Patient satisfaction, physician engagement and other CMO headaches

Miller: You will be judged. There's no way around it so why not use the great data that we have to deliver the message to people?

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Howerton: I am Russell Howerton, the Chief Medical Officer at Wake Forest Baptist Health.

Miller: I'm Thomas Miller. I'm the Chief Medical Officer at the University of Utah Hospitals and Clinic.

Howerton: Tom, help me know the strategies and tactics that have brought Utah to such a level of performance in patient experience.

Miller: Basically, this journey started about five, six years ago with our previous vice chair president and the important thing was we didn't feel like our patient experience was good enough. And we judged that anecdotally for the most part and things were not good. We got a lot of letters, a lot of complaints.

And one of the things in this journey that I learned is about all the social media out there on rating products, rating hotels, rating apparel. Whatever you think about gets rated now. I also noticed a rise of third party vendors that have no filters in terms of rating physicians and pretty quickly, I decided that the best defense was an offense. And I decided that if we could deliver our patients satisfaction, what we collect, especially in the outpatient side, that that would be better than anything that's available on the Web.

Howerton: I understand that you have wide acceptance now amongst your physician community with the concept that the comments and ratings are widely viewable. Talk me through the process by which you got there.

Miller:Right, I think there's certainly resistance to the concept that physicians will be rated by their patients. That's something that is alien to most physicians. I think most people in business understand you're going to be rated now and they don't have as much of a problem with it. The way that I tried to get by that was to put this in the framework of you will be judged, there's no way around it, so why not use the great data that we have from our external vendor that has filters to deliver the message to people?

And we have a great informatics team and a great PR team that was able to make sure that given the vast number of comments and ratings by patients, we would rise per position to the top of the Google search. And just to give you an idea of what I mean by the faith that our patients have in us, our lowest rating is about an 82/84%. That's the lowest out of a faculty of about 700 physicians who are clinically involved.

If you look at these third party vendor sites, there are many fewer comments and the problem is there are no filters on it. Anybody can write in. it could be the ex-girlfriend or boyfriend, it could be somebody that's got an ax to grind, it could be a competitor, and it could even be the physician writing his own glowing reports. I just felt that we should get to the future before the future gets to us. The vast majority of physicians have bought into this. I'd say the younger physicians understand that just because of their awareness of social media and their use of social media so they get that. As more people join onto the social media ratings and things, what's good enough, I think there's now a tiny bit of push back about do you really have to be 99.99 percentile in terms of experiential excellence?

Howerton: So you have seen improvements since you started this?

Miller: We've definitely seen improvements and we also see patients using our website or the physician's Google search and looking at their ratings from our institution when they make a decision.

Howerton: And would you have knowledge of what the interventions that the individuals and clinics who have improved have used? Is that centrally known or is essentially illumination allowing autonomous improvement that's not really capturable other than in the outcome metric?

Thomas: Good question. So number one, we have an experiential team so we support a team of individuals and one person in particular who's a very good educator around patient satisfaction and training for it and how to improve. And so as you can imagine, a number of clinics were struggling with this a little bit, "How do we get on board? How do we do this?"

And some people needed training and so we would go around to the clinics that needed training for the staff and the managers and do that part, and then also meet with physicians who initially may not have been concerned about but once those ratings went live, they really wanted to do a good job. Vetting this with the faculty took me some time and there was some heartburn. And one of the things that I learned was to never go on a vacation when you're going to turn something on.

It's interesting. I think you really don't get . . . there's almost no way around it. You're going to get negative feedback, but you won't get it until you turn something on and then you just have to deal with that.

Howerton: Is there a next big thing that you're working on to improve that aspect of your care model?

