Develop a patient experience program to improve your practice and increase satisfaction among patients and caregivers.

Building a Patient Experience Program

  • Adrienne Boissy, MD, MA Cleveland Clinic Health System
  • Stacy Lloyd, MPH American Medical Association
CME Credits: 0.5

How will this module help me build a patient experience program for my practice?

  1. Outlines six steps to creating a successful patient experience program
  2. Provides answers to commonly asked questions
  3. Provides tools and resources to use during and after program implementation
  4. Provides examples from other practices describing how they have implemented patient experience programs and their impact

CME accreditation information 

Increasing administrative responsibilities—due to regulatory pressures and evolving payment and care delivery models—reduce the amount of time physicians spend delivering direct patient care. Enhancing the experience of patients and their loved ones is crucial in today's health care environment. This module provides insight on how to create a successful patient experience by creating a burning platform for change, leveraging transparent feedback and providing effective training. In addition, this module also acknowledges that a comprehensive strategy relies on team engagement and provides guidance to practices on how to create a culture of empathy that is palpable to patients.

Building a Patient Experience Program
Release Date: May 2017
End Date: May 2020

Objectives

At the end of this activity, participants will be able to:

  1. At the end of this activity, learners will be able to explain the importance of prioritizing initiatives that work to improve the patient experience
  2. At the end of this activity, learners will be able to successfully implement a patient experience program within their practice.
  3. At the end of this activity, learners will be able to cite different methods of obtaining feedback from patients on their current state of satisfaction.
  4. At the end of this activity, learners will be able to apply different improvement strategies to enhance patient satisfaction and the overall experience.

Target Audience

This activity is designed to meet the educational needs of practicing physicians, other clinicians and practice managers may also be interested in this activity.

Statement of Competency

This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice and also address interdisciplinary teamwork and quality improvement.

Accreditation Statement

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement

The American Medical Association designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claiming Your CME Credit

To claim AMA PRA Category 1 Credit™, you must 1) view the module content in its entirety, 2) successfully complete the quiz answering 4 out of 5 questions correctly and 3) complete the evaluation.

Planning Committee

  • Alejandro Aparicio, MD, CME Program Committee Advisor, AMA
  • Marie T. Brown, MD, FACP, PS2 Senior Physician Advisor, AMA
  • Bernadette Lim, Program Administrator, AMA
  • Lisa Lipinski, Manager, Physician Education Resources, AMA
  • Stacy Lloyd, MPH, Senior Practice Development Specialist, AMA
  • Christine A. Sinsky, MD, FACP, Vice President, Professional Satisfaction, AMA

Author(s)

  • Adrienne Boissy, MD, MA, Chief Experience Officer of Cleveland Clinic Health System
  • Stacy Lloyd, MPH, Senior Practice Development Specialist, American Medical Association

Faculty

  • Michael C. Bennick, MD, MA, AGAF, FACP, Associate Chief of Medicine, Medical Director of the Patient Experience, Yale New Haven Hospital
  • Pam Guler, MHA, FACHE, CPXP, Vice President, Chief Patient Experience Officer, Adventist Health System
  • Sandy Myerson, MBA, MS, BSN, RN, CPXP, Senior Vice President and Chief Patient Experience Officer Mount Sinai Health System
  • Allison Winkler, MPH, Senior Practice Development Specialist, American Medical Association

About the Professional Satisfaction, Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, "Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy," and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement

The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

Media Types

This activity is available to learners through Internet and Print.

