Patient Experience and Why its Important Tanveer Gaibi

Patient Experience and Why its Important Tanveer Gaibi MD FACEP Em. Care North Division Regional Medical Director

Page 2 ED CAHPS / ED PECS/ HCAPS atient ED Patient xperience of Experience Care Survey

Purpose of ED-CAHPS Survey • Better understand the ED experience from the patient’s perspective • Allow for objective comparisons of care patients receive • Improve the quality of ED visits across the country. Update: March 2015

Page 4 VBP Highlights

Value Based Purchasing 5

Page 6 2015 VBP 1. 5% HAC 1. 0% Total of 5. 5% of Inpatient Medicare reimbursement at Risk Readm 3. 0%

VBP Bonus/ Penalty • • • 2014 1, 25% at Risk: Base operating DRG payments 45% of hospitals (1231) received Bonus payment 53% of hospitals (1451) received Penalty 1. 6% (46 hospitals) neither bonus/ penalty Total Hospitals Impacted (2728) Average Bonus: 0. 24% Average Penalty: 0. 26% The hospital with the largest VBP bonus received a 0. 83% Medicare pay hike; hospital with largest penalty received a 0. 9% reduction. 2015 1. 50 % Base operating DRG payments

Page 8 Background

Background • Value Based Purchasing (VBP) program established by Affordable Care Act (ACA) to tie payment to quality rather than volume of services. • 2013: VBP Based on 12 clinical process of care measures + 8 patient survey measures (HCAHPS survey)

Assumptions • Anticipate ED Survey will be similar to Inpatient Survey, given need for consistency for VBP scales. • Survey developed in accordance with other CAHPS Survey Design Principles • Will definitely be tied to Value Based Purchasing for Medicare/Medicaid Reimbursement in near future

Current State • 3 Versions of the Survey in development • Field Testing completed 2014 • 12 hospitals participated in field test (300 surveys each), 18, 000 patients • CMS conducting testing of Survey instrument and implementation protocol. • Pilot testing: Draft instruments not ready for use. • Survey to be submitted to AHRQ for recognition as a CAHPS survey • No schedule for implementation yet announced Source: www. cms. gov/ Research-Statistics-Data-and- systems Update: March 2015

Development Process • Beta Testing - Completed • Field Testing - Completed • Federal Register proposal • Comment period, then Waiting period • Final Rule published • Expect gap between publication of Final Rule notice and official mandate

Reporting Timeframe • Could be voluntary reporting initially, then mandatory, but no official word. • Could be mandatory right away ( like Home Health CAHPS; Survey released Oct. 2010, had until July/ Sept 2011 to collect data • Fiscal year 2015 likely for mandatory rollout, must publish in Federal Register if mandatory for participation or linked to reimbursement for Medicare

THE SURVEY

Disclaimer • Please note that this information pertaining to the actual ED CAHPS survey is based on unverified reports found through media/literature sources. The questions listed herein are those that are anticipated to be included based on references cited in this presentation. • The “ED CAHPS” questions should be considered as proposed/ preliminary items that can serve as a guide to the prepare for the official ED CAHPS survey to be forthcoming.

ED PEC Survey • Called “Patient Experience of Care” survey • 3 versions developed – Discharged to Community version ( 63 questions) – Admitted to Hospital – Stand alone version (57 items) – Admitted to Hospital (HCAHPS Add on version) (39 items) • Field Testing now in process

Patient Experience of Care survey Questionnaire comprised of topics which include: • • • Emergency Department Arrival Communication about Medicines Pain Management Test or Procedures during ED Visit Interpreter Services Nursing Care Physician Care Discharge Information Overall Rating of ED Care Wilingness to Recommend

ED CAHPS: Survey Questions Discharged to Community version ( 63 questions) A. Going to the Emergency Room ( 4 questions) 1. Main reason (accident, new problem, ongoing condition? ) 2. Ambulance arrival (Yes/ No) 3. Greeter/ Reason for ED visit (how long? 5 min, 10 min, more than 15 min) 4. When you first arrived in the ED, how important was it for you to get care right away? ( Scale 0 -10 = Very Important 5. Care received within 30 minutes of arrival? (Yes/ No

