Pa­tient. Con­sumer. Cus­tomer. Guest.

Hospi­tal lead­ers dif­fer sharply in how they de­fine the pa­tient ex­pe­ri­ence and how they pri­or­i­tize their im­prove­ment ini­tia­tives, lead­ing to a clash within the in­dus­try

Modern Healthcare - - NEWS - By El­iz­a­beth Whit­man

As pa­tients lie in their hospi­tal beds, hardly a sound en­ters their pri­vate rooms from the hive of ac­tiv­ity out­side, thanks to noise-re­duc­ing rub­ber floors, walls and doors con­fig­ured to muf­fle sound, and sound-ab­sorb­ing ceil­ing pan­els.

Sun­light fil­ters through translu­cent shades rolled down for pri­vacy. The bath­room is a few steps from the pa­tient's bed, rather than across the room, sav­ing a pa­tient from hav­ing to nav­i­gate ob­sta­cles. These are stan­dard pa­tient rooms in the Lun­der Build­ing at Mas­sachusetts Gen­eral Hospi­tal in Bos­ton.

Con­sider the al­ter­na­tive. Older Mas­sachusetts Gen­eral build­ings have harsh flu­o­res­cent light­ing and drab walls. The hall­way in­ter­com blares ev­ery few sec­onds, and the door to the sup­ply closet across the hall from pa­tient rooms clicks each time a nurse punches in the key code. Each pa­tient room has two beds, so pa­tients hear their room­mate’s coughs, wheezes and groans. The clat­ter of feet and the din of the voices of staff and vis­i­tors con­tin­u­ously as­sault pa­tients’ ears.

The gap be­tween these two ex­pe­ri­ences is the fo­cus of grow­ing at­ten­tion, as hospi­tal sys­tems work to im­prove the pa­tient ex­pe­ri­ence. Ex­perts say hap­pier pa­tients are health­ier pa­tients, and that hospi­tal stays should be restora­tive, not de­hu­man­iz­ing and ex­haust­ing.

Hospi­tal lead­ers are keenly aware that en­hanc­ing the pa­tient ex­pe­ri­ence has the po­ten­tial to lift their bot­tom lines. A sign of the grow­ing in­ter­est in this area is the wide­spread emer­gence of chief ex­pe­ri­ence of­fi­cers at a grow­ing num­ber of health sys­tems.

“The fo­cus on im­prov­ing the ex­pe­ri­ence is clearly ev­ery­where,” said Dr. Jim Mer­lino, pres­i­dent and chief med­i­cal of­fi­cer at Press Ganey, who pre­vi­ously served as the Cleve­land Clinic’s chief ex­pe­ri­ence of­fi­cer.

But hospi­tal lead­ers dif­fer sharply in how they de­fine the pa­tient ex­pe­ri­ence and how they pri­or­i­tize their im­prove­ment ini­tia­tives, lead­ing to a clash within the in­dus­try. Should such ef­forts fo­cus on aes­thet­ics or on clin­i­cal pro­cesses and com­mu­ni­ca­tion? Or, should it marry the two? And how should the pa­tient ex­pe­ri­ence bal­ance clin­i­cal care—giv­ing a pa­tient the care they need, even if it’s un­pleas­ant—

with ameni­ties, such as bet­ter park­ing or lux­ury toi­letries?

Dr. Ashish Jha, a pro­fes­sor of health pol­icy at the Har­vard School of Pub­lic Health, fears that hos­pi­tals are too fo­cused on su­per­fi­cial as­pects of pa­tient ex­pe­ri­ence. Hos­pi­tals are “wast­ing a lot of re­sources do­ing things that are not par­tic­u­larly im­por­tant,” such as art­work and park­ing, which they think mat­ter for pa­tient ex­pe­ri­ence, Jha said. Yet, “what we know is that pa­tient ex­pe­ri­ence scores are not go­ing up,” he added.

The lack of a widely agreed-on def­i­ni­tion of pa­tient ex­pe­ri­ence is “one of the most frus­trat­ing top­ics in the en­tire in­dus­try,” Mer­lino said. “I think that hurts our abil­ity to im­prove.”

Many hos­pi­tals and health sys­tems treat the pa­tient ex­pe­ri­ence as a mat­ter of im­prov­ing the cus­tomer ser­vice ex­pe­ri­ence. Mer­lino con­sid­ers that flatly wrong. “The ser­vice piece is a com­po­nent of it, but it's not the pri­mary piece,” he said. In­stead, he prefers Press Ganey's def­i­ni­tion of a good pa­tient ex­pe­ri­ence as safe, high-qual­ity health­care de­liv­ered in a com­pas­sion­ate, em­pa­thetic en­vi­ron­ment.