Hardware/software Requirements

Adobe Flash 9.0.115 or above
Audio speakers or headphones
Screen resolution of 800X600 or higher
MS Internet Explorer 8.0 or higher, Firefox, Opera, Safari, etc.
Adobe Reader 5.0 or higher

References

  1. Agency for Healthcare Research and Quality. Compare survey data. Updated March 2016. Accessed December 1, 2016.
  2. Agency for Healthcare Research and Quality. Get the clinician & group survey and instructions. Updated June 2016. Accessed November 9, 2016.
  3. Agency for Healthcare Research and Quality. Service Recovery Programs. Published June 2015. Accessed March 24, 2017.
  4. Association for Patient Experience. Case studies & best practices. Accessed October 26, 2016.
  5. Association for Patient Experience website. Accessed December 12, 2016.
  6. Beaulieu-Volk D. Patient trust, perception of teamwork drives practice loyalty. FierceHealthcare website. Published September 1, 2015. Accessed October 26, 2016.
  7. Centers for Medicare and Medicaid Services. HCAHPS: patients’ perspectives of care survey. Updated September 25, 2014. Accessed October 26, 2016.
  8. Cleveland Clinic Patient Experience Advisory Group. Service excellence training. Accessed October 26, 2016.
  9. Frankel RM, Stein T. Getting the most out of the clinical encounter: the Four Habits Model. The Permanente Journal. 1999;3(3).
  10. Gibbons EJ, Graham C, King J, Flott K, Jenkinson C. Developing approaches to collection and use of evidence of patient experience below the level of national surveys. Patient Experience J. 2016;3(1):92-100. http://pxjournal.org/cgi/viewcontent.cgi?article=1118&context=journal
  11. Harvard Business Review. Employee Engagement Drives Health Care Quality and Financial Returns. Published October 30, 2013. Accessed March 24, 2017.
  12. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) website. Accessed October 26, 2016.
  13. Medicare.gov | Hospital Compare. Patient experience of care domain. Accessed October 26, 2016.
  14. Press Ganey Research Note. Consumerism: earning patient loyalty and market share. Published 2015. Accessed October 26, 2016.
  15. Sherwood R. Employee engagement drives health care quality and financial returns. Harvard Business Review website. Published October 30, 2013. Accessed October 26, 2016.
  16. The Beryl Institute. Defining patient experience. Accessed October 26, 2016.
  17. The Four Habits Model. Published 2011. Accessed January 5, 2017.
  18. The Sharp Experience. AIDET: Five Steps to Achieving Satisfaction. Accessed March 24, 2017.
  19. Windover AK, Boissy A, Rice TW, Gilligan T, Velez VJ, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Experience. 2014;1(1):8-13.

Introduction

Enhancing the experience of patients and their loved ones is crucial in today's health care environment. Competition in the health care market has led patients and insurers to become more informed consumers who expect higher quality, more value and better outcomes. Patient satisfaction is viewed as an important indicator of quality of care and assists in understanding patients' perceptions of their care.

That being said, building a better patient experience goes well beyond patient satisfaction scores.

Patients make choices based on how you make them feel, not just the quality of clinical care you are providing. Therefore, a comprehensive strategy relies on team engagement to create a culture of empathy in the practice that is palpable to patients. Successful patient experience efforts are grounded by creating a burning platform for change, leveraging transparent feedback and providing effective training. Building a patient experience program is not only important for improving patient satisfaction, but can also be a rewarding activity for your practice.

enhancing the experience of patients
  • What is patient satisfaction and how does it differ from patient experience?

    Patient satisfaction is the term used to describe the extent to which a patient is content with the health care provided to them and is often measured by their responses in surveys. Patient experience considers a patient's end-to-end journey through the continuum of care. Individual experiences can be influenced by interactions with practice clinicians and staff as well as how their physical, emotional and spiritual needs are addressed in various health care settings. We encourage practices to think bigger and more holistically about the entire care experience beyond what can be shared on a survey. Physicians are often meeting patients when they're at a challenging time in their life, so the goal can't always be to make them happy, but rather to improve their experience with how care is delivered.

  • What factors affect a patient's experience?

