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Mission Experience:Transforming Care in the Ambulatory Setting

CJ Merrill, MSN, CPXP, CPHQPatient Experience OfficerMission HealthNorth Carolina Division of HCA

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•700-bed medical center in Asheville, NC•NC’s 6th largest health system– 7 hospitals – Primary Care Practices– Pediatric Specialty Practices – Specialty Practices•13,000 team members and 2,000 volunteers •Level II Trauma Center

Mission Health System

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Unprecedented six out of seven years.

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Mission Health’s BIG(GER) AimTo get every person to their desired

outcome, first without harm, also without waste, and always with an exceptional experience for each person, family and

team member.

The Mission Experience

How do we define the Mission Experience?1

Who is responsible for the Mission Experience?

How do we achieve the Mission Experience?

1 Adapted from the Beryl Institute http://www.theberylinstitute.org/?page=Mission

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Mission Experience Across the Continuum

• I – Introduce yourself

• C – Connect & Communicate

• A – Ask if there are any questions & Anticipate needs

• R – Respond promptly with updated expected wait time until next interaction

• E – Exit after Ensuring needs are met by asking, “What else can I do for you before I go?”

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Ambulatory Improvement Planning and Preparation: FY16

Mapping Current State

We partnered with the Experience Innovation

Network, and used their experience mapping

model, to evaluate team member workflows for

opportunities to improve patient

experience.

Problem StatementWe have 115 ambulatory clinics,

all with unique team cultures and serving diverse populations.

We have superstars across our system, so we decided to manage up the knowledge and experience

of our high performers

We did not have standardizedclinic workflows, focused on

providing an exceptional patient experience.

Analyze Current State

We identified three cross-cutting opportunities for

improvement:

The check-in and check-out process

The clinical intake and rooming process

Warm hand-offs between each step of the visit

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Ambulatory Improvement Plan Development: FY17

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Training

Measurement and Analysis

Sustainability

Accountability

• Leader Meetings• Train The Trainer• Online Learning Module• Leader-led Staff Training

• Post-training Audit: Team Member Observation • Results Report-out To Leaders• Practice Leader-led Results Meeting• Leader and Team Member 1:1s• On-site Best Practice Survey • CG CAHPS Survey Data

• Reminder cards• Monthly Patient Surveys• Survey Results Feedback• Monthly Newsletter

• Learning Module Compliance Report• Practice Leader-led Monthly Reinforcement• Leadership Attestation

Implementation Model

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Mission Experience Best Practices Workflow1. Friendly greeting2. Welcome new patients3. Introduction4. Confirm appointment time5. Set wait expectations6. Reason for visit7. Warm hand-offs8. Care narration9. Clear instructions10. Explain next steps11. Exit hand-off12. Check for questions13. Friendly closing

CommunicationTransparency

Assumptions Uncertainty Anxiety Frustration

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Baseline Performance Prior to Best Practice TrainingCommunity

MedicineFriendly Greeting Welcome Intro.

Appt. Time Wait

Warm Hand-off Narration

Next Steps

Clear Directions

Check for Questions

Friendly Closing

Total Interactions

Admin (n= 23) 93% 0% 0% 64% 29% 54% 80% 66% 91% 11% 97% n=208

Community Medicine

Friendly Greeting Welcome Intro.

Warm Hand-off Narration

Next Steps

Exit Hand-off

Clear Directions

Check forQuestions

Friendly Closing

Total Interactions

Provider (n= 31) 100% 100% 76% 85% 89% 98% 83% 99% 49% 99% n=149

Community Medicine

Friendly Greeting Intro. Wait

Warm Hand-off Narration

Next Steps

Clear Directions

Check forQuestions

Friendly Closing

Total Interactions

Clinical Staff (n= 36) 93% 33% 14% 57% 92% 100% 98% 27% 97% n=153

Data for 9 community medicine practices included in MEBP Wave 1.

