One of the best ways to achieve a sense of community in health care is through storytelling. Stories make for good medicine. They inspire empathy, laughter, hope and healing. Because we can relate to the experiences of human beings as told in stories, we more easily learn and retain information presented that way.

By its very nature, health care has a wealth of wonderful stories to tell. This is a field that is about life and death, tragedy and redemption, despair and hope. Through stories, we can help patients overcome fear and anxiety. We can teach valuable public health lessons. We can show how physicians and nurses care about the people they treat. And we can help employees connect to the larger purpose of the organization.

Our patients share the stories of their health care experiences through surveys. The caregivers are the characters in the stories – a cast that includes doctors, nurses, techs, aides, support and leaders. These ordinary people make extraordinary contributions to people’s lives and to our society at large. It’s vital to share the stories of the events these characters take part in – the everyday victories and discoveries that touch our hearts.

I often tell people about the Press Ganey story, about how a company that has affected so many lives basically began in the kitchen of a Notre Dame professor. Our company now has offices in multiple locations, hundreds of employees and thousands of clients, but people love to hear about its humble beginnings. History, as told through stories, helps people connect to an organization.     

More than a decade ago, I read a story about a young emergency department physician who had realized as his shift was ending that the homeless patient he had been caring for through the night had no shoes. So he left the man his own shoes. A co-worker was so moved by the generosity that she felt compelled to share the story. I think about that so often. It’s heartwarming and validates the goodness and compassion that we look for in those who provide care, but I would have never known about it had the young doctor’s co-worker not taken the time to tell the story.

There is no hard and fast rule on how stories can be told or shared. Make a point of including them in department meetings. Dedicate a spot on your organization’s intranet and solicit staff to contribute. Share patients’ stories so that everyone can celebrate the victories and benefit from lessons learned. 

After many years in nursing, I have so many stories stored away as memories and often bring them out as reminders. Different ones evoke different emotions – happiness, sadness, pride, love; they are a chronicle of my experiences, none of which I ever want to forget. 

One of my favorites is the story of a 100-year-old lovely little lady brought to the ED with blurred and double vision. The physician walked over to the bedside and, taking her hand, asked, “So, you are seeing double of everything?” At first she was silent, but after a bit responded, “Young man, at my age, I’ve seen most things at least double, some more times than that!”

What’s your story?

Read Barbara’s full profile.

Effective communication is critical, particularly in the health care setting. It is an important component of high-quality care and helps achieve better outcomes. It is estimated that as much as 50% of substandard care is related directly or indirectly to physicians’ communication with patients. And patients sense it; poor communication scores are leading contributors to poor overall satisfaction scores.

Building better relationships with patients means overcoming some verbal and non-verbal behaviors that impede real communication. These behaviors are so ingrained, and the actions in which they are associated are so simple, that it may be surprising to some doctors that they have hurdles to surmount and that it might take some thought and practice to change. 

And yet, the bottom line is that the changes really aren’t that daunting. In a way, it is going back to basics on interpersonal skills. We all fall into personality types, and doctors are no different. So here are some examples and reminders of verbal and non-verbal communications with patients:

Our first example may be called Dr. Cross. This otherwise talented physician is found rounding on a patient. She sits on a window seat, remembering she needs to get down to the patient’s level. She is making good eye contact, but each time the patient speaks to answer or ask a question, the doctor crosses her arms. So while she may be listening, her body language says, “I am not open to hearing you.” This is a sign to the patient to shut up. Dr. Cross needs to open up her arms when the patient speaks.

Second up is Dr. Keepaway. This talented surgeon comes into the patient’s room, stands at the foot of the bed and talks to the patient’s foot, which he is going to be operating on tomorrow. He tells the foot that he is the doctor who helped it when it first came into the hospital, and now he is getting ready to fix it in surgery. All the while, there is a live patient who is trying to catch the doctor’s gaze. Dr. Keepaway needs to sit at the patient’s level, make eye contact and give the patient a gentle touch. This will build trust, show empathy and communicate to the patient that this doctor is a human being who is there to make this patient’s life better.

A close cousin to Dr. Keepaway is Dr. Dashby. Not only does this physician not get close, she is barely in the same Zip code, leaning in from the hallway and loudly speaking into the patient’s room (while reading from a chart) for a moment, then dashing off to the next room. It is unfortunate that our physicians are forced to be more productive in order to generate income, as it leaves them with little time to spend in direct conversations with their patients. The result in one recent study showed that physicians spend less than one minute per day on average inside the room of a patient in the intensive-care unit.

