The Link Between Patient Experience and Patient and Family Engagement Powerful Partnerships: Improving Quality and Outcomes Mission to Care Florida Hospital Association Hospital Improvement Innovation Network Patient and Family Engagement Learning Collaborative s First Annual Patient and Family Engagement Summit Sari Siegel, Ph.D., CPHQ, Westat July 21, 2017 Definition of Patient Experience vs. Patient Satisfaction Patient experience is the sum of all interactions, shaped by an organization s culture, that influence patient perceptions across the continuum of care. - Beryl Institute Everything we say and do that affects our patients thoughts, feelings, and well-being. -Society of Hospital Medicine Patient satisfaction, on the other hand, is about whether a patient s expectations about a health encounter were met. Agency for Healthcare Research and Quality (AHRQ) 2 Florida Hospital Association 1
How can we improve patient experience? Cannot improve what we cannot measure: need data CMS asked AHRQ to develop HCAHPS to: Provide objective and meaningful comparisons of domains of hospital care that are important to patients Create incentives for hospitals to improve Enhance public accountability 3 HCAHPS: Standard 32 questions Topics include Communication with nurses and doctors Pain management Responsiveness Environment clean/quiet Discharge information Care transitions Overall rating Willingness to Recommend 4 Florida Hospital Association 2
Limitations of HCAHPS in improving patient experience Despite best efforts to standardize, patient perceptions vary HCAHPS data gives insight into where to prioritize improvement, but does not provide a strategy to improve patient experience HCAHPS does not offer data on individual providers 5 Value-based purchasing incentivizes patient experience FY 2017 CMS Hospital VBP topics and weights 6 Source: Centers for Medicare & Medicaid Services, Hospital Value-Based Purchasing webpage Florida Hospital Association 3
Patient engagement is key to positive patient experience even a score of high satisfaction on a validated survey does not necessarily imply high quality care has been provided. To be successful in improving health services to meet patients needs and preferences, providers must have comprehensive patient engagement strategies that include the patient and/or their family members as full partners in the enterprise. Canadian Foundation for Healthcare Improvement 7 Patient engagement is key to positive outcomes The emerging evidence is that patients who are actively involved in their health and health care achieve better health outcomes, and have lower health costs, than those who aren t. - Susan Dentzer, Health Affairs, in Rx for the Blockbuster Drug of Patient Engagement Cite: Dentzer S. "Rx For The Blockbuster Drug Of Patient Engagement"; Health Aff February 2013 vol. 32 no. 2 202 8 Florida Hospital Association 4
HCAHPS is but one component of patient engagement Collection of satisfaction and experience data is but one component of a broader patient engagement strategy. To overcome some of the limitations of [patient] surveys, providers may begin asking more open-ended questions or form patient/family advisory councils, participatory models that are reflective of genuine patient involvement. Patients can also be intimately involved in efforts to (re)design care. Canadian Foundation for Healthcare Improvement 9 Low patient satisfaction and experience is a national problem Source: D. Schulke & C. Brady, FHA AHRQ HCAHPS Learning Community, August 2013 10 Florida Hospital Association 5
HCAHPS data from neighboring states vs. U.S. 11 *Contains the average "top-box" scores for each of the eleven HCAHPS measures at the state and national level. Source: Hospital Compare April 2017 upload Critics and Counter-Arguments Critics suggest Patients are not clinical experts and HCAHPS may reflect frustration if the care does not match expectations J.J. Fenton, MD, MPH found association between higher satisfaction and 1) higher utilization, 2) higher mortality Patient experience is also influenced by experience at home, after discharge, so it is beyond the scope of hospital interventions 12 Sources: Using Information Therapy to Put Patients First by A. Malpani, MD; Fenton JJ et al., The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med 2012 March. Florida Hospital Association 6
Rebuttals about importance of PFE on patient experience PFAs counter The very argument that patients do not act in their best self-interest is paternalistic on its face and is indicative of the challenges in getting staff/physician buy-in on PFE. PFA Patients know when their environment is unclean or loud. PFA As average LOS decreases over time, transitions are rightfully a part of our care experience. - PFA 13 Citation: PCORI Transitional Care Patient Partner Meeting, Nov 2016 Examples from Partnership for Patients Evaluation: Patient safety and decreased readmissions linked with PFE Among Vizient s 146 HEN hospitals, those meeting 4+ PFE metrics had consistently lower rates of falls with injury (vs. those meeting 0-3 metrics) Minnesota s HEN: hospitals meeting 4+ PFE metrics had consistently lower rates of potentially preventable readmissions (vs. those meeting 0-3 metrics) 14 Florida Hospital Association 7
