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12/1/2015
1
IHI ExpeditionPutting your Patient Experience Data to Work
Session 5: Fast and Slow Feedback – Best Practices for Both
December 1, 2015
These presenters have
nothing to disclose
Kevin Little PhDKristine White RN, BSN, MBAAngela Zambeaux
Today’s Host2
Rebecca Goldberg, Project Coordinator, Institute for
Healthcare Improvement (IHI), coordinates multiple
projects focused on increasing value in health care by
improving quality and reducing costs. Currently,
Rebecca’s primary responsibility is coordinating and
hosting IHI’s Expeditions, monthly virtual support
programs focused on specific topic areas. Rebecca is a
recent graduate of Georgetown University in
Washington, D.C., where she obtained her Bachelor of
Science degree in human science with a minor in public
health.
12/1/2015
2
Audio Broadcast3
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listen to the
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12/1/2015
3
WebEx Quick Reference
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chat to “Host”
5
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Raise your hand
6
Chat
6
What is your favorite December activity or
holiday?
Please send your message to All Participants
12/1/2015
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Expedition Director
7
Angela G. Zambeaux, Senior Project Manager, Institute
for Healthcare Improvement (IHI), has managed a wide
variety of IHI projects, including a project funded by the US
Department of Health and Human Services that partnered
with the design and innovation consulting firm IDEO
around shared decision-making and patient-centered
outcomes research, the STAAR (STate Action to Reduce
Avoidable Rehospitalizations) initiative, virtual
programming for office practices, and in-depth quality and
safety assessments for various hospitals and hospital
systems. Prior to joining IHI, Ms. Zambeaux provided
project management support to a small accounting firm
and spent a year in France teaching English to elementary
school students.
Expedition Objectives
At the conclusion of this Expedition, participants will be able to:
List the variety of patient experience data available in your organization
Identify and avoid wasted effort in use of required data
Discuss the use of complaint data for improvement
Place patient stories in context
Define fast and slow feedback and provide examples of when each is appropriate
Explain the role of leaders in interpreting and using data to drive improvement
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12/1/2015
5
Expedition Sessions
Session 1 – Data Sources: What’s Out There and What Do
You Have?
Session 2 – Understanding Potential Pitfalls and How to
Avoid Data Craziness
Session 3 –Using Surveys, Letters, and Complaints as Data
Session 4 –Storytelling: Patient, Clinician, and Staff Stories
Session 5 – Fast and Slow Feedback – Best Practices for
Both
Session 6 – Leadership from Where You Are and Where You
Are Going
9
Faculty
10
Kevin Little, PhD, Improvement Advisor, Institute for Healthcare
Improvement (IHI), is a statistician specializing in the use of
information to study, understand, and improve system
performance. His experience in application of statistical methods
includes direct work with scientists and engineers in a range of
disciplines. He has also coached improvement teams in a range of
industries. Dr. Little served as Improvement Advisor to the
National Health Disparities Collaboratives from 2001 to 2006, and
to IHI's Hospital Portfolio of projects from 2010 to 2012. Recently,
he has worked on the measurement strategy for the Healthier
Hospitals Initiative and led a pilot to improve physician
communication behaviors.
12/1/2015
6
Faculty
11
Kristine K. S. White, RN, BSN, MBA, Principal, Aerate Consulting, and
Co-Founder, Aefina Partners, LLC, previously served in senior leadership
roles at Spectrum Health. Her areas of expertise include leadership and
system design for cultures of excellence and innovation, integrating
innovation practices and skills into organizations, and readying cultures
and organizations to solve problems and identify new tools and
processes for the future. Ms. White has worked with physicians to
increase the effectiveness of physician communication efforts and with
leaders and teams to drive meaningful improvement in the patient and
family experience in organizations of all types and understand and utilize
patient experience data sets. She has also coached senior teams to
strategically focus and prioritize efforts that yield value to patients within
their systems. Ms. White is passionate about integrating patient and
family advisors into the design and evaluation of health care and has
helped many organizations build the infrastructure and processes to do
so. Her aim is to connect leaders and health care teams to a clear
purpose, with measurable and sustainable impact and value to patients
and their families.