Stop and think about how patients feel when the person leading the care team doesn’t have time for them. I realize that the physician has many competing demands, but a priority must be placed on going into each patient’s room, introducing him- or herself if it’s a first visit, establishing eye contact and spending at least one minute to make a human connection. The doctor should ask the patient about his family and what he likes to do in times when he is not facing a health crisis, and share some personal details as well.

Bringing some warmth to the conversation can pay off in the mind of a patient – then the doctor is more than just a clinician. She is the doctor whose child just got back from soccer camp or who likes to read mysteries.

Doctors need to practice these behaviors. Knowing that they are limited on time, they need to find out how to make that short visit more meaningful by connecting with the patient through verbal and non-verbal communication.

Health care leaders need to support the communication needs of patients and physicians by using technology (video, bedside computers, CDs), physician extenders, nursing staff, patient self-management tools, patient navigators and patient advocates. They need to bring effective communication to the top of the to-do list, and work with physicians, patients and employees to find ways to support effective communication.

Physicians need the support, and patients deserve it.

Read Mary’s full profile.

As providers and hospitals adjust to the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) survey instrument, several questions have arisen about the CAHPS response categories. The HCAHPS survey asks patients to evaluate how often a specific event occurred during their stay in the hospital. The responses range from “never” to “always,” with the Centers for Medicare and Medicaid Services (CMS) regarding “always” as the optimum answer. Many providers have wondered if satisfaction scales, such as Press Ganey’s, can predict how often a patient would say something happened “all the time.” After all, the CMS questions are more about the patient’s perception of the frequency of events than his or her satisfaction with events. The pivotal question is: How do we get someone to say that something happened “always?” The answer is relatively simple: How often you think something happened is a part of how satisfied you are with it when it happens.  

So what is the connection to Press Ganey’s satisfaction scale? How can “very good” predict “always?” It is a matter of cognitive function. The connection of “very good” to “always” lies in the psychology of how humans judge frequency of occurrence. The ability of ratings questions (Press Ganey) to predict occurrence (CAHPS) lies in the ability of patients to reflect on what they thought was exceptional about their service. Simply put, satisfaction provides respondents with a point of reference for evaluating frequency of occurrence (see Susie Linder-Pelz’s “Toward a Theory of Patient Satisfaction” in Social Science and Medicine, Vol. 16). Our perception of how often staff responded promptly to the call button is a “piece” of our satisfaction with promptness in responding to the call button. Satisfied patients are more likely to say that staff “always” responded to the call button in a timely fashion. Other disciplines use this same type of cognitive connection. For example, our judgment of satisfaction with political figures is tied to how often we feel they voted for policies we like. In short, if we like something when it happens, we will report that it happened often.

Furthermore, there is a distinct lineage of research on the effect of happiness on our perception of time (see “Time Estimation and Orientation Mediated by Transient Mood,” a 1992 article by Jacob Hornik in The Journal of Socio-Economics). A person’s perception of how often something occurred and our perception of time passing are related to our contentedness during that time. This effect is amplified when the amount of time is subjective, like asking if something happened always versus sometimes. We have all heard the expression “time flies when you are having fun.” The same simple adage can be applied to patients in a hospital setting. If a patient is happy with services, they will report that the service happened all the time. However, keep in mind that humans are fickle creatures. Patients can be satisfied with a service nine out of 10 times, but, if on the 10th time they are dissatisfied, they will likely say that a particular service did not always occur.

In short, keeping patients satisfied is the most effective way to get them to say that a particular aspect of their care happened “always.”  

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Patient satisfaction scores are increasingly used to help determine physician compensation, so it’s no surprise that physicians are becoming more concerned about those scores, and, understandably, questioning them. Reactions range from healthy skepticism to outright rejection. The reactions may be based on misunderstanding or ignorance, on a heavy-handed application of rules by administrators or as part of a larger distrust of institutions outside of medicine. Physicians should know how their scores were determined, the science behind the survey instruments used to “grade” them and exactly how their scores will be used. If they don’t, they should ask questions. On the other hand, physicians sometimes reject the entire process because it is easier to shoot the messenger than to take the message (“you need to do better”) seriously.

This post is aimed at helping those of us who work with physicians to understand the basis of their concerns, deal with them and help physicians accommodate to their new reality.