    A variety of things influence a patient's experience, but the factor with the greatest impact is how you and your team make the patient feel. Every moment in the continuum of care matters. Communication between the patient, staff and physician are among key determinants of the experience. Clinical factors also have an impact. Comorbidities such as depression are correlated with lower patient satisfaction scores. In hospital settings, as length of stay increases, patient satisfaction scores decrease. The severity of a patient's illness as well as whether their problem is medical or surgical also influence the patient's perception of their experience. Anecdotally, patients just having had surgery tend to feel that they are being “fixed” and this is reflected in their feedback.

  • Why should I develop programming that enhances the patient's experience?

    A patient experience program can be utilized by practices of all sizes and is an effective way to:

    • Improve patient engagement and patient-physician relationships
    • Identify areas for improvement
    • Improve patient outcomes
    • Identify and celebrate what you do well
    • Differentiate your practice or organization
    • Co-create new programs with patients
    • Increase practice reputation and patient loyalty
    • Support service recovery3, which can drive brand loyalty to your clinic

    It can also improve your patient satisfaction scores, but beyond that, it is the right thing to do for your practice, staff and patients. Building more effective relationships with patients benefits physicians and their staff and supports other programs designed to bring joy back to practice.

Six steps to create a patient experience program

  1. Assess the current state of patient satisfaction
  2. Define your "North Star"
  3. Engage key stakeholders in experience design
  4. Develop and implement your patient experience strategy
  5. Analyze feedback and determine impact
  6. Recognize accomplishments and improve over time
  1. 1

    Assess the current state of patient satisfaction

    Start by gaining an understanding of the current state of patient satisfaction in your practice. There are several options for collecting patient feedback in a timely and cost-effective manner. One way is to provide patients with a patient satisfaction survey. Surveys give patients the opportunity to provide anonymous feedback that can be used to make improvements. This is a popular and simple approach that can also be used to continually evaluate the patient experience over time.

    You could also enlist members of your team to have brief, casual conversations with patients during their clinic visit. Anyone in the practice can get a pulse on patient experiences by simply asking patients "How was your visit today?" or "Do you have any feedback you'd like to provide to us?" These questions can be asked by staff at check-out, by a medical assistant as they escort the patient out of the exam room at the completion of the visit or by anyone in the practice that finds themselves sharing an elevator with a patient. Any pertinent positive or negative feedback can then be relayed to the practice manager. If accessible, reviewing patient complaints and grievances can also offer perspective.

    Review the results of the current state assessment to identify themes and trends you can highlight when discussing the program direction with other practice stakeholders. The feedback collected could help create guiding principles for the program and serve as a catalyst for change.

  • What should be included on the patient satisfaction survey?

    Practices can utilize existing surveys or create and customize surveys based on their practice needs. Some common themes on patient satisfaction surveys include access, teamwork, communication, front desk friendliness, office cleanliness and billing. You could also consider asking, "Would you recommend the practice to a friend?" This question establishes "likelihood to recommend," which is a loyalty indicator and an indirect measure of patient experience. Many surveys aim to understand how patients feel about specific components of the practice and then how likely they are to return and refer others to the practice.

  • How should I go about surveying my patient population?

    After a visit, consider handing the survey to the patient at check out, mailing the survey or sending it via email. Set a limit to the number of surveys or designate a period where you'll hand out surveys to every patient who comes to the clinic. This will prevent survey fatigue, especially if the patient sees multiple physicians in the same practice or organization. For example, make a rule that a patient can only be surveyed once every three months. To get unbiased feedback, you should also make sure patients are surveyed randomly. If you only survey patients from one day of the week, you may not get a realistic perception of the practice or clinician.

    Any survey you use should be short and simple. This module contains a template that you can adapt to fit your needs. You may also consider using the free, six-page long Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) outpatient satisfaction survey developed by the Agency for Healthcare Research and Quality. If you choose to send the survey out via mail or email, consider creating a quick cover letter to introduce the survey and its importance in improving patient experience in your practice.

  • Do patients provide honest feedback during face-to-face interactions?