ED CAHPS: Survey Questions (con’t) B. During Your Emergency Room Visit (Medications) 6. Did doctors/ nurses ask about ALL medicines you were taking? ( Yes, somewhat, no) 7. Were you given any medicine you had not taken before? ( Yes, Don’t know, No) 8. Before giving a new medicine, did doctors, nurses tell you what medicine was for? Yes, Definitely, No 9. Before giving you any new medicine, did the doctors, nurses describe the possible side effects in a way you could understand? ( Yes, definitely, Yes, somewhat, No.

ED CAHPS: Survey Overview (con’t) During Your Emergency Room Visit 10. Did you have any pain? 11. Did you get any medicine for pain? 12. Did the doctors and nurses do everything they could to help you with your pain? 13. Did you have a blood test, x-ray, or any other test? (Yes, No) 14. Did doctors, nurses give you as much information as you wanted about the result of these tests? Responses: Yes, definitely Yes, somewhat No

ED CAHPS: Survey Overview (con’t) During Your Emergency Room Visit 15. Did you need an interpreter? ( Yes, No) 16. When you needed an interpreter, did you get one? ( Yes, No)

ED CAHPS: Survey Overview (con’t) People who Took Care of You (con’t) 21. Doctors treat you with courtesy & respect? 22. How often did doctors listen carefully to you? 23. How often did doctors explain things to you in a way you could understand? 24. Did doctors spend enough time with you?

ED CAHPS: Survey Overview (con’t) 5. Leaving the Emergency Room ( 6 questions) 25. Understand your main health problem? ( Y/N) 26. Understand symptoms, problems to watch out for? ( Y/N) 27. Instructed to take any new medicines? (Y/N) 28. Explanation given as to reason for New medicines? ( Y/N) 29. Instructions given to make Follow-up appointment? ( Y/N) 30. Asked if you could get this follow-up care? ( Y/N)

ED CAHPS: Survey Overview (con’t) 6. Overall Experience ( 2 questions) 31. Rate your care ( Scale 1 -10 ( highest) 32. Would you recommend this ED to family, friends? 7. Your Health Care ( 4 questions) 33. # of Times in the 30 days before this visit you came to this ED to get care for yourself? • # of Times in last 6 months? 34. Other Resources available? Doctors office, clinic, etc? • # of Times you utilized in last 6 months

ED CAHPS: Survey Overview (con’t) 8. About You ( 2 questions) 33. Rate your overall health ( Excellent , VG, Good, Fair, Poor) 34. Rate your overall mental / emotional health 35. In last 12 months, seen physician 3 or more times for same condition or problem? o Has the condition lasted at least 3 months? o Do you need or take medicine prescribed by doctor? o Is this medication to treat a condition that has lasted at least 3 months? 36. Demographics ( 7 questions) 37. Functional Assessment ( 6 questions)

Collection Techniques • Survey vendor will collect data by: – Mail only – Telephone only • using CATI – Computer assisted Telephone Interviewing – Mixed mail/ telephone • Two patient types – Discharged to community – Patients admitted to hospital

Patient Eligibility • Largely based on Hospital CAHPS eligibility criteria. – All ADULT patients are eligible for survey • Exclusions: – – – – Mental health or substance use diagnosis Patients discharged to hospice, nursing homes, SNF Transfers to other hospitals Patients requesting they not be contacted “no publicity” Patients who Left Without Being Seen Prisoners Patients with foreign address

Other CAHPS Surveys • Clinician & Group Survey (1. 0 released 2006) – Asks about patients’ experiences with their provider over the last 12 months or most recent visit; include questions re: access to care • Surgical Care (released Dec. 2011) – Expands the Clinician/ Group Survey; assesses patients’ experiences with surgical care in both IP/OP settings – Addresses informed consent, anesthesia care, post op follow-up, etc.