Press Ganey co-founder and Notre Dame professor-emeritus Irwin Press, PhD, taught medical anthropology for many years. Press applied the tools of cultural anthropology (interviews, participant observation, analysis of documents, etc.) to the contemporary practice of medicine and found that, like other “tribes,” it possessed a distinct culture, with its own language, customs and worldview. Known as “biomedicine,” important parts of this culture are passed along to new recruits as they proceed through medical education; newly minted physicians practice within biomedicine and, in turn, transmit it to others.

(Attempts to describe a culture run into dangers of oversimplifying and stereotyping. Nonetheless, and at the risk of not doing the subject proper justice, I will try to describe physician culture; I base my description on 21 years of experience teaching in a family practice residency program.)

Features of biomedical culture include faith in physical and biological science as bedrocks of knowledge and ultimate determinants of truth; “show me the data” expresses this faith. Training emphasizes the awesome responsibility involved in caring for patients and the autonomy required to shoulder it. “You’re the doctor” speaks of society’s expectation that physicians can and should make vital decisions that affect lives. While the patient’s own preferences (e.g., among treatment options) are becoming more important, it is still the physician who must sign the order sheet. Another feature is loyalty to the profession itself. At least since Hippocrates, physicians have come to regard one another as part of a fraternity, different from lay people. Modern medical education, with its long and rigorous induction into the profession, reinforces these ideas. As long as professional loyalty is balanced with moral obligations to patients (“first do no harm”), there is nothing wrong with it. Yet another feature is the realization that learning and striving to be better never stops; continuing education and periodic re-certification is a fact of life for doctors.

As well, medicine as practiced in the U.S. incorporates peculiarly American cultural biases: Action is better than inaction; sacrifices in the present are necessary for future benefits. Americans are individualists, and the interests of individual patients (rather than third parties or the larger community) are primary. This orientation warrants the pursuit of expensive, sometimes futile, treatments.

Some of the values of biomedicine are in conflict with contemporary reality. Although medical education still emphasizes individual responsibility, today much medicine is practiced by treatment teams (think surgery), or in group settings where other professionals have a legitimate say in what happens. The emphasis on individual patients, without regard to consequences that accrue to the community at large, is simply not sustainable. Autonomy is under attack from other health professionals (such as nurse practitioners) and governmental as well as business regulators. Each time a physician must justify a treatment choice to a payer represents a decrease in that physician’s independent decision-making. Every test a physician orders so as to defend him- or herself from a potential lawsuit, rather than to promote the patient’s welfare, is a mute reminder of the profession’s decreased autonomy.

In fact, cultural and financial riptides now affecting the medical profession have led some physicians to view their profession as under siege, especially from government and from business interests. In such a climate, it should not be surprising to think that some physicians see patient satisfaction as just another demand from “the suits” who don’t understand patient care from “the sharp end.” And they respond accordingly.

In my opinion, our job as a company, as well as our jobs as individuals, is to help physicians get past the shock, denial, anger, etc. that may accompany encounters with disappointing patient satisfaction scores. First, we should listen to and acknowledge their concerns, because to be concerned is to deem the data important enough to care about. Second, it will work better to frame our interactions with these physicians as teaching opportunities, rather than wrestling matches. This means that we understand how their data came about, that we can explain and transform data into information that can be acted upon to enhance clinical and business outcomes. Survey results are unique in that they can help physicians enhance their practice (and their patients’ treatment outcomes) by providing insights into patient experiences that are otherwise unavailable. Third, we need to stand firm. With value-based purchasing on its way, patient satisfaction is only going to have a bigger role in improving the quality of health care.

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By William Faber, MD, MHCM, Medical Director, Chicago Region, Advocate Medical Group

When Jim Skogsbergh, the president and CEO of Advocate Health Care, told a large gathering of system leaders in 2006 that within a year every group within the Chicago-area system needed to achieve a patient satisfaction score of at least the 50th percentile, I doubted that our group could attain the goal. For years, I had been a medical director in one of the large medical groups within Advocate where patient satisfaction scores had traditionally hovered in the single digits. Members of our team wondered how practices at the other end of the spectrum did it. Through a focused pursuit of high patient satisfaction, we got some interesting answers … and results.

My former medical group, Advocate Health Centers (AHC), merged with several other Advocate physician groups in January 2009 to form the new Advocate Medical Group (AMG), which now employs more than 800 physicians.

