Improving Patient Experience Ratings

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Improving Patient Experience Ratings

• Diane Stewart
• Director, Performance Improvement
• Pacific Business Group on Health
• IHA Steering Committee
• October, 2008

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Agenda

• Overview of the California Quality Collaborative
• Improving Patient Experience Scores
• Results from 2006 Patient Experience
  Collaborative
• Changes that improved patient ratings of care at
  the practice site
• Changes that improved patient ratings at the
  group
• CQCs program to support improvement in PAS
  scores

3
Common Measures IHA and CCHRI

• Clinical Outcomes
• Patient Experience
• Efficiency/Total Cost

• Improvement Support
• CQC
• What/Best Practices
• How/Execution

• Incentives
• Plans and State of CA
• Public Reporting
• P4P Financial Incentives

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CQC Offerings

• Implementation Collaboratives 12 month programs
  to deliver measurable improvement at practice and
  group
• Improving Patient Satisfaction Scores (PAS)
• Improving Clinical metrics
• Improving Efficiency/Total Cost
• Coordinating disease management between health
  plans and physician groups and IPAs
• Disease-specific learning exchanges
• Regional Learning Networks
• Inland, Los Angeles Co., Orange Co.
• Training Sessions for Group Leaders
• Engaging Physicians in Change
• Data Analysis and Project Management

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• Engage Groups
• Thru Health Plan Reps and CAPG
• Link to IHA P4P
• Regional Learning Networks (Inland, LA, OC)

• Clinical Outcomes
• Patient Experience
• Efficiency/Total Cost

• Increase Readiness for Change
• 1-Day Conferences
• Teleconferences (i.e Medication adherence,
  advanced access)
• Management skills training

• Implement System Change
• 1-year Collaboratives

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On-site participation from Physician Groups
outside Kaiser
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Who Steering Committee
Lance Lang, MD Co-Chair Vice President, Senior
Medical Director, Health Net Nancy Oswald,
PhDExecutive Director, Redwood Community Health
Coalition Susan Payan-Lopez California Diabetes
Program Linda Sawyer, PhD, APRN , BC Chief
Operating Officer, Lumetra Wells Shoemaker, MD
Co-Chair Medical Director, California
Association of Physician Groups Michael Van
Duren, MD Medical Director Sutter Connect

• Mike Belman, MD, MPH
• Staff VP Medical Director Quality Management,
  Blue Cross of California
• Michael-Anne Brown, MD
• Sr. Medical Director of Quality ,
• Blue Shield of California
• Hattie Hanley
• Department of Managed Health Care
• State of California
• Elizabeth Haughton
• Chief Counsel, NAMM
• Halsted Holman, MDProfessor of Medicine,
  Stanford University 
• David Hopkins, PhDDirector of Quality
  Management, Pacific Business Group on Health/CCHRI

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Improving Patient Experience
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Where We StandCalifornia v. National
CA Ave 68.3
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Where we Stand Modest Positive Gains Statewide
on PAS
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Three-Year Trend by Performance Quartile
Overall Rating of Care
4th quartile saw a 1.1 point change compare to
0.9 point gain for 2nd and 3rd quartiles, and no
gain for 1st
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Result for Groups in 2006CQC Collaborative
Participants Affinity, Greater Newport, Muir
Medical Group, Monarch. (Completed training
program January 2007)
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Improvement Framework
Strategic
Tactical

• Leadership Actions
• Communications Systems
• Rewards and Recognition
• Technical Support and Training
• Systematic monitoring and feedback

• Practice
• Doctor-patient communication
• Access to care
• Coordination of care
• Staff-patient communication

With Group Support
Implementation
Sustainability
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Tactical Key Changes at the Practice

• Communication Techniques
• Negotiate the agenda with the patient at the
  start of each visit
• Make a personal connection through eye contact
  and demonstrate empathy through empathic
  statements
• Provide closure to the visit by summarizing next
  steps and action plan
• Coordination of Care
• Notify patients of all test results, whether
  positive or negative
• Review patients chart prior to starting the
  visit
• Regular Feedback
• Conduct regular practice team meetings and/or
  daily brief check-ins (huddles) and measure
  practice site satisfaction at least quarterly

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Results at the Practice Study funded by
Commonwealth Fund

• 12 physicians drawn from 4 large IPAs
• 8 PCPs, 1 DERM, 2 OBGYN, 1 PEDS
• Matched control physicians within same IPA
• Matched for Age, gender, specialty type, practice
  size and performance (in MD/PT comp and
  recommends MD)
• Commercially insured HMO and POS enrollees PPO
  patients added to supplement samples
• Adjusted for regression to the mean effect
• PAS instrument used for baseline and post
  collaborative measurements
• Study Design and Analysis Bill Rodgers, PhD, New
  England Medical Center and Cheryl Damberg, PhD,
  RAND