Agenda
Assignment Review
The Prius Principles for Feedback
Case Example 1: Access Community Health Center
Case Example 2: Christiana Care Chemotherapy
Outpatient Unit
Case Example 3: Improving Physician Communications
in acute care
Summary
Assignment for Session 6
12/1/2015
7
Assignment for Week 5
13
The Assignment: Fast and Slow Feedback
Fast Feedback: Information about performance that gets
studied and acted on within 24 hours-- the "S A" steps of
PDSA for control or improvement.
Over the next two weeks, be a bit of a detective:
– Find out if your organization is doing anything around “fast
feedback” to improve patient experience.
– Look at a recent formal project to improve patient
experience in your organization, did the project incorporate
"fast feedback?" Why or why not?
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What is Slow Feedback?
Any feedback that is not fast.
Typical slow feedback will be formal patient
experience surveys required by government
agencies and similar formal surveys. The survey
response is usually separated by days or weeks
from specific care experiences.
15
Pinnacle Health Fast Feedback
Rounding by Nurse Manager
Patient Experience Coach interview process"These individuals not only round on the staff, they coach and validate staff on their patient interaction skills. This program also provides tools that helps ease and improve communication between our patients, providers, and staff members. Another facet of this program is interviewing patients directly, to gather information on their experience and determine if the coaching has had a positive effect. This project does incorporate fast feedback. Coaching and validation occurs in real-time and is presented after live observations of the staff members between patients. The use of fast feedback in this case gives staff members support on behaviors and actions that they are performing well and one area for improvement that can help their interactions with our patients in the future."
16
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Be Careful with Question Wording!
"The questions asked of our patients cover subjects relevant [to HCAHPS], but may not be directly related to the HCAHPS surveys "
--Pinnacle Health example emphasis added
HCAHPS regulations limit the kinds of questions and wording you may ask of patients in hospital. Is
this true of other government surveys?Reference: http://www.hcahpsonline.org/Files/QAG_V10_0_2015.pdf pp. 22-24
17
Feedback Example: Driving a Prius
18
Informing Ecological Design, LLC has designed and developed feedback
systems related to energy use in buildings since 1999. The feedback
systems have had only intermittent impact. Why?
12/1/2015
10
Does Feedback Change Behavior?
“The next big force for behavioral change
may be technology that brings consumers
face-to-face with their energy consumption.
A simple version of such energy feedback is
the dashboard of a Toyota Prius hybrid car,
which displays the rate at which the car is
burning gasoline. No one has carried out a
controlled study of how drivers react to it,
but ‘every person I know who has a Prius,
they get a big grin when I mention feedback,
and they have to tell me their personal story
about how they’ve reduced their energy
use,’ says Armel [Carrie Armel, Stanford
University].”
Science 14 August 2009: Vol. 325 no. 5942 pp. 804-811, "Leaping the Efficiency Gap" by Dan Charles
Prius 2010: display above steering20
12/1/2015
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Why feedback works in a Prius-I
Performance measurements are defined and captured reliably--Toyota engineers figured out how to
(a) calculate the instantaneous mileage;
(b) capture the right values; and
(c) transmit signals to drive the dashboard display .
They’ve worked out the data plumbing and have refined the display design over several model cycles.
http://www.hybridcars.com/hybridcarscom-gets-75-mpg-2010-toyota-prius-25680/
21
Why feedback works in a Prius-II
(1) Display in your face, all the time;
(2) Easy to interpret display for better mileage;
(3) You change accelerator and brake behavior to
move the display;
(4) You control the pedals--you're in the driver's
seat!
(5) Prius drivers are motivated to actually drive
differently and many do so.
22
Given the data plumbing…
12/1/2015
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Chat Question
Is the Toyota Prius mileage feedback
designed to be
Fast?
or
Slow?
23
Feedback changes performance if…
You can get the data (the data plumbing works)
and you:
(1) sense the data (see, hear, smell, touch…)
(2) interpret the data: what do the data mean?