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What was needed

How it was implemented

How it was understood

How it was taught

How it was designed

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Employee Training

• Post-Training Audit• Audit Results Follow-up• Patient Feedback• Monthly Reinforcement• Coaching and Support

Accountability and Sustainability

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Post-training Audit: Team Member Observation

5 patient interactions per provider and clinical team member

10 patient interactions per administrative team member

30 minutes – 1 hour per administrative team member

2-3 hours per clinical team member

3-4 hours per provider

3 team members per observer per day

Interaction Type

Friendly Greeting Welcome Intro.

Confirm Appt. Time

Set Wait Expectations

Reason for Visit

Warm Hand-off Narration

Clear Instructions

Next Steps Exit Hand-off

Checks for questions

Friendly Closing

Staff Name

Example: Check-in yes no n/an/a no yes yes n/a yes yes yes n/a n/a no yes Beth

Answer Choices

yes no n/a

Check-in Clinical Provider

Check-out

yes no n/a

yes no n/a

yes no n/a

yes no n/a

yes no n/a

yes no n/a

yes no n/a

yes no n/a

yes no n/a

no n/a

yes-walked yes-staff

yes-directions yes-asked

yes no n/a

yes no n/a

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Administrative Observation Results Example

Already aligned with best practices: • Friendly Greeting – 95%• Giving clear instructions – 100%• Friendly Closing – 95%

Opportunities to align with best practices: • Introduction – 38%• Welcome – 0% (n=2)• Confirming provider – 67%• Confirming appointment time – 44%• Setting wait expectations – 88% (n=8)• Narration – 55%• Checking for questions – 40%

Best Practice Examples: • Good morning/ afternoon. I am ____; how can I help you

today?• I see you are a new patient establishing care with us.

Welcome to practice name; we are glad you are here!• You are seeing provider today at 11am; he/she is running on

time.• I apologize, provider is running a little behind. It looks like

there are two ahead of you. We will call you back as soon as we can; or you can reschedule if you are not able to wait.

• Please bear with me for a minute while I update your information; scan your insurance card; process your payment.

• Okay, I have all the information we need/ checked you in/ notified the clinical staff that you are here. Is there anything else I can do for you?

• Please have a seat. It was nice to see/ meet you. Hope you feel better soon!

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Clinical Observation Results Example

Already aligned with best practice: • Friendly Greeting – 100%• Introduction – 100%• Setting wait expectations – 100%• Confirming reason for visit – 95% • Warm hand-offs – 100%• Giving clear instructions – 100%• What will happen post-visit – 100% (n=1)• Exit hand-offs: 100% (n=2)

Opportunities to align with best practice:• Welcome new patients - 0% (n=1)• Narrating care – 70%• Checking for questions – 80%• Friendly Closing – 75%

Best Practice Examples: • Good morning/ afternoon, how are you? I am

name and title. • This is your first time seeing provider? Well I think

you’ll like him/ her; he/she is great. • I am going to get your oxygen level, blood

pressure, and temperature. • Provider is in currently in with another patient,

and then he/she will be in with you. / There are two patient(s) ahead of you, and then provider will be in to see you.

• Do you have any questions for me? / Is the anything else I can help you with?

• It was nice to see/ meet you. I’ll be outside at the nurse’s station if you need anything.

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Provider Observation Results ExampleAlready aligned with best practices: • Friendly Greeting – 100%• Introduction – 92%• Confirming reason for visit – 96% • Warm hand-offs – 100% (n=8)• Giving clear instructions – 100%• Explaining what will happen post visit – 100%• Exit hand-offs: 95% (n=21)• Friendly Closing – 91%

Opportunities to align with best practices: • Welcome new patients - 0% (n=1)• Narrating care – 88%• Checking for questions – 61%

Best Practice Examples:• Good morning/ afternoon, I am name and title. • I understand you are here today about your diabetes.

Do you have any other concerns we need to address today?

• Explain to patient what you are going to do/ what you are doing throughout the visit, including during the physical exam.

