without interruption
(2 minute rule)
Paraphrase the patient history
Eye contact maintained for 80 percent of
encounter
Exam Room-The Middle
Convey
Con
e physical
ph sical e
exam
am findings
while doing the exam
EmpathyE
th “I am sure thi
this mustt be
b
tough for you”
The Exam Room-The End
EXPLANATION - A clear summary of the treatment
plan, including medications (name, purpose,
duration, side effects)
Clarity on what will happen next (Appointments,
Testing information)
THANK YOU - Finish With:
“I am glad you came in today, I know we can
h l ”
help.”
“You are doing very well, keep up the good
work…”
k ”
Follow Up Phone Calls - Quality
Type of Adverse Events
“Nearly 1 in 5
patients”*
p
Other
400 patients surveyed
76 (19%) had
h d adverse
d
events after discharge
Fall
Nosocomial
Infection
Procedure
Related
13%
4%
5%
16%
62%
Adverse
Drug
Event
* 81 events
t occurredd in
i 76 patients
ti t
* “Adverse Events After Discharge from Hospital”, Annals of Internal Medicine, February 2003
Outcome: Post Visit Calls
Inpatient
“Likelihood of Recommending”
g
98
100
98
99
98
98
99
98
90
Perrcentile R
Rank
80
75
76
70
60
60
59
56
62
64
No
Call
No
Call
50
40
30
20
10
0
No
Call
Call
3Q06
No
Call
Call
4Q06
Source: New Jersey Hospital, Inpatient
admissions=75,065, Total beds = 775
No
Call
Call
1Q07
No
Call
Call
2Q07
No Call
Call
No
Call
Call
3Q07
Call
4Q07
Call
1Q08
Outcome: Post Visit Calls
“Likelihood of
Recommending”
g
100
90
P
Percentile
e Rank
93
62
60
47
38
32
27
70
63
47
50
76
77
70
30
93
76
80
40
95
87
88
29
25
20
10
0
No
Call Call
No
CallCall
No
Call Call
No
Call Call
No
Call Call
No
Call Call
1Q 06
2Q06
3Q06
4Q06
1Q07
2Q07
Source: New Jersey Hospital, ED Visits: 85,034, Inpatient
admissions=75,065, Total beds = 775
No
Call
Call
3Q07
No
Call Call
No
Call Call
4Q07
1Q08
No Call
Call
Summary – For Our Patients
Sit Down/ before you get up, use a key phrase
(e.g., “Do you have any questions? Is there
anything else I can do for you? or “Does this all
make sense to you?”
you?
Think AIDET – Touching all the bases –
Acknowledge
g ((nonmedical q
query)/Introduce
y)
((Build
confidence)/Do your thing/Explain what and how
long (Underpromise & Overdeliver)/Thank
(Closure)
Follow up Phone Calls – start with 2 per shift or
per day
Physician as Team Player
Our Most Difficult Task:
Philosophy
Goals
Passion
Commitment
C
it
t
must be shared by
everyone . . .
Create the Team
Think Football
• If on a football
team what
team,
position do you
play?
• Do q
quarterbacks
win games?
Colleague as Customer
“What
What can I do to help you have a great day in
working with me today?”
Say Thank You More
The Simplest
p
Recognition:
g
Saying “Thank you” at the
end of the day (shift)
Everyone
on Board
Standards
– Either
you have
them or
you don’t
***
No Double
Standards
What Can We Do?
Everyone
E
er one has to
get on board
Iff you permit it
you promote it
Summary
We live in an experience economy.
“Satisfy”
Satisfy is not enough
enough.
If the other guy’s
guy s getting better . . .
Quality
yg
gets yyou in the g
game.
Service helps you win.
Thank you.
Jay Kaplan MD,
MD FACEP
[email protected]