In 2006, the annualized Press Ganey patient satisfaction score for AHC was near the 9th percentile, and the score for the older, smaller AMG was near the 19th percentile. Over the following three-year period, however, a remarkable transformation occurred, with these groups achieving average scores at the 73rd and 89th percentiles, respectively, in 2009.

There is no doubt in my mind that Skogsbergh’s publicly stated goal for the organization was vital to our eventual success. His declaration provided a burning platform for us to find and implement effective strategies. Support for such an initiative as a top priority, from the top of the organization, is necessary for achieving this kind of change. Skogsbergh has raised the bar each year since.

Vision is necessary but not sufficient. Our management teams devised strategies and tactics and ensured that each tactic was executed. The goal engaged every member of the team, from facilities to operations to medical management. Everyone looked at how his or her own division could contribute to a better patient experience.

Two important incentives were established to support success. Our management teams structured their own bonus plans to reward achievement of specific patient satisfaction targets. This applied to the CEO and all the vice presidents and directors, not just to some. We also engaged physicians by putting a portion of their compensation at risk for hitting specific patient satisfaction targets. Tiered incentive dollars are distributed to physicians according to their individual Press Ganey scores (based on at least 30 responses), and the highest performing physicians can earn a bonus above the amount reserved from their biweekly compensation. Because effective local group functioning affects physician satisfaction, this incentive supports physicians to use their role as team leaders to improve quality and service at their sites.

In addition to aligning incentives, we embarked on a number of specific tactics to increase patient satisfaction. We found the most fruitful tactic to be a disciplined process of having a nurse telephone a patient on the day after an appointment. Some of the staff predictably challenged this tactic because they already felt overextended. As it turned out, the time spent proactively calling patients probably saved an equivalent amount of time that would have been spent responding to calls initiated by patients. Patients who are not doing well greatly appreciate further advice and those who are doing well take these calls as an expression of our care.

Patient satisfaction became an item of discussion at every meeting, and whole meetings were devoted to the subject. We became internally transparent with site-specific monthly patient satisfaction reports, then shared best practices across all practice locations and used Press Ganey data to evaluate new initiatives and PDSA (plan-do-study-act) cycles. We provided scripting and behavioral expectations for our associates and encouraged patients to respond if surveyed. We responded to each patient comment made on a survey. We used feedback from Press Ganey surveys to improve our access, throughput and messaging. The Press Ganey client improvement manager was a useful resource behind the scenes, pointing us to Solutions Starters and helping us to better understand and accurately report the data.

Physician scores were also tracked. Medical directors personally coached physicians on their communication skills and bedside manner. AHC and AMG invested significantly in a professional coaching program for low-performing physicians. Approximately 10% of the physicians in the cohorts described here took advantage of the program. Physicians who participated showed significant improvement in their individual scores.

As patient satisfaction started to steadily climb, so did morale, which created a positive feedback loop of a better patient experience. Going through a merger did not slow the improvement of either group. The wider sharing of best practices further enhanced improvement. As just one example, the practice of patient calls by nurses the day after an appointment was quickly expanded from one site to all others.

There is a very important epilogue to this success story. At AHC there was a marked drop-off in performance during early 2010, and we are pained to admit that this trend has persisted into the second quarter of 2010 for both groups and AMG as a whole. In the fall of 2009, AMG shifted focus to the huge initiative of rolling out an electronic health record to hundreds of physicians and associates. Although the EHR will ultimately serve patient service, rolling out an EHR decreases patient access because throughput is slowed for a few months as users learn the system. At first, we assumed that this was the cause of our fall-off in patient satisfaction.

An honest look at the data, though, provides an important insight. It turns out that patient satisfaction scores have dipped across all of AMG, even at sites where the EHR was already established or where the rollout has not yet begun. Our management team agrees that the more rational and accountable conclusion is that the EHR rollout replaced patient satisfaction as our No. 1 priority. Analogous to the performance of an athlete, high patient satisfaction cannot be simply checked off a list, but rather requires the ongoing pursuit of specific behaviors that produce results. That is the good news. We know how to do it.

“Communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.”  —Etienne Wenger

Press Ganey’s Online Forum recently celebrated a new milestone with over 21,000 members. The Forum is the nation’s largest online community dedicated to health care improvement and networking. Clients connect with their peers to improve service, and operational, clinical and financial performance. It has been called “THE best practice resource.” Members network, share knowledge and discover solutions to the challenges they face every day.

On a typical day, you will find discussions about a wide variety of topics on the Forum. From improving wait times and discharge instructions to developing service standards and, yes, even scheduling floor waxing.