The Beryl In­sti­tute, which fo­cuses on im­prov­ing the pa­tient ex­pe­ri­ence, de­fines it as the “sum of all in­ter­ac­tions, shaped by an or­ga­ni­za­tion's cul­ture, that in­flu­ence pa­tient per­cep­tions across the con­tin­uum of care.”

The myr­iad ways health­care or­ga­ni­za­tions fo­cus their ef­forts on the pa­tient ex­pe­ri­ence re­flect the range of def­i­ni­tions. Some are ren­o­vat­ing and re­design­ing en­tire build­ings. Oth­ers fo­cus on im­prov­ing com­mu­ni­ca­tion. And some work on both.

The con­cept of con­sumer ex­pe­ri­ence ap­plies dif­fer­ently in health­care than in other in­dus­tries. “At the end of the day, it is about hav­ing bet­ter health out­comes and well-be­ing for peo­ple,” said Joan Kelly, chief pa­tient ex­pe­ri­ence of­fi­cer for NYU Lan­gone Health Sys­tem in New York City. “The re­al­ity is, peo­ple don't choose this. They only want to use it when some­thing is wrong. It's very dif­fer­ent from a pur­chas­ing mind­set.”

The goal in de­sign­ing Mas­sachusetts Gen­eral's Lun­der Build­ing, which opened in 2011, was to stream­line work­flow and care de­liv­ery for providers while be­ing mind­ful of the needs of pa­tients and their fam­i­lies, said Joan Saba, a part­ner at ar­chi­tec­ture firm NBBJ and the lead ar­chi­tect of the build­ing. Its ma­jor de­sign el­e­ments re­flect that, with use of noise-re­duc­ing ma­te­ri­als, ad­justable light­ing, and rooms and doors an­gled to give pa­tients greater pri­vacy.

In­stead of form­ing a ring of pa­tient rooms around a clus­ter of work­sta­tions, or load­ing cor­ri­dors on both sides with pa­tient rooms, Lun­der's floor plan re­sem­bles two let­ter Cs fac­ing each other but shifted so their ter­mini don't align, Saba demon­strated with her hands.

Pa­tient rooms are lo­cated along the Cs, with ser­vice and sup­port rooms sta­tioned in the curve of each, mit­i­gat­ing the is­sue of staff con­gre­gat­ing in a sin­gle noisy nurs­ing sta­tion. A cen­tral di­ag­o­nal spine short­ens travel dis­tances around the floor.

For im­prov­ing the pa­tient ex­pe­ri­ence, “the pri­vate rooms are key,” said Su­san Cronin-Jenk­ins, co-direc­tor of real es­tate and fa­cil­i­ties at Mas­sachusetts Gen­eral. “If I have two pa­tients in a room, ev­ery time I take care of one, the other pa­tient usu­ally asks for some­thing.”

A 2016 study in the Jour­nal of Crit­i­cal Care found that the cost of build­ing pri­vate rooms can be off­set by re­duc­ing hospi­tal-ac­quired in­fec­tions. The study, how­ever, only fo­cused on the in­ten­sive-care unit.

The feel of Lun­der con­trasts sharply with that of El­li­son in other ways. At older build­ings, hall­ways are clut­tered with mo­bile com­puter work­sta­tions. Nurse desks and sup­ply rooms are lo­cated di­rectly across from pa­tient rooms.

“All this stuff makes noise,” said Cronin-Jenk­ins, swip­ing her ID badge to demon­strate the clicks and pings that ac­com­pany open­ing the sup­ply closet door. “If you're across the hall and you're try­ing to sleep, it's very dis­rup­tive.”

The noise level is 10 to 15 deci­bels lower in Lun­der than in El­li­son, an older Mas­sachusetts Gen­eral build­ing. Higher noise lev­els in hospi­tal rooms have been linked to dis­rupted or poor-qual­ity sleep, which can de­lay a pa­tient's re­cov­ery.

The dif­fer­ences be­tween Lun­der and other build­ings are re­flected in pa­tient-sat­is­fac­tion scores. Pa­tients stay­ing in Lun­der con­sis­tently re­spond more pos­i­tively on the Hospi­tal Con­sumer As­sess­ment of Health­care Providers and Sys­tems, or HCAHPS, than do pa­tients who re­ceived care in other Mas­sachusetts Gen­eral build­ings.