    There is some evidence that patients are hesitant to give honest negative feedback for fear of retribution that might affect their care. However, some practices have found that patients are honest and respectful when giving feedback during face-to-face encounters. The patients were pleasantly surprised to be asked about their visit or experience in the practice. If you are uncomfortable with this approach, some other tactics include surveys or a comment box.

  • What are some other ways to appreciate the patient perception of the practice?

    Consider using the gemba or "go and see" methods of Lean to observe the frontline staff in their daily roles. This can be extremely helpful for administrative leadership to understand the interactions that occur between staff and patients during daily operations. You could also put together a "mystery shopper" style approach where hired and/or outside colleagues can provide you with valuable feedback related to their experience as a patient in your practice. If you choose this approach, be sensitive to your staff's reaction, so they don't feel they are being targeted or deceived. Informing them that they may be observed during a certain time period can set appropriate expectations and eliminate surprise.

  1. 2

    Define your "North Star"

    Your North Star is what your practice will strive towards and guides your program's purpose and structure. When defining your North Star, make sure you gather and discuss different team member, patient and caregiver perspectives. Take time as a team to characterize the ideal patient experience and outline goals for the program. Consider how you'll engage other physicians, staff, patients, families and loved ones.

  • What are some examples of North Stars?

    Your North Star will unite your practice around a common goal and support the development of your patient experience program. Your North Star may be defined by your organization's mission or vision statement. Some examples of guiding principles include:

    • "Patients First" at the Cleveland Clinic
    • "Healthcare that Cares" and the pineapple image, a symbol of warmth and hospitality that all patients can expect, at Baptist Health
    • "Advancing Health Together" at Duke Health
    • "Humankindness heals. Mind, body and spirit." at Dignity Health
  1. 3

    Engage key stakeholders in experience design

    Culture is critical in creating a sustainable patient experience program. To build a relationship-centered program, you need to have a culture that encompasses teamwork, integration, good communication and an environment supportive of continuous learning.

    Involve all clinical care team members, administrative leadership, front desk and scheduling staff, physicians and, perhaps most importantly, your patients in program creation. Share the results of your assessment of the current state of the patient experience and discuss reactions and trends. Hold a brainstorming session to come up with ideas for your patient experience platform. Take the opportunity to ask employees about the challenges they face in daily operations to identify areas where additional training could be useful. You can also include patients in the design process by holding a focus group to evaluate ideas.

  • Why is it so important to include stakeholders at all levels in experience design?

    There is not one ideal patient experience program, as different practices and patients will have varying preferences and expectations. Including stakeholders from all levels and areas in your practice can help you uncover valuable and sometimes surprising insights. For example, team members who work in the front desk area may notice that there is inadequate seating on busy clinic days or that the waiting area music is too loud. These are things that care team members may notice in passing without recognizing the impact that they are having on a patient's experience. Patients can offer the customer perspective that staff can often forget when they are focused on their work. That is why it is important to include personnel at all levels of your organization and partner with your patients to create a program that best fits your environment and patient population.

  • Should we consider including other types of clinicians or services in the planning stages?

    This will depend on your practice type, location and size, but it can be an important consideration. For example, if you are a surgical practice, you encounter your patients not only in the clinic but also in the operating room. Patients look at their experience in its entirety so they often don't distinguish between the two distinct care environments and staff. In this scenario, you may decide to include pre-operative testing staff, surgical waiting room staff and nurses and the patient transport team in your experience design process because their feedback may cover both environments.

    Patients often have complaints about billing processes, so including leadership from this group in experience design can also be beneficial.

  • Should we benchmark against other practices or organizations in our area to help set strategy?

    While you may choose to look at what your competitors are doing well and emulate best practices, this should not be the major driver for creating a patient experience program. Vendors exist that enable benchmarking, but if your efforts are grounded in your local culture and patient needs, you are on the right track.