• Clinical staff name will be back to give you the injection/ draw blood/ take you to x-ray and then you will be ready to check-out

• Do you have any questions or concerns about what we discussed today?/ What questions do you have for me about your visit today?

• Thank you for coming in today. It was nice to see/ meet you. If you have any questions after your visit, please call our office. Have a nice day!

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Leadership Report-Out

• Review what the Mission Experience team audited

• Review criteria for meeting best practices

• Review next steps

• Review team report-out presentation

• Leaders will be prepared to present observation results to teams, including:– Identifying parts of workflows that were

observed– Explaining the purpose of observation– Explaining Best Practice criteria

• Leaders will be prepared to give 1:1 feedback to each team member

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Observation Results Example

Team Members

Friendly Greeting Welcome Intro.

Appt. Time Wait

Reason for Visit

Warm Hand-off Narration

Clear Directions

Next Steps

Exit Hand-Off

Checks for Questions

Friendly Closing AVG Interactions

All (11) 98% (65) 0% (4) 74% (42) 44% (16) 96% (26) 96% (45) 87% (45) 72% (64) 100% (65) 100% (26) 96% (23) 60% (63) 87% (63) 82% 65

Provider (5) 100% (25) 0% (1) 92% (12) n/a n/a 96% (25) 100% (8) 88% (24) 100% (25) 100% (25) 95% (21) 61% (23) 91% (23) 92% 25

Clinical (4) 100% (20) 0% (1) 100% (14) n/a 100% (18) 95% (20) 100% (19) 70% (20) 100% (20) 100% (1) 100% (2) 80% (20) 75% (20) 82% 20

Admin (2) 95% (20) 0% (2) 38% (16) 44% (16) 88% (8) n/a 67% (18) 55% (20) 100% (20) n/a n/a 40% (20) 95% (20) 68% 20

• The observation results are displayed at the practice level,

for each role, and for each individual team member.

• We explain to leaders how to read the table and interpret the data.

• We also provider leaders with a qualitative data summary

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Individual Team Member FeedbackTeam Member and # of Patients

Best Practices Observation

Recommendations to Align with Best Practices Additional Feedback

Josh (5)

Always: gives a friendly greeting, introduces self, confirms reason for visit, gives clear instructions, confirms who the patient is seeing next, and friendly closing. Almost always: narrates care. Sometimes: sets wait expectations. Missing: checks for questions.

Set expectations by explaining to the patient whether he/she is next to be seen or how many patients there are ahead of him/her. Explain what you will do/are doing while taking vitals to keep the patient informed. Check for questions at the end of the interaction to be sure the patient does not need anything else.

Exceptional friendly greetings and introductions during intake. Excellent tone with patients. Great directions to the room and excellent instructions throughout interactions. Excellent examples of confirming the reason for visit. Excellent warm hand-offs and friendly closings. Almost perfectly aligned with best practices, just need to add checking for questions and do each step with each patient. Keep up the great work!

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Provider Observation Results ExampleAlready aligned with best practices: • Friendly Greeting – 100%• Introduction – 92%• Confirming reason for visit – 96% • Warm hand-offs – 100% (n=8)• Giving clear instructions – 100%• Explaining what will happen post visit – 100%• Exit hand-offs: 95% (n=21)• Friendly Closing – 91%

Opportunities to align with best practices: • Welcome new patients - 0% (n=1)• Narrating care – 88%• Checking for questions – 61%

Best Practice Examples:• Good morning/ afternoon, I am name and title. • I understand you are here today about your diabetes.

Do you have any other concerns we need to address today?

• Explain to patient what you are going to do/ what you are doing throughout the visit, including during the physical exam.

• Clinical staff name will be back to give you the injection/ draw blood/ take you to x-ray and then you will be ready to check-out

• Do you have any questions or concerns about what we discussed today?/ What questions do you have for me about your visit today?

• Thank you for coming in today. It was nice to see/ meet you. If you have any questions after your visit, please call our office. Have a nice day!