“By look­ing at the scores, you can guess where it is. (Lun­der) is a bet­ter place,” said David Han­itchak, vice pres­i­dent for real es­tate and fa­cil­i­ties at Mas­sachusetts Gen­eral. Em­ploy­ees pre­fer Lun­der too, he added.

Skin in the game

Health­care has fol­lowed other in­dus­tries, such as re­tail and tech, in fo­cus­ing on cus­tomer ex­pe­ri­ence.

One fac­tor driv­ing this is that pa­tients are tak­ing more con­trol over where they get their care be­cause of the rise of high-de­ductible health plans. Pa­tients pay­ing more of their own bills out-of-pocket are more likely to de­cide where they can get the best value.

The in­tro­duc­tion of the HCAHPS sur­vey, which asks Medi­care pa­tients to grade hospi­tal clean­li­ness, com­mu­ni­ca­tion and other el­e­ments of their ex­pe­ri­ence gave pa­tients a chance to tell hospi­tal lead­ers what they re­ally

“As in­sur­ance com­pa­nies are start­ing to move from pay-for-vol­ume to pay-for-value, part of that value equa­tion is the pa­tient ex­pe­ri­ence.” Scott Perra, CEO Mo­hawk Val­ley Health Sys­tem

thought of their stay. The CMS be­gan re­quir­ing hos­pi­tals to col­lect and re­port this in­for­ma­tion in 2007. In 2008, the CMS be­gan pub­lish­ing HCAHPS re­sults.

HCAHPS is just one piece of the broader tran­si­tion to value-based pay­ment. The Obama ad­min­is­tra­tion set the goal of ty­ing 90% of spend­ing in the tra­di­tional Medi­care pro­gram to value by 2018, through a mix­ture of al­ter­na­tive pay­ment mod­els, qual­ity mea­sure­ments and fi­nan­cial penal­ties and in­cen­tives. Pri­vate in­sur­ers are at­tempt­ing to do the same.

Medi­care’s new value-based physi­cian pay­ment sys­tem is also prompt­ing the in­creased fo­cus on pa­tient ex­pe­ri­ence.

“As in­sur­ance com­pa­nies are start­ing to move from pay-for-vol­ume to pay-for-value, part of that value equa­tion is the pa­tient ex­pe­ri­ence,” said Scott Perra, CEO of Mo­hawk Val­ley Health Sys­tem, an in­te­grated de­liv­ery sys­tem in up­state New York. “If you didn’t have rea­son to work on it be­fore, you have rea­son to work on it now.”

Mo­hawk Val­ley Health is plan­ning a new, 750,000-square­foot cam­pus, de­signed by NBBJ. Pa­tient ex­pe­ri­ence was one rea­son for up­grad­ing from its two cur­rent build­ings, which are 60 and 100 years old.

Frank Bea­man, CEO of Faith Com­mu­nity Hospi­tal, a 41-bed fa­cil­ity in Jacks­boro, Texas, with a Level 4 trauma cen­ter and a ru­ral clinic, said he’s keenly aware that en­hanc­ing the pa­tient ex­pe­ri­ence can be pow­er­ful in pro­tect­ing or boost­ing mar­ket share, even in a ru­ral area where the clos­est com­peti­tor is 35 miles away.

In 2015, Faith Com­mu­nity opened a new hospi­tal. It has sep­a­rate en­trances for dif­fer­ent de­part­ments, mak­ing nav­i­ga­tion eas­ier and more con­ve­nient. And it in­cludes the Faith Cafe, which Bea­man said has be­come a des­ti­na­tion for the com­mu­nity.

Over­all, staff should be cour­te­ous, the hospi­tal clean and the land­scap­ing well-groomed, said Bea­man, who refers to pa­tients as “guests.” The hospi­tal also has fo­cused on speed­ing up billing and reg­is­tra­tion pro­cesses. “We don’t want any­one to have to wait more than 10 min­utes,” he said.

On the clin­i­cal side, pa­tients can fill out a 45-sec­ond ex­pe­ri­ence sur­vey on an iPad be­fore they leave. Giv­ing pa­tients that out­let has helped pre-empt an­gry pa­tients who can eas­ily “vomit all over so­cial me­dia,” Bea­man said. In a small com­mu­nity, such com­plaints res­onate.

Scrap­ing the sys­tem

NYU Lan­gone Med­i­cal Cen­ter built the lux­u­ri­ous Tisch El­e­va­tor Tower af­ter Su­per­storm Sandy wrought nearly $1 bil­lion in dam­age at the hospi­tal in 2012. Its in­ter­pre­ta­tion of pa­tient ex­pe­ri­ence blends the aes­thetic, the struc­tural and the clin­i­cal.