What has always excited me about the online community is its passion. Members are passionate about the role they play in improving the health care of their patients and sharing their stories to help others.

Change is happening so fast in health care that it’s often hard to keep up. We can either passively accept the change or use the tools and resources we have available to grow and continuously improve. Having a community of peers whose expertise you can draw upon for answers is invaluable today. When community members share ideas or help one another, they increase the personal knowledge of other community members. They also learn what has worked for others and – more important – what hasn’t worked.

As one of our hospital members writes, “I visit the Forum to read about best practices at other facilities. I also gain knowledge about what ‘didn’t work for us’ from other hospitals, which saves me time when implementing new practices.” She continues: “It is helpful to know that you are not alone in this journey. That many hospitals experience the same type of opportunities in their patients’ perception of care. The Forum provides an avenue to read about small wins and movements within other organizations. I’m grateful for this tool, use it often and suggest it to many of my team members and leaders within my organization.”

Ask yourself, “Is it possible that someone has already done what I am about to do?” If the answer is yes, then it is likely that you could learn something from others to increase your chances of success. A sense of community is built on an exchange of ideas and knowledge creation. Find opportunities to share what you and your staff are doing to improve health care. 

One of the Baldrige Criteria for Performance Excellence concerns how organizations collect and transfer knowledge internally. An organization’s performance can be measured by how well it manages its critical knowledge and solutions.

If you haven’t, consider forming communities of practice within your organization to share best practices and lessons learned. Use your intranet, e-mail or employee-lounge bulletin boards to collaborate; whatever works. Create communities among employees to help each other solve everyday work problems. Share information, passing along insights, tips and tricks, and other nuggets of knowledge to your colleagues.

The journey of improvement begins with one step. If you’re not a member of Press Ganey’s online community, there’s never been a better time to join and share what you know. If you are already a member, thank you for your participation and your passion. Keep sharing your experiences to improve health care for us all.

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“How do you feel?” It’s the simplest and arguably the most important question in all of medicine. Even with the burgeoning complexity of our health care knowledge and technology, it is still the most important question to ask, and the most important to answer. It would be the first item on any doctor’s checklist during an initial exam, the last question that should be asked before a discharge from the hospital and the first question asked during follow-up. Arguably, it’s all that really matters. How does the patient feel? 

 Unfortunately, it’s the question we’re not asking, at least not in any structured or consistent way. More precisely, we don’t routinely ask about how a patient fared following treatment.

Amidst all our knowledge, systems and funding for comparative effectiveness and medical research (approximately $100B in the U.S. each year), we don’t have much of a clue about the outcomes of actual patients treated in the real world.  Phase-four trials of medications, the evaluation of patients’ functional and health status following surgical therapy, the comparative effectiveness of lifestyle changes and watchful waiting – these are all things that we physicians don’t generally collect, analyze or report upon, although there’s little doubt that we care.

We care if Helen, who underwent a radical mastectomy 10 years ago and brought the office staff cookies, beat breast cancer. We care if Charles had a good quality of life following prostatectomy, and we care if the new blood pressure medicine we started Gina on was more effective than the old therapy. We may seem like an “out of sight, out of mind” group, but we’re not. But how often do we ask? How often do we ask about the outcomes of patient care in a way that would allow us to better understand what works in health care, and what does not? We inherently trust the research that would guide a new drug or therapy to market, but beyond that, our knowledge of population-wide outcomes is “lost to follow-up.” 

Whether its physicians or policy-makers, there is definitely support for collecting patient-provided information. Dr. Don Berwick, appointed by President Obama to be the next CMS administrator, wrote in his December, 2009 article in JAMA, “Measuring Physicians’ Quality and Performance, Adrift on Lake Wobegon:” “(P)atients can and should be asked directly about their experiences of care. The uniform use of the Hospital Consumer Assessment of Healthcare Providers and Systems survey measures in Medicare goes in the right direction, but much more should be invested in listening to patients and their families, helping them to describe how well they feel treated. The correlations between such ratings and pure, technical care quality are modest, at best, but attributes of care like “patient-centeredness,” “timeliness,” and overall responsiveness that patients can and do observe, are important qualities in their own right and each physician’s entire patient panel can contribute to sample size for these qualities.” 