RARE: Reducing Avoidable Readmissions Effectively in Minnesota Results: 7,030 readmissions avoided (as of Q3 2013) Exceeded original goal of 6,000 readmissions Helped patients spend 24,844 more nights sleeping comfortably in their own beds Reduced inpatient costs by an estimated $55 million 2013 winner of the John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality 15 Source: Vizient, January 2016 HEN 1.0 Learning: Correlation of Adverse Event Areas & PFE Adverse Event Area PFE Total Score (r s ) Adverse Drug Events 0.03 Venous Thromboembolism 0.28* Pressure Ulcers 0.17* Injuries from Falls and Immobility 0.11* Catheter-Associated Urinary Tract Infections 0.12* Readmissions -0.03 Early Elective Deliveries 0.23* Other Obstetrical Adverse Events 0.17* Ventilator-Associated Pneumonia 0.20* Central Line-Associated Blood Stream Infections 0.0001 Surgical Site Infections -0.04 16 *p<= 0.05; ** Spearman Correlation Florida Hospital Association 8
PFE: simultaneously improving clinical outcomes and patient & staff experience CMS 5 Star Hospitals (i.e., has high HCAHPS scores) has fewer hospital-acquired infections Employee perception of teamwork among units is positively associated with patient experience and negatively associated with infection rates. Leveraging the untapped healthcare workforce (i.e., family and friends) has added benefit: helps prepare family for involvement in post-discharge care When patients perceive their hospital as clean, the actual rate of infection is lower. Source: Press Ganey 17 Beyond clinical outcomes, PFE improves patient experience 18 Graphic courtesy of Cancer Care Ontario Florida Hospital Association 9
How do we improve patient experience? Engage patients and families Engage staff to improve work environments We can only treat patients as well as we treat one another. - Barbara Balik, RN, Ed.D., IHI senior faculty member 19 Improving patient experience by improving staff experience Kutney-Lee, McHugh, et al. examined relationship between nursing and patient satisfaction across 430 hospitals. Nurse work environment significantly positively associated to all HCAHPS patient satisfaction metrics Mean % who would definitely recommend : 10% points higher in hospitals with better vs. worse nurse work environments (69.9% vs. 59.6%) 20 Source: Kutney-Lee A, McHugh MD, et al. Nursing: A Key to Patient Satisfaction. Health Affairs July/Aug 2009, vol 28, no 4. Florida Hospital Association 10
Interdependence of staff & patient experience 21 Source: D. Schulke & C. Brady, FHA AHRQ HCAHPS Learning Community, August 2013 Teamwork Drives HCAHPS Likelihood to Recommend (LTR) All Patients 74.8% Top Box LTR (Definitely Yes) 28.4% of patients 69.5% of patients Low: Staff worked together 41.7% Top Box LTR High: Staff worked together 88.9% Top Box LTR 10.4% of patients 17,8% of patients 27.5% of patients 40.3% of patients Low: RN Courtesy 22.4% Top Box LTR High: RN Courtesy 53.1% Top Box LTR Low: Disch Pref 80.2% Top Box LTR High: Disch Pref 95.0% Top Box LTR 9.2% of patients 0.8% of patients 14.3% of patients 2.8% of patients 10.6% of patients 15.5% of patients 6.9% of patients 31.6% of patients Low: Disch Pref 20.1% LTR High: Disch Pref 51.0% LTR Low: Disch Pref 49.2% LTR High: Disch Pref 74.3% LTR Low: Rm Clean 72.8% LTR High: Rm Clean 85.4% LTR Low: Rm Clean 88.5% LTR High: Rm Clean 96.5% LTR 22 2014 Press Gainey, Institute for Innovation Florida Hospital Association 11
Evidence-based PFE Strategies to Improve Patient Experience Establishing PFAC / patient & family advisor (PFA) program Patient rounding/shadowing Leveraging PFAs experience in Document and signage review HCAHPS data review Staff/clinician education https://youtu.be/fm7w36vpllu 23 HRET study: Having PFAC associated with increased HCAHPS scores 24 Florida Hospital Association 12
HRET s research 25 25 Associations Between PFE Practices & HCAHPS PFE Practice Percentage points of patients rating a hospital 9 or 10 Statistical Significance Committee Engagement Hospital-wide patient & family advisory council compared to no PFAC 1.5 pts. higher p<.05 Over 50% of PFAC is patient & family members compared to under 50% 1.7 pts. higher p<.05 PFAC meets at least quarterly compared to less often or never 1.8 pts. higher p<.05 Inclusion of patients & family members in other hospital committees above average compared to average or below 1.0 pts. higher p<.05 Excerpted from: Health Research & Educational Trust. (2015, April). Patient and family engagement and patient satisfaction: Results of a national survey. Chicago, IL: Health Research & Educational Trust. Retrieved from www.hpoe.org. 26 Florida Hospital Association 13