(3) connect interpretation to timely actions that can improve
performance
(4) have the power to act based on (3) "be in the driver's seat"
(5) actually act
24
12/1/2015
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Prius Principles and Rounding by Nurse
Manager: Why it Works-I
The "data plumbing" doesn't need computers or
wireless connections to the cloud—data acquired
and summarized by brains of smart people who
are adaptable, flexible and able to sense
performance.
Maintenance does not require IT technical support
(though may require caffeine and strong culture
focused on great patient care)
25
Prius Principles and Rounding by Nurse
Manager: Why it Works-II
Principle Details
Sense Hear patient words, see face and body language….
Interpret Use training and human experience to get meaning
Connect to timely action
Mitigate service/care problems right away; identify coaching opportunities for staff to improve use of standardized work
Have the power to act
Nurse manager has authority and accountability--in the driver's seat!
Actually act Management system should expect Nurse manager to act--standard work for leader.Director of Nursing can round to study!
26
12/1/2015
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Access Community Health Centers Primary Care Clinic Case Example
Dan Martin, Director of Quality
12/1/2015
27
Background
Federally Qualified Health Center, not required
to submit patient experience surveys to U.S.
Government but have used CG-CAHPS
Have used Avatar to manage patient experience
surveys; will terminate contract with launch of
new system (in the past, patients might get both
Avatar and CG-CAHPS surveys)
Focus: Core patient experience questions
related to access and provider interactions
12/1/2015
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12/1/2015
15
Informing Ecological Design, LLC • Madison, WI12/1/2015
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CG-CAHPS type questionswill be asked (no more than eight); can also add two optional, for each clinic's focus
Informing Ecological Design, LLC • Madison, WI12/1/2015
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Primary Care Clinic Patient Experience Daily/Weekly Data Flow—Plan Fall 2015
Pat
ien
tC
linic
Man
ager
3rd
Par
ty D
ata
Syst
em
Phase
Answer questions about experience
after visit using iPad at kiosk/station
Review Daily Report
Process Daily Patient
Responses in close to real
time
Generate Daily Report on N Patients via email
Follow up with individual patients if
flags raised (logic TBD)
Generate Weekly report on patients for entire clinic
and by provider via email
Review Weekly report for trends and opportunities entire clinic and by
provider
Interact with Clinic Manager, depending
on review of daily report
Identify changes to test to improve performance; allocate staff time and
resources
Update Dashboard, accumulate data
Surveys anonymous but may be
able to match pt to
comment?
Dan will monitor the response rate: surveys
completed/clinic volume
12/1/2015
16
Degree of Belief-1 Why will patients take
time at check-out to respond?
(1) If clinic staff see the data demonstrate
improvements (e.g. in access to appointments)
and if data are used to acknowledge individual
staff members from comments, then staff will buy
into the use of fast(er) feedback.
(2) If clinic staff buy into the use of fast(er)
feedback, then they will encourage patients to
take the time to respond at checkout.
12/1/2015
31
Degree of Belief-2 Why will patients take
time at check-out to respond?
Call with a community health center using the
system "just like us" sealed the deal on this
approach to fast(er) patient experience feedack.
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Strengths of the Plan
Outsource the data plumbing and management to
experienced vendor; sister CHC has used vendor and
been satisfied.
Dedicated project team has tackled the challenges
systematically (e.g. how surveys and data will affect
workflow)
Addressing challenge of preferred language (e.g. Hmong
patients will need translator initially)
Initial question focus will be on access, improvements
already planned (e.g. adding providers); match admin data
T3NAA to patient perception.
12/1/2015
33
Plan strengths, generalized
Outsource tasks that are not core value-adding
services
Systematic approach to addressing problems:
dedicated work group with schedule of tasks and
decisions
Attentive to population differences
Focus initial application on area where the data
can demonstrate change
12/1/2015
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12/1/2015
18
Poll Question about response rate
One clinic will use a kiosk with iPad in the waiting area, one clinic will have an iPad at the check out desk.
Which clinic do you expect to see a higher response rate?