The citation that Dr. Berwick referenced on the modest correlations between patient ratings and technical care quality is entitled Quality monitoring of physicians: linking patients’ experiences of care to clinical quality and outcomes by TD Sequist. He and his colleagues studied patient experience survey measures including doctor-patient communication, clinical team interaction, health promotion support, integration of care, office staff, visit-based continuity of care and organizational access, and their correlation with quality measures (HEDIS prevention, disease monitoring and outcomes measures, which are all technical care quality metrics).

The challenge with using only technical care quality metrics is that in most smaller practices there is either a lack of structured data or an insufficient number of patients to achieve a sample size with any significance for most quality measures. Rather than limit outcomes measurement to large practices, there should be an opportunity to use the patient to provide feedback about what matters most to them: whether or not the treatment worked (or is working). There is a much greater likelihood in small practices that sample sizes using this method will be adequate.

Hospitals have a higher patient volume than medical practices, and so their job of submitting quality measures to CMS is a bit easier (and soon these “Core Measures” will be used as part of value-based purchasing). But even in hospitals how is it that we require the public disclosure of 12 acute MI care measures from every hospital in the U.S., and yet we don’t have any information whatsoever on how those patients fared a year or two after treatment?  We don’t have that information available by hospital, and certainly not by physician. How is that we can ask physicians to submit seven PQRI measures surrounding diabetes care, but only the HbA1c measurement gives any real insight into the outcome of care (and even that requires coded lab result data)? 

I’ve had the opportunity to read a couple of recently published books that examine the quality of our health care system and models for improvement. In Dr. Thomas Lee’s and Dr. James Morgan’s Chaos and Organization in Health Care, the authors argue that our growing knowledge and technical prowess have resulted in chaos, and the way forward out of this chaotic cloud is to create “systemness”, or organization. Whether through the use of electronic systems, better coordination of care, payment reform to encourage accountable care or through the public reporting of patient care – or some combination of these – organization needs to arise out of the chaos in order for patients, providers and payers alike to create a more effective and efficient health care system.

In his book, The Checklist Manifesto, Atul Gawande recognizes that there is great benefit in the knowledge and technology of modern health care, with the caveat that sometimes simple checklists are needed to ensure we have our bases covered to ensure patient safety and avoid unnecessary complications.

In both these “must read” books, it is recognized that our system is chaotic, and there are practical (and sometimes very simple) steps that can be taken to improve it. Both works reinforced for me the importance of the voice of the patient, and that “Ask the patient how they feel” should be listed on performance measurement checklists.

So how can we use patient-reported information to reliably measure outcomes? Whether for the purpose of determining the most effective treatments or for determining which physician or hospital is providing the best care, having patients self-report their outcomes will likely involve measuring their baseline health and functional status, including both physical and mental health, and their health and functional status at a specified period of time following treatment. It’s important to collect information about co-morbid conditions to adjust for the severity of the patient’s health, there needs to be reliable sampling (i.e. patients can’t be cherry picked), and there will need to be disease- or treatment-specific questions at baseline and in follow-up.

Here are a few examples:

1. Knee surgery: In addition to baseline and post-therapy health and functional status assessment, it is important to understand how well controlled pain is, whether they were able to return to their work or favorite hobbies and whether or not their expectations of therapy were met.
2. Prostate cancer therapy: In addition to functional and health status, it is important to understand if the patient experiences incontinence or impotence, their level of pain control and if their expectations of therapy were met.
3. Diabetes care: Health status, blood sugar control and quality of life, along with whether their expectations of therapy were met, measured over time.
4. Back surgery: In addition to functional and health status, it is important to understand pain control, if they are able to return to work or their hobbies, if they’re experiencing neurologic symptoms and (seeing a pattern here?) if their expectations of therapy were met

Notice the importance I place on whether the patient’s expectations of therapy were met. Fundamental to the results of asking patients about their outcomes is the expectation that was set before therapy. It’s ironic to think that patients who have much more severe illness may have better self-reported outcomes because their expectations might be more realistically set compared to more healthy patients (for whom a rosy picture is almost invariably painted).

Setting more realistic expectations will mean that the outcomes that patients report will likely be better (AND coincide with higher satisfaction). Perhaps that’s one of the reasons we don’t routinely ask patients “How do you feel?”. Maybe we’re worried that the expectations we had set were not met. But maybe, just maybe, if we partner with our patients and set more realistic expectations we can ask them “How do you feel?” without hesitation, routinely, and in a structured and consistent way… following the initiation of any therapy… and not only might we start gearing our therapies to those that result in the best patient-reported outcomes, we might even agree to be measured on the results.    