Miller: What we're working on now, and I think the new frontier for everybody, is how you improve your HCAHPS scores. It's difficult on the inpatient side, more difficult on the inpatient side because you can't tie your patient satisfaction surveys directly to one physician as you can in the outpatient setting. So you have multiple physicians, residents, medical students and I think this for me is really how we're going to improve our competency of professionalism with the ACGME. But we don't yet have a way to identify individual med students and residents with particular patients and I think it would be fantastic where we could do that.

Howerton: So our colleague, Andy Thomas at Ohio State, shared some strategies they're using around this yesterday and they actually do a tribute HCAHPS at the discharging physician level like many of us attribute other things. They over-sample their HCAHPS so they don't do the required federal sample. They sample everybody so they have an up data. They then use the data aggregated at a department level so though it's attributed to an individual physician, they then group the [HemOnc] physicians or the trauma physicians.

Miller: Right.

Howerton: They then find their institutional mean and understand how it splits across, say, different buildings or geography because overall will be impacted by, say, an old building or poor processes. And they're able to net that out and show gaps from the organizational mean to impact the data. And then they also focus upon the physician-sensitive metrics of the communication with doctors and the pain management.

Miller: This is the tough one is the pain management question and MD and nursing communication for us. Now, some units do very well and others don't do very well at all. And it's sort of surprising. Some of the units that are not doing well you might have expected them to do quite well, and we're sort of in the middle of that, trying to sort out . . . we're trying different things. What's difficult is we want to stay away from any kind of a blame game.

Howerton: Right.

Miller: And physicians, again, they're used to the kind of culture of blame and we want to get away from that and have people try different things for six months and see how it works and then come back and [inaudible 00:07:22] it.

Howerton: Perhaps that speaks to a point I have held and don't know if you share. Other than turning on the public viewing of outpatient comments, these processes are hard to improve by a sudden system-wide mandate. This is somewhat of a retail improvement effort, not a wholesale.

Miller: It is. It is. That's true. I mean, the one thing about the Google site, and again and again I say this is . . . you're putting really good information out there, once physicians start to see that and then they begin to see the universe around it on social media, then they're okay with that. But on the inpatient side it's different because so many people touch the patient. It's hard to really . . . there are different projects, how physicians communicate with nurses, how nurses communicate with patients, how physicians round. I mean, I don't know about your organization at Wake Forest, but if I have my choice, I'd put everybody into teams on rounds. I would not let people round separately.

Howerton: I absolutely agree. I don't know if you had a chance to hear [Inaudible 00:08:20] introductory remarks to the IHI last year. She described two sets of rounds of wonderful multi-disciplinary team-based rounds at Children's Hospital in Boston and then in the afternoon of that same day, coincidentally her brother-in-law was in a hospital in that region, a different hospital. And, parenthetically, perhaps if your processes aren't ideal, having the IHI president's relative in your facility is not the best strategy.

Miller: That helps a lot, yeah.

Howerton: Well, she went to see her rounds there, and every defect that we could imagine of uncoordinated, uncommunicative care and multiple providers with no shared agenda was present. So 10,000 or so of us at the IHI got to hear about that. Now, I am certain we have both kinds of rounds in our organization today. The great challenge is what is the fraction, 95/5, 40/40? Our goal is to get the good kind higher. I'm not going to say on this broadcast what I think the distribution is today.

Miller: Right, what it should be, yeah, okay. No, understood. The trouble with separate rounding of different professionals is that it creates tribalism and we've got to move away from that.

Howerton: So her premise that I subscribe to is really no patient should encounter any professional that doesn't know the shared opinion of all professionals. And that in our lexicon is what we're seeking to ask people to ascribe to. It doesn't actually prescribe what you need to do, but if you do a little mental modeling, if you don't make team-based rounds, you have created an almost infinite number of communication needs to get that to happen.

Miller: It's not very lean, is it?

Howerton: Not very lean.

Miller: Not very lean at all. Creates a lot of wasted time.

Howerton: Right. But, hopefully, we will help our teams come to see that on their own as opposed to a compulsory team-based rounding, which is a challenge to make.