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Aligning with Best PracticesCheck-in and Check-out:• Introduction – 38%• Welcome – 0% (n=2)• Confirming provider – 67%• Confirming appointment time – 44%• Setting wait expectations – 88% (n=8)• Narration – 55%• Checking for questions – 40%

Providers:• Welcome new patients - 0% (n=1)• Narrating care – 88%• Checking for questions – 61%

Patient Rooming:• Welcome new patients - 0% (n=1)• Narrating care – 70%• Checking for questions – 80%• Friendly Closing – 75%

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Best Practice Reminder Cards

Administrative:• Welcome new patients• Introduce yourself• Confirm appointment time• Confirm provider• Set wait expectations• Explain what you’re doing• Check for questions

Providers:• Narrate during exam• Check for questions

Clinical:

• Narrate while taking vital signs• Check for questions• Friendly closing

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Mission Experience Goal

Create a culture of patient and family

centered care, ensuring that

everyone always has an exceptional experience from

their first interaction

through their last.

Introduce yourself

Connect & Communicate

Ask if there are any questions & Anticipate needs

Respond promptly with updated expected wait time until next interaction

Exit after Ensuring needs are met by asking, “What else can I do for you before I go?”

Mission Experience Demands Compassionate Conversations

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Sympathy versus Empathy

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Empathy

• Essential component to compassion; However does not always lead to compassion

“…the ability to step into the shoes of another person, aiming to understand their feelings and perspectives, and to use that understanding to guide our actions.”

Roman Krznaric, Advisor to United Nations

Roman Krznaric. “Six Habits of Highly Empathetic People.” 2012

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Four Attributes of Empathy

• To be able to see the world as others see it• To be non-judgmental• To understand another’s person’s feelings• To communicate the understanding of that person’s feelings

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Compassion

“Sympathetic consciousness of others' distress together with a desire to alleviate and relieve that suffering.”

Merriam-Webster.com

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Practices of Compassion

• Kindness• Gratitude• Appreciation• Presence

“Compassion is a two-step process of understanding and acting but empathy is only one step and it is about

emotionally absorbing the feelings of another.”Dr. Chris Kukk

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Making Time to Care• Invest time at the beginning of each patient contact to build trust and rapport• Use skills to get to the heart of the patient’s concerns quickly• Practice compassionate caring in parallel with necessary clinical tasks• Remember compassion is shown in the tiniest of acts• Appreciate that the deepest and most meaningful connections occurs in a

mere moment• Reorganize care so that it is proactive, seeking to understand patient needs

first

Dr. Robin Youngson. “Time to Care.” 2012

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+

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We would greatly appreciate your honest feedback about your experience with each staff member during your visit today.

Check-In:• Did the check-in staff introduce themselves to you today? • Did the check-in staff confirm which provider you are seeing today? • Did the check-in staff tell you whether or not your provider is running on-time today? • Did the check-in staff ask you if there was anything else they could help you with?

Clinical Staff:• Did the clinical staff introduce themselves to you today?• Did the clinical staff explain whether you are next to see the provider or how many

patients are ahead of you? • Did the clinical staff ask if there was anything else they could help you with?

Provider:• Did the provider verify the reason for your visit today? • Did your provider ask you if you had any questions at the end of your visit today?

Open-ended:• What was outstanding about your visit today?• Is there anything that could be changed to improve your experience?

YES NO N/A (I already know their name)YES NOYES NOYES NO

YES NO N/A (I already know their name)

YES NOYES NO

YES NOYES NO

On-site Best Practices Patient Experience Survey

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Best Practice Patient Experience Survey Results

72%

94%

46%

71%

76%

97%

37%

67%

75%

98%

59%

79%82%

96%

80%

88%

67%

87%84%

77%77%

99%

92%

87%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Introduction Confirmed WhichProvider

Set Wait Expectations Offered Help

Administrative Staff

95%

76%

92%

100%

91%

69%

93%

99%100%

97%

80% 80%

99%98%

93%96% 98%95%

89%

100% 100%97%

93%

99%

Clinical - Introduction Clinical - Set WaitExpectations

Clinical - Offered Help Provider Reason forVisit

Provider - Asked IfHad Questions

Clinical Staff & Providers

January

February

March

April

May

June

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Engagement: Survey Results Feedback

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FY17 & FY18 Progress

43 Practices

• 7 specialty • 12 pediatric• 18 primary

care• 4 convenient

care• 2 women’s

Patient Visits• 26,877 avg.

patient visits per month

• 322,526 avg. patient visits per year

376 Team Members

• 148 Providers

• 147 Clinical• 81 Admin.