(1) "Waiting Area" clinic
(2) "Check out desk" clinic
12/1/2015
35
Christiana Care outpatient Chemotherapy Case example
Ann-Marie Baker, Senior Program Manager Patient Experience
Christiana Care
P36
12/1/2015
19
Informing Ecological Design, LLC • Madison, WI12/1/2015
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30-50 patients a day for GYN Oncology chemotherapy unitsUnit A operated/owned by Christiana Care, with CC physicians (10-15 pts/day)Unit B operated by Christiana Care, with mix of community and CC physiciansUnit C managed by another entity, CC responsible for the physical space
Informing Ecological Design, LLC • Madison, WI12/1/2015
38
1. Press-Ganey patient experience surveys have flagged issues:We're not explaining what to expect during treatment; not explaining side effects, not explaining follow up.
2. Incomplete information shared by office practices, leading to gaps in information and inability of CC to provide seamless care, e.g. re: follow up after treatment.3. Very low number of PG surveys returned (e.g. 6 patients of 28 replied to recent survey request); PG survey results are delayed--many days after service event.
12/1/2015
20
Informing Ecological Design, LLC • Madison, WI12/1/2015
39
Chemotherapy Patient Experience Daily Data Flow—Plan Fall 2015P
atie
nt
Un
it M
anag
erV
ice
Pre
sid
ent
CC
Dat
a Sy
stem
Phase
Answer questions about experience
during Chemo session
Review Daily Report
Accumulate Daily Patient Responses
Generate Daily Report on N Patients; looks like existing Daily Clinical
Report
Follow up with individual patients if
flags raised (logic TBD)
Generate Weekly report on patients; looks like existing
Weekly Clinical Report
Review Weekly report for trends and opportunities
Review Weekly report for Trends and opportunities
Interact with Clinic Manager, depending
on review of daily report
Identify changes to test
to improve performance; allocate staff
time and resources
Informing Ecological Design, LLC • Madison, WI12/1/2015
40
Review of Questions Oct/Nov 1. Patient-Family Advisors reviewed the initial draft of questions, suggested focus2. Ann-Marie and managers discussed the key items that managers were working on to tie questions to a few items.
Too Many questions!
Proposed Question Topics September 20151. Ease of scheduling appointment1.1 Easy to check in2. Wait to be seen3. Suite clean and tidy4. Communication with patient topics5. Nurse listening re concerns and questions6. Doctor conversation prior to visit7. Expectations met question8. Change one thing to be better question9. Open Comment Box
12/1/2015
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Informing Ecological Design, LLC • Madison, WI12/1/2015
41Revised Questions, Nov 2015
Strengths of the Planning
Unit Managers are eager for faster and more complete
data on patient experience.
Pt Family Advisors reviewed the draft questions.
Will deploy in the smallest unit starting 23 November;
this unit is owned and operated by CC.
The questions and report can be further refined; IT
support person available/skilled.
Leveraging existing investment in iPads and in-house
data acquisition/report preparation related to depression
screening.
12/1/2015
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12/1/2015
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Planning strengths, generalized
Data systems should start with end-users
engaged
Get Patient perspective
Start small and learn by doing
Assure resources available for revision of data
system
Manage costs of your data systems (bang for
buck)
12/1/2015
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Poll Question
In the current plan, every patient will be asked to respond to the experience survey. In addition some patients will receive a similar experience survey from Press-Ganey.
Based on your experience, do you expect the response rate on the Press-Ganey surveys to
(a) increase (b) stay the same or
(c) decrease
once the new in-clinic surveys are in place?
12/1/2015
44
12/1/2015
23
Physician CommunicationProject: From theory to feedback
Kevin Little, Ph.D. IHI Improvement Advisor
45
Background
Six hospitals explored an intervention to improve
patient evaluation of physician communication
(as measured by U.S. HCAHPS survey)
Focus was on hospitalists; several hospitals
extended the work to ER docs, surgeons, OB
GYNs.
HCAHPS survey data viewed as slow feedback.
46
12/1/2015
24
47Driver DiagramOutcome Primary Drivers
HCAHPS raw scores and
percentile scores will improve in 12
months
Bundle 101-Four Behaviors
1. Knock
2. Introduce self
3. Sit
4. Ask the most worried/concerned
question.
48
12/1/2015
25
Our Fast Feedback Method
The feedback form
– Behaviors
– Patient perceptions
Method to administer form (steps)
– Feedback to physicians: Who, What, When.