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Health care reform brings with it an alphabet soup of programs aimed at pushing medical group practices to provide more patient-centered care. Acronyms such as PQRI and ACO are now common parlance at health policy gatherings, but for patients – and, indeed, most providers – they are a foreign language. It’s hard to see how they will blend to help a practice meet the overarching goal of providing the best possible outcome and experience for the patient.

Broadly, the Physician Quality Reporting Initiative (PQRI) and accountable care organization (ACO) are supposed to apply a new process to the existing health care system for the purpose of achieving better outcomes while reducing costs. Rather than explaining these specific efforts, I will indulge myself by speculating on how they could have a positive effect on a single patient and one health care challenge: patient engagement.

The value of patient engagement can be measured in terms of the desired outcomes sought by both the provider and the patient. When the patient engages with the provider and the provider engages with the customer, both will find the experience of care more satisfying as measured by patient satisfaction and physician satisfaction. When patients feel they are receiving the full attention of an expert provider, their likelihood of following treatment suggestions (taking meds, doing self-care, etc.) will increase, which leads to improved health. The net benefit of patient engagement to the provider is reduced re-admissions, fewer follow-up treatments, fewer missed appointments and a greater sense of loyalty to the health care provider who has engaged with them. (Press Ganey has in development a survey tool that will evaluate patient behavior related to treatment recommendations and protocols, which should give providers a window into their effectiveness in engaging patients as full participants in their care.)

So let’s take one diabetic patient, JoAnn, through our alphabet soup prescription. When a practice begins managing its entire patient population for high blood pressure control in diabetes mellitus (one PQRI measure), a couple of things can occur. The simple act of tracking the population (and sharing with the team of caregivers) brings light to those patients who are not meeting the control goal. The enlightened provider can create a new dialogue with the patient at a regular visit about the importance of blood pressure control. For example, JoAnn can be introduced to the National Committee for Quality Assurance standard without requiring any deep standards education. The practice team member engages JoAnn by sharing a simple goal such as, “Our practice’s goal for this year is to get 90% of our diabetic patients to less than 140/80 readings. We want you to be in the 90% group. What can we do to get there together?”

An ACO reimbursement model takes JoAnn, whose blood pressure is now in control, and extends the practice’s engagement activities to include her full team of health care providers. Through paying for value rather than paying for delivering services and procedures, this community of caregivers now wraps its arms around JoAnn with the collective goal of keeping her well. After a full year with no emergent care events, JoAnn decides she’s healthy enough to start taking those walks with her neighbor friend again. Soup anyone?

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For those of us who study and strive to improve patient satisfaction, it is evident that the degree of satisfaction is heavily influenced by patients’ needs and expectations. Although this has been described by others in great detail, I and some colleagues found a valuable set of data to support that finding in an unlikely place – on the front lines with deployed members of the Israel Defense Forces (IDF).

The health services provided and the clinician-patient interactions in the military may not be all that dissimilar to those of civilian settings, but the military provides a singular perspective because medical teams are both health care providers and military personnel fulfilling obligations to both patients and commanders. When deployed, care is quite a different experience altogether. And yet I believe that the experiences and insights gained from developing, studying and analyzing the IDF patient satisfaction survey program are instructive not just for others who provide military health care but for all providers of care. 

In October 2001, the IDF Medical Corps initiated a large-scale patient satisfaction survey throughout a large number of primary care clinics in various units – both in the field and on the home front. The satisfaction questionnaires were prepared and validated based on interviews with customers (army personnel and health care providers) and earlier pilot studies. Using factor analysis in pilot studies allowed us to determine four primary categories of variables that strongly influenced patient satisfaction: Working environment, courtesy/interpersonal attitude, health evaluation and outcome and accessibility/availability. Demographic details were also included in the survey, although the questionnaire remained anonymous. The questionnaires were handed out to all patients before visiting the doctors’ offices. Patients were instructed to answer according to former and current experience and to return the completed questionnaire before leaving the clinic.

Using this well-established satisfaction survey method, my colleagues and I specifically were interested in measuring and comparing satisfaction with health care services at two very different military settings: battalion soldiers during active front deployment and during training activities. In this study, we specifically sampled army personnel satisfaction in battalions during deployment along the Israeli-Lebanese border and then for the same units during training in the Golan Heights.