Other CAHPS Surveys • • Pediatric HCAHPS (planned release 2014) Home Health Care (endorsed, March 2009) In-Center Hemodialysis (endorsed, Nov. 2007) Nursing Home (endorsed, Nov. 2007) Health Plans (endorsed, July 2007) Dental Survey (endorsed, Dec. 2006) American Indian 6 Supplemental Item Sets (Medical Home, IT)

Collect Information • Start Data collection – Formal Patient Survey: Use Inpatient CAHPS Survey as a model to track outcomes, assess performance (for a post discharge survey) – Informal: Use questions for a Rounding process; realtime with patient; requires staff accountability

CAHPS/ HCAHPS: WHAT IS IT? Consumer Assessment of Healthcare Providers and Systems • Family of surveys designed to assess patient perceptions of care Health Plan CAHPS Hospital CAHPS (HCAHPS) Clinician and Group CAHPS (CG-CAHPS) Home Health Care CAHPS (HH-CAHPS) Source: Studer Group 31

HCAHPS: Hospital Consumer Assessment of Healthcare Providers & Systems What is HCAHPS Why is it important? How will it be used? A standardized survey tool of 27 questions to measure the patient’s perception of quality care provided during their experience while a patient at an acute-care hospital. The patient perception of care will be publicly reported with other quality metrics on the Hospital Compare website. www. hospitalcompare. hhs. gov The information will be used to provide meaningful data for improvement efforts as well as provide comparisons between hospitals to help consumers choose a hospital. Source: Studer Group 32

HCAHPS COMPOSITES AND QUESTIONS Composite Nursing Communication 8 Value Based Purchasing Measures Doctor Communication Responsiveness of Staff Pain Management Communication of Medications Discharge Information Cleanliness and Quietness of Hospital Environment Overall Rating Willingness to Recommend will continue to be reported but not included in VBP formula Question Summary Response Scale Nurse courtesy and respect Nurses listen carefully Nurse explanations are clear Doctor courtesy and respect Doctors listen carefully Doctor explanations are clear Did you need help in getting to bathroom? 2 Staff helped with bathroom needs Call button answered Did you need medicine for pain? 2 Pain well controlled Staff helped patient with pain Were you given any new meds? 2 Staff explained medicine Staff clearly described side effects Did you go home, someone else’s home, or to another facility? 2 Staff discussed help need after discharge Written symptom/health info provided ALWAYS, Usually, Sometimes, Never ALWAYS, Usually, Sometimes, Never Yes No (screening question) ALWAYS, Usually, Sometimes, Never Yes, No (screening question) ALWAYS, Usually, Sometimes, Never Own home, Someone else’s home, Another facility (screening question) YES, No Area around room kept quiet at night ALWAYS, Usually, Sometimes, Never Room and bathroom kept clean ALWAYS, Usually, Sometimes, Never 0 to 10 point scale (percent 9 and 10 reported) DEFINITELY YES, Probably Yes, Probably No, Definitely No Hospital Rating Question Willingness to Recommend

Incentive Bonus/ Penalties

HCAHPS: Physician Scorecard Doctors "always" communicated well Doctors "usually" communicated well Doctors "sometimes" or "never" communicated well Average For All Reporting Hospitals In The United States 80% 15% 5% Average For All Reporting Hospitals In Your STATE 80% 16% 4% HOSPITAL A 79% 16% 5% HOSPITAL B 78% 18% 4% HOSPITAL C 81% 15% 4% Source: http: //hospitalcompare. hhs. gov/

“Always” is Best Practice Never Sometimes Usually Always Source: Studer Group 36

ED Percentile Rank & HCAHPS Source: Studer Group 37

Patient Priorities (Press Ganey PATIENT PRIORITIES: PRESS GANEY Tool) Source: Studer Group 38

Patient Perception ~66% of healthcare choice decisions are based on word of mouth~ • Its not who we say we are • Its who THEY say we are AHA Reality Check II, AHA, 1998 Source: Studer Group 39