Summary feedback table and graph
– Used to engaging physicians
49
Fast and Slow Feedback Together
Fast Feedback
– Allow patients to assess specific physician
behavior in Bundle 101, proposed to "make a
difference"
– Show that use of Bundle 101 corresponds to
better patient perceptions of an encounter
Slow Feedback (HCAHPS)
– To show connection with Fast Feedback
50
12/1/2015
26
Fast Feedback
1. Feedback form on
paper
2. First four questions—
yes or no on behaviors in
the bundle
3. Next four questions—
patient perception of the
conversation
4. One open-ended item.
51
Using Fast Feedback
Purpose Which encounters?
Feedback Cycle
Action Focus
Cement link between providerbehavior and pt perception
Encounters of specific providers testing or using the behaviors
Minute to hours
Provider
Track group performanceover time
Randomencounters
Days to weeks Group(s) of providers
52
12/1/2015
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Individual Events History 53
54
HCAHPS Physician Communication Scores Top Box Jan 2011-Oct 2013 with median thru Aug 2012 (vertical dashed
line and start of intervention) ; national percentiles 12 months ending
Sept 2012, Hospital A
Use of Bundle 101 is associated with better immediate patient perception of communications and
higher (better) HCAHPS scores
good
12/1/2015
28
Weakest Points in our work
Data Plumbing: Maintaining the effort to acquire
the patient feedback
Actions to align behavior with Bundle 101:
physician agreement to behave consistently in the
defined way.
55
Summary
56
12/1/2015
29
Key Points
• The Prius principles apply to fast and slow feedback.
• Slow feedback typically is weak in helping you interpret & connect data signals to specific actions.
• Fast feedback has the potential to drive fast improvement but it is not just a matter of hardware & software
57
Prius PrinciplesPerformance measurements
are defined and captured
reliably
AND you
1. sense the data
2. interpret the data
3. connect the
interpretation to timely
action
4. have the power to act
5. actually act
Assignment for Session 6
58
12/1/2015
30
Assignment
If you were the CEO of your organization, what
would you do starting today to get greater impact
from patient experience data?
From your current position, what is ONE thing you
will do and ONE thing you need to create a
sustainable and balanced data plan?
Expedition Communications
• All sessions are recorded
• Materials are sent one day in advance
• Listserv address for session communications:
• To add colleagues, email us at [email protected]
60
12/1/2015
31
Session 661
Leadership from Where You Are and Where You Are GoingDecember 15th, 1-2pm EST
Thank You!
62
Angela Zambeaux
Rebecca Goldberg
Please let us know if you have any questions or
feedback following today’s Expedition webinar.
12/1/2015
32
Appendix: Method Notes
If you want to test and then implement fast feedback about patient
experience in your organization, we offer a few reminders.
63
Hypothesis: Dr Chris Hayes
Change initiatives
that do not add
additional workload
and have high
perceived value
are more likely to
be adopted, cause
less workplace
burden and
achieve the
intended outcomes
More adoptable
Less adoptable
Perceived value
Workload
SameReduced IncreasedSource: Chris Hayes, MD, MSc, MEd, FRCPC http://highlyadoptableqi.com/
12/1/2015
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Informing Ecological Design, LLC • Madison, WI
source: Table 7.1 G. Langley et al. (2009), The Improvement Guide, 2nd edition, Jossey-Bass, San Francisco © Associates in Process Improvement, used with permission.
Guidance on Scale of a Test
Repeated Use of the PDSA Cycle
Hunches Theories
Ideas
A P
S D
A P
S D
Investigation Demonstration Implementation
66
Unless changes are integrated into "daily work", changes will not stick. E.g. job descriptions and job training following current best known methods, link to supervision, etc.
12/1/2015
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Core competency: training and coaching
1. Identify key jobs
2. Teacher* breaks down job
“Know what”“Know how”
“Know why”
3. Teach one-on-one
4. “If the student hasn’t
learned, the teacher hasn’t
taught.”
67
”the way to get a person to quickly remember to do a job correctly, safely and conscientiously.” p. 73
*supervisor!