Associations Between PFE Practices & HCAHPS 27 PFE Practice Percentage points of patients rating a hospital 9 or 10 Excerpted from: Health Research & Educational Trust. (2015, April). Patient and family engagement and patient satisfaction: Results of a national survey. Chicago, IL: Health Research & Educational Trust. Retrieved from www.hpoe.org. Statistical Significance Patient Access to Information 24/7 access to online patient information portal compared to no 24/7 access 1.8 pts. higher p<.05 Full access to health records in hospital compared to partial or no access 2.0 pts. higher p=.053 High commitment to accommodating lower English literacy compared to moderate or low commitment 1.9 pts. higher p<.05 Patient & Family Inclusiveness 24/7 unrestricted access to patients by family & partner across all units compared to some or no units 3.0 pts higher p<.05 High levels of including patients & families in nurse shiftchange reports compared to moderate or no inclusion 1.3 pts. higher p<.05 AHRQ PFCC LC s HCAHPS Data Analysis: Methods 10 Florida hospitals submitted HCAHPS data Date range of data: Sept 2014 Dec 2015 Various HCAHPS vendors: Press-Ganey, Avatar, Health Stream, PRC, National Research Corp., Data not available for all measures (number of measures included in datasets ranged from 19-38) Half of datasets included only composite measures 28 Florida Hospital Association 14
AHRQ PFCC LC s HCAHPS Data Analysis: Methods Organized monthly data submitted by hospitals Nurse communications Doctor communications Willingness to recommend Used top box data with robust sample size Developed scatter plots with linear trend lines to illustrate trajectory over time 29 Data Analysis Limitations Confounding factors likely (i.e., other initiatives may be affecting HCAHPS scores) Survey administrative time periods varied Summary analysis groups together composite and individual measures PFACs launched at different points in time No control group 30 Florida Hospital Association 15
Communication with Nurses 4 hospitals saw improvement over time (baseline to follow-up) on top box measures of Communication with Nurses. Increased No trend Decreased 32 *Data unavailable for 2 hospitals. Communication with Doctors 5 hospitals saw improvement over time (baseline to follow-up) on top box measures of Communication with Doctors. Increased No trend Decreased 33 *Data unavailable for 2 hospitals. Florida Hospital Association 16
Willingness to recommend 6 hospitals saw improvement over time (baseline to follow-up) on % who would definitely recommend hospital to family & friends. Improved No Trend Decreased No decrease 34 *Data unavailable for 3 hospitals. Using LCs to Implement, Sustain PFE Gains that Impact Experience LCs can provide a rich collaborative environment that motivates organizational changes Use of AHRQ s Innovations Exchange to share solutions and experts helped create positive change Offered access to experienced innovators with real-world perspective is invaluable for implementation Provided proven PFCC strategies for LC members to adopt Shares resources (e.g., templates) to aid implementation Access to innovators, who offered ongoing guidance on implementation, sustainability 35 Florida Hospital Association 17
AHRQ PFCC LC outcomes that enhance patient experience 7 new patient/family advisor programs established (4 had existing patient family advisory councils that they expanded) 73 new patient and family advisors (PFAs) across the 11 LC member hospitals PFAs volunteered an estimated 3,700 hours to LC member hospitals between September 2015 and July 2016 8 established 24-hour welcoming policy 10 implemented evaluations of hospital processes or protocols 6 developed staff training on PFCC 7 implemented the use of a patient communication notepad 7 now include PFCC concepts in hospital policies 36 Value of LCs: AHRQ PFCC LC member satisfaction on selected outcomes Stronger, enhanced, & more meaningful PFACs 88% More knowledge of patient centeredness 90% More empathetic team members 90% Greater family involvement caring for loved ones 70% Decreased readmissions attributed to better communications 50% Increased knowledge 90% Higher patient satisfaction scores 60% Diffusing PFCC into the fabric of the culture 70% 37 37 0% 20% 40% 60% 80% 100% Percentage of respondents extremely or very satisfied Florida Hospital Association 18
Previous FHA Activities on Patient Engagement and Experience: Learning Communities FHA/AHRQ HCAHPS Learning Community Goal: To support hospital teams in effectively using HCAHPS as a tool for improving quality, safety, and the patient experience AHRQ Patient- and Family-Centered Learning Community Goal: To support hospitals seeking to advance the practice of patient- and family-centered care by implementing proven strategies Common link: better patient & family engagement Building on its momentum: FHA s PFE HIIN Learning Collaborative 38 In Summary HCAHPS is a critical aide, but by itself, it is just a measurement tool PFA review of data can provide powerful and actionable feedback to improve care quality and the patient experience Patient and family engagement is an evidence-based strategy to enhance the patient experience FHA s HIIN PFE LC will provide members with the opportunity to learn about PFE strategies that work, brainstorm challenges with faculty and other members, and receive technical assistance in implementing PFE activities Review the Freedcamp site for additional resources, or contact FHA s Allison Sandera (allisons@fha.org) 39 Florida Hospital Association 19
Questions? email: sarisiegel@westat.com 40 Florida Hospital Association 20