• https: //www. youtube. com/watch? v=CNh. Yb. Jb qg-Y

PATIENT SATISFACTION, COMPLAINTS & LAWSUITS • Physicians with lower patient satisfaction results are more likely to have patient complaints • Each one point decrement in patient satisfaction scores is associated with a – – 6% increase in complaints – 5% increase in risk management episodes • Lower performing physicians were at greater risks for lawsuits • 75% of complaints were related to communication issues Stelfox HT, et al, The American Journal of Medicine 2005; 118: 1126 – 1133 Source: Studer Group 41

Five Fundamentals of Service A I D E T Acknowledge Introduce Duration Explanation Thank You Source: Studer Group 42

A Acknowledge Key message: You are important § Say Hello! Acknowledge everyone with patient § Make Eye Contact §Smile § Like you love what you’re doing § Even when on the phone – yes, you can hear a smile through the phone §Call the customer by name §Make the customer feel that you expected them §Empathize with common feelings §Knock before entering a room Source: Studer Group 43

Importance of the GREETING • 78. 1% of patients wanted their physicians to shake hands • 91. 3% of patients wanted to be addressed by their name Makoul G, Zick A, Green M, Annuals of Internal Medicine 2007; 167: 1172 – 1178 Source: Studer Group 44

I Introduce : INTRODUCE First Generation • Name • Title • Patients name Next Generation • Your role in the team of care givers • Your years of experience, credentials • Other information to MANAGE UP Source: Studer Group 45

D Duration : DURATION Key Message: I anticipate your concerns • How long will the visit take? • How long will the test, procedure, wait actually be? • How long will it take to get the results? • How long to see the doctor? Source: Studer Group 46

E Explanation : EXPLANATION Listen to the patient’s story • Active Listening • Clarifying questions • Empathy Explain the treatment plan • Using language that patients can understand • Use key words • “Do you need more explanation”? Source: Studer Group 47

Explanation: Perception vs. Reality During a 20 minute encounter – Physicians self-report spending 9 minutes “providing information” – REALITY: Physicians spent 1. 5 minutes Source: Studer Group 48

Reality Of Explanation • Excellent communication between the patient and the provider improves adherence to medication regimens • Patients who do not comprehend all aspects of their disease or the importance of the treatment in controlling the disease and preventing adverse outcomes are less likely to be adherent with the treatment plan Harmon G, et al, Curr Opin Cardiology 2006; 21: 310 – 315

• 78% of Emergency Department patients do not understand at least one area, and 50% do not understand two or more areas of their care plan, their diagnosis, their treatment, their instructions for home care, and warning signs of when to return to hospital • Of those 78%, 20% do not even realize that they do not comprehend their care plan

Reality of Explanation • 72% of patients unable to list medications they were prescribed • 58% of patients unable to recite their own diagnosis

T : THANKThank You YOU! Key Message: I appreciate the opportunity to care for you • Closing key words – Thank for choosing our clinic – Thank for waiting – Thank for coming in today – What other questions do you have? Source: Studer Group 52

AIDET Works! Source: Hazel Hawkins Emergency Department; discharge date Source: Studer Group 53

MANAGE UP: YOURSELF, YOUR COLLEAGUES • Decrease anxiety • Improved customer (internal and external) experience • Increase efficiency • Increase compliance Source: Studer Group 54

MANAGE UP! Your Skills & Expertise Source: Studer Group 55

POST VISIT PHONE CALLS Source: Studer Group 56

Why Post Visit Phone Calls? • Improve Clinical Outcomes • Improve the Patient’s Perception of Care/Service • Find Opportunities for Reward and Recognition • Find Opportunities for Process Improvement • Engage patient in the survey process • Confirms that we care about the patient Source: Studer Group 57

IMPACTS Source: New Jersey Hospital, Total beds = 775; 3 Q 2007 – 2 Q 2010 Source: Studer Group 58

HOW YOU CAN HELP • Role model AIDET • Reward and Recognize • Tie Key words and AIDET to every customer/every co-worker every time (don’t forget they can be used at home too) Source: Studer Group 59

Thank You Questions? tgaib@lifebridgehealth. org Source: Studer Group 60