Medical care delivery in active front units has to adjust to different military settings in order to maintain high quality standards. During training periods, the battalion troop clinic is stationary and situated near the personnel, with easy accessibility and 24-hour availability of staff for emergencies. On the other end, during active deployment, the battalion’s personnel are stationed at small, isolated outposts throughout a large area along the border. Delivering medical service to these outposts requires the medical staff to perform rounds twice weekly, preferably at regular intervals. Medics, who are stationed in the outposts, deliver daily and emergency health care, while the doctor, who is stationed at the central battalion command, serves as the department head. These outposts are located about an hour’s drive from the central battalion command. It would have been presumed that better health care service was delivered at the training setting with higher patient satisfaction.

According to this rational, our results were somewhat surprising. Patient satisfaction proved to be higher on the front lines, despite obvious disadvantages for caregiving (see graphic). The analysis of the different questionnaire categories showed that satisfaction was specifically higher in questions concerning staff’s attitude and health evaluation and outcome. Patients found the doctors more courteous and thorough and perceived the treatment better on the front lines. General satisfaction was best predicted by the patient perception of the quality of care received in deployment settings and by the clinic environment during training activity.

The fact that patient satisfaction in active deployment was higher compared with patient satisfaction in training is indicative that patients’ needs could be addressed even in combat conditions. By implementing a mobile clinic routine, patient satisfaction was kept high in spite of the challenging working environment and lack of basic facilities. Although availability and accessibility of medical care was unquestionably lower during deployment, patients perceived their doctor to be just as available as during training. This is attributed, probably, to the “personal care” perceived by these patients when their doctor makes “house calls” to their outpost.

Patient’s perception and expectations can be an important factor that influences satisfaction. According to our results, one can suggest that soldiers during active deployment had lower expectations regarding health care services. When actual experience exceeded those expectations, their satisfaction and perception of health care outcome was high. This is probably true for the perceived availability, the perception of the medical facilities and the overall quality of health care services.

In this real-life example, I had the unique opportunity to study the effects of consumer expectations on perceived satisfaction. This was achieved through the exceptional ability to have a satisfaction snapshot in an almost laboratory environment, where the providers and the consumers are constant and the variables are the health care setting and the environment. Since those early studies in my career, and having worked since mostly in civilian settings, I have grown to further appreciate our conclusions and the importance of patient’s expectations when they encounter health care services. It is this experience that has shaped my understanding that health care managers – who are constantly concerned with health care quality improvement on one hand and attracting consumers on the other – have to understand and react appropriately to patients’ expectations.

I have had the privilege recently of working with three exceptional organizations that have embraced the philosophy of employee partnership and view it as a key component to becoming high-performing organizations. Each has assessed its employees so that it can address the issues that impact satisfaction as well as work to create an environment that fosters employee engagement. Aspects of employee engagement are highly correlated with overall patient satisfaction. These organizations understand the link between an engaged workforce, patient satisfaction and their overall success.          

As defined by William A. Kahn, a professor of organizational behavior at Boston University’s School of Management, engagement is an emotional or psychological state where employees display ideal organizational behaviors. Simply put, it means employees who go above and beyond what is required of them. It means employees focusing on the needs of those they care for and those they serve before their own needs. It is employees who are equally concerned for their own success and the success of the organization. They look for ways to improve processes, quality, safety and service. They are partners. And really, who wouldn’t want to be cared for by an engaged employee? That is why engaging the workforce is so important to an organization’s success.

The organizations mentioned above have been successful at creating a culture that encourages engagement. They each work to create an environment where it is safe and encouraged to share concerns and suggestions about the work and how it is accomplished (safe social climate). Suggestions, input and differing views are encouraged. These organizations consider employee input necessary to arriving at the best possible decisions and to generating buy-in for implementation of change. They regularly assess employees’ perception of how well they involve them in decisions that affect their work. They ask about, and look for, additional opportunities to involve employees. They cultivate partnership.

Another way these organizations create an environment that encourages engagement is by supporting the delivery of high quality service through training and resources. They know that employees who believe the quality of care to be excellent and who would recommend the organization for health care services are more likely to have satisfied patients. These organizations are committed to quality and they demonstrate this commitment by ensuring employees have the tools to deliver quality service (adequate equipment, processes and ongoing training). They know that when asking employees to do quality work they need to provide the equipment and training to achieve high quality. Supported employees are then free to focus on delivering high quality service and focusing on the needs of others, which in turn will make the organization successful.

The organizations above understand the link between employee engagement and organizational performance. They have experienced the positive effects of an engaged workforce and will continue to create a culture of engagement.  

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