2,112 Patient

Interactions observed for

an exceptional experience

Scope & Resources

75 Practices in 18 Counties

• 26 Specialty• 21 Pediatric• 19 Primary Care• 5 Convenient Care• 4 Women’s

1 FTE

• 600 hours annually, unpaid interns

Mission Experience Best Practices Overview

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CG CAHPS Score ComparisonMission Experience Best Practice Wave 1 Sites (FY17)

• The table above compares the scores for the CG CAHPS domains and global questions, before best practice training, and the current QTR to date.

• The data above are averages of the domain and composite scores for the 20 practices that completed Mission Experience Best Practice implementation in FY17.

CG CAHPS Domains and

Global Questions

% Top Box Before Training

Oct-Dec 2016

% Top Box After Training Jan-Mar 2019

Top Box Percentage

Increase 2016 to 2019

Overall Provider Rating 82 87 6%Recommend Provider Office 90 91 1%

Provider Communication 90 93 3%Courteous & Helpful 85 94 11%Getting Timely Care 70 79 13%

Care Coordination 80 78 -3%Recommend Mission Health n/a 69 n/a

Data Source and "N" PRC Data PG Data; N = 533

Data Updated 3/8/19

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CG CAHPS Score Comparison: Before and After Best Practice Training 2017

8283

8587

90

92

9092

9091

9293

8586

94 94

70 70

817980 80

78 78

60

65

70

75

80

85

90

95

100

Before Training: Oct-Dec 2016 After Training: Oct-Dec 2017 After Training: Oct-Dec 2018 After Training: Jan-Mar 2019

Overall Provider Rating Recommend Provider Office Provider Communication

Office Staff Access to Care Care Coordination

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CG CAHPS Score ComparisonMission Experience Best Practice Wave 2 Sites (FY18)

• The table above compares the scores for the CG CAHPS domains and global questions before best practice training, and the current QTR to date.

• The data above are averages of the domain and composite scores for the 21 practices that completed Mission Experience Best Practice implementation in FY18.

CG CAHPS Domains and

Global Questions

% Top Box Before Training

Jul-Sept 2017

% Top Box After Training Jan-Mar 2019

Top Box Percentage

Increase 2017 to 2019

Overall Provider Rating 74 82 11%Recommend Provider Office 78 87 12%

Provider Communication 84 90 7%Courteous & Helpful 78 91 17%Getting Timely Care 70 77 10%

Care Coordination 70 74 6%Recommend Mission Health n/a 66 n/a

Data Source and "N" PRC Data N = 702

Data Updated 3/8/19

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CG CAHPS Score Comparison: Before and After Best Practice Training 2018

74

8785

78

89 89

84

93 92

78

93 94

70

7876

70

77 76

50

55

60

65

70

75

80

85

90

95

100

Before Training: Jul-Sept 2017 After Training: July-Sept 2018 After Training: Jan-Mar 2019

Overall Provider Rating Recommend Provider Office Provider Communication

Office Staff Access to Care Care Coordination

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Mission Experience Best Practices FY19

13 practices• 6 Specialty• 4 Pediatric• 1 Primary Care• 1 Convenient Care• 1 Women’s

Implementation

13 practices• 2 Specialty• 7 Primary Care• 4 Convenient Care

Follow-up

26 practicesVisit Impact:• > 20,634 avg.

patient visits per month

• > 247,607 patient visits per year

FY19 Total

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Patient Stories and Feedback

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Mission Experience Video

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Questions?