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Results at the Practice - cont

• Quantitative Results
• Greater improvements in all communication and
  care coordination measures compared to controls
  (2-3 points versus .6 points)
• Gains sustained after 6 months
• Statistically significant gains for the following
  survey questions
• Recommends doctor
• Clear instructions,
• Respect for patient,
• Can tell the doctor anything, and
• Helpful staff
• Physicians with Largest Gains
• Started with lower scores at baseline
• Demonstrated greater engagement as compared to
  controls (6 point gain)

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Results at the Practice - cont

• Qualitative Results
• Semi-structured interviews with 10 of 12
  practices
• 100 believe they can sustain changes
• 80 believe staff satisfaction improved
• 80 believe practice culture improved
• 80 report improved personal job satisfaction
• 72 report improved relationship with IPA
• 71 reported that their practice is a better
  place to work than 12 months ago compared to 58
  pre-intervention

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Strategic Key Changes at the Group

• Leadership Actions
• Strategic initiative, part of planning process
• Part of personnel evaluations and hiring
  decisions
• Develop physician champions
• Rewards and Recognition
• Significant part of practice incentives
• Technical Support and Training
• Sponsor initial training sessions
• Provide on-going coaching and training
• Systematic monitoring and feedback
• At least quarterly feedback to practices

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Program Outline
Spread to Target Sites
Implement at Demonstrator Sites
Months 9 -18
Diagnosis
From Months 3 to 10
From Months 1 - 3
10 - 20 Practices
Identify which practices and which interventions
required to improve groups scores

• Generate practice results
• Develop internal champions
• Test practice
• support systems

• Boost group-level results
• Build systems for sustainability

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Improving Patient Experience Collaborative

• Analyze Group Scores Identify domains
• Analyze Doctor-level scores and select at least
  one-third of practices for improvement
• Select Demonstrator Practices (up to 20) from
  targets
• Implement fully at Demonstrator practices and
  measure results
• Required Communication Techniques (2 Clinician
  training sessions)
• Optional Access, Coordination of care, Office
  staff communication

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Improving Patient Experience Collaborative

• 4. Decide which changes to spread across network,
  and how..
• 5. At the same time.. build for sustainability
• Leadership actions to support patient-centered
  care
• Build measurement and feedback systems
• Build capacity for improvement
• Develop Physician champions
• Improvement skills for managers
• Adjust Incentives

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Example Group in Round 2

• Aim X strives to improve our overall rating of
  health care by 2 points on 2010 PAS from 81.6
  (20th Percentile) to 83.6 (50th percentile)
• Spread plan
• May Dec 13 Demonstrator Sites
• Oct. Mar. 09 76 sites and 60,000 patients
• Feb. 09 Dec 09 148 sites and 120,000 patients

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Improving Patient Experience Collaborative Summary

• 2006 Participants (Round 1)
• Affinity, Greater Newport, Muir Medical Group,
  Monarch
• 2008 Participants (Round 2)
• Beaver, Bristol Park, Facey, Mercy Physicians MG
  Primecare, PMG Santa Cruz, St. Joseph Heritage
• 2009 Program (Round 3) Currently Recruiting
• Starts March 2009
• Physician Group Commitment
• 8,000 13,000 per group (based on enrollment)
• Project Team attends all sessions
• CQC Commitment
• Training for first round of physicians in
  Doctor-Patient Communication techniques locally
  (10,000 value)
• Quarterly on-site sessions
• One-on-one coaching

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From Current Participants..

• Why did your organization decide to join the
  Collaborative 2008?  
• We thought this was a cost effective program
  to provide proven strategies for improving
  patient satisfaction scores. 
• What did your team find most valuable?
• The most valuable part of the collaborative was
  working with other groups that are working
  towards the same goal. The sharing of ideas, what
  worked, what didn't, was very effective.
• This program provides a systematic process to
  analyze your data, determine areas of
  opportunity, plan not just your strategies but
  also your "spread", and track your work in a way
  that was new to me. The tools we were provided to
  support taking on a project like this is was
  useful not just to this project, but will be
  useful in many others as well.

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AimImprove the average patient experience
ratings statewide over three years by 25Target
MY2009 Mean for Overall Rating of Care rises by
1.7 points over MY2006
Goal
Baseline