The sys­tem is build­ing new units and fa­cil­i­ties, such as the 830,000-square-foot Kim­mel Pavilion, which will be the only hospi­tal fa­cil­ity in New York City with pri­vate rooms when it opens next year. Renderings prom­ise spa­cious lob­bies full of com­mis­sioned art­work, New York-themed pe­di­atric wait­ing rooms, and pri­vate rooms out­fit­ted with 74-inch flat-screen mon­i­tors.

At the same time, the hospi­tal is painstak­ingly re­design­ing clin­i­cal pro­cesses un­der the eye of Chief Ex­pe­ri­ence Of­fi­cer Joan Kelly. She works with a team of pa­tient ex­pe­ri­ence de­sign­ers ex­am­in­ing ev­ery step in the care process, look­ing for weak points from both the pa­tient’s and the clin­i­cian’s per­spec­tives.

A vis­ual de­signer maps ev­ery step in the care process and pro­duces large flow­charts fea­tur­ing arrows and color-coded bub­bles. This in­ven­tory dis­cov­ered the star­tling fact that some pa­tients re­ceived 41 sep­a­rate pieces of pa­per be­fore even re­ceiv­ing a pri­mary di­ag­no­sis. “It’s over­whelm­ing,” Kelly said. “You can’t man­age that.”

When the team looked at how providers com­mu­ni­cated with pa­tients, they re­al­ized the process was al­most like a po­lice in­ter­ro­ga­tion. Pa­tients saw a slew of dif­fer­ent providers, each of whom went over the same ques­tions, which pa­tients had to an­swer again and again.

With these dis­cov­er­ies in mind, Kelly and her team came up with pa­tient-cen­tered so­lu­tions. For in­stance, NYU Lan­gone has de­vel­oped book­lets, in hard copy and dig­i­tal for­mats, to guide pa­tients through the course of treat­ment, for in­stance list­ing every­thing a sur­gi­cal pa­tient should know. That in­cludes what to ex­pect from surgery, how to pre­pare for it, what hap­pens af­ter surgery, what ex­er­cises to do, and ques­tions to ask the doc­tor.

For hospi­tal staff, Kelly’s team de­signed a train­ing pro­gram called Pa­tient Ex­pe­ri­ence 101. Over two years, the en­tire NYU Lan­gone staff-17,000 peo­ple, in­clud­ing nurses, physi­cians, house­keep­ing staff, and food ser­vices-went through this train­ing, which pushed them to al­ways con­sider the pa­tient’s per­spec­tive.

At the Cleve­land Clinic, a 14-hospi­tal sys­tem, the range of pa­tient ex­pe­ri­ence ini­tia­tives is broad. In one ini­tia­tive, it tapped famed fash­ion de­signer Diane von Fursten­burg to cre­ate a more dig­ni­fied med­i­cal gown.

“The ex­pe­ri­ence of putting on a gown is ex­cep­tion­ally de­hu­man­iz­ing,” said Dr. Adri­enne Boissy, Cleve­land Clinic’s chief ex­pe­ri­ence of­fi­cer. “Ul­ti­mately, she pro­duced a gown that wrapped around so that no­body’s back­side was hang­ing in the wind.”

Sev­eral years ago, the Cleve­land Clinic started putting its providers through a re­la­tion­ship-cen­tered train­ing pro­gram. That re­sulted in a sta­tis­ti­cally sig­nif­i­cant im­prove­ment in the “re­spect” do­main of the or­ga­ni­za­tion’s HCAHPS score, as well as im­prove­ments among physi­cians on mea­sures of em­pa­thy and burnout.

Many health­care lead­ers hope that im­prov­ing the pa­tient ex­pe­ri­ence will help move health­care away from the ster­ile im­per­son­al­ity of mod­ern medicine and back to­ward a strong re­la­tion­ship be­tween pa­tients and providers marked by kind­ness and car­ing.

“You don’t need ex­pen­sive tech­nol­ogy or train­ing to be em­pa­thetic and com­pas­sion­ate. You just need to be present and in the mo­ment,” said Press Ganey’s Mer­lino. “It’s eas­ier than peo­ple think. It’s just about get­ting back to the ba­sics.”



Left and above, the rooms and lay­out of the Lun­der Build­ing at Mas­sachusetts Gen­eral Hospi­tal are de­signed for a bet­ter ex­pe­ri­ence for pa­tients, their fam­i­lies and their care­givers.

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