  1. 4

    Develop and implement your patient experience strategy

    Work with your patient experience program team to determine which processes or changes to implement first. To ensure success, start small and pick an option that is sustainable and scalable for your practice. Here are some ideas:

    1. A
      Consider creating a Patient and Family Advisory Council (PFAC). A PFAC is a partnership between patients, families, caregivers and members of the care team that encourages honest feedback and constructive criticism to make the practice better. A PFAC ensures the voice of the consumer is integrated into prioritization of decisions your practice makes related to changes that will affect the patient community. Strengthening the partnership between the practice and its patients can help you achieve goals and provide better care to patients.
    2. B
      Institute regular leadership "rounding," where leaders are out in the clinic speaking directly with patients, families and caregivers about their experience in the practice. Rounding enables the clinic leadership to connect with patients in real time to gain a deeper understanding of tactics to strengthen care. This approach also provides opportunities for immediate service recovery and feedback for staff and physicians. You could assign a team of leaders to specific clinics or request that the manager, administrator or lead physician engage with patients in their own clinic. Leadership rounding can occur on a weekly, bi-weekly or monthly basis.
    3. C
      Make improving employee engagement a priority. Employee engagement is imperative to a successful patient experience program. It is important to understand what drives employees and why they come to work each day. Consider conducting an employee engagement survey to better understand how staff members feel about their work environment. Communication, teamwork, safety, confidence in management and the ability to provide quality care are key topics to cover in an employee engagement survey. You can also personally check in with your staff through leadership rounding to get a better understanding of what is working and what needs further attention. Listening with empathy to your employees is just as important as listening to your patients. Studies show that less than half of the U.S. healthcare workforce is highly engaged in the work they do.11 It is important to make positive changes to the work environment based on the employee feedback received so that staff feels that they are being listened to, which itself can make them more engaged. More engaged employees make for more satisfied patients.
    4. D
      Implement service excellence training for employees at all levels. Service excellence is more than a friendly face. It requires a core set of standards that yield a framework for treating patients with courtesy and respect while offering the highest quality of care. Such training teaches staff how to effectively handle patient concerns in real time as well as how to respond in a way that demonstrates empathy to the patient's concerns. Acknowledge, Introduce, Duration, Explanation and Thank You (AIDET®)18 and Communicate with H.E.A.R.T.® are examples of common service excellence training tools that help teams establish powerful communication frameworks for staff to use with patients, families and each other.

      Service excellence training will not prevent all service breakdowns, so it is also important to have a strong service recovery strategy. Service recovery can turn a disgruntled patient into someone who is happy and loyal to your practice. In the event that service recovery is needed, staff should be prepared to apologize and acknowledge the breakdown in service, listen to the patient's concerns and act quickly to fix the service issue. While all practice staff should be prepared to handle these types of situations, it is helpful to identify an individual, often a supervisor or practice manager, to lead service recovery efforts.
    5. E
      Teach effective and empathic communication. The strength of the relationship between a patient and their physician and other care providers significantly impacts the patient experience. A strong relationship is founded on effective communication. Initiate conversations with clinicians to understand how they are currently introducing the computer, working with patients on agenda setting and other aspects of the patient encounter to understand any challenges they are facing in effectively communicating with their patients. Find avenues to maximize communication and peer training. Practice listening with empathy, teach-back and other methods to foster strong communication. Consider applying evidence-based models such as the REDE Model of communication, which stands for Relationship, Establishment, Development and Engagement19, or the Four Habit Model17. REDE emphasizes creating a safe and supportive atmosphere as you establish the tone for the conversation with the patient.
  • What is the expense associated with building a patient experience program?

    Staff time is needed to collate and analyze survey data, although for many practices the time needed is minimal. If service excellence training is new to your practice, there will be some cost associated with staff time and training; however, consider incorporating the program into your new employee orientation to reduce future expense. Many of the other patient experience program strategies, such as leadership rounding or a PFAC, tend to be inexpensive and can also offer valuable insight into ways to improve the practice, maintain an engaged patient population and build a referral base without a lot of data analysis.

  • What are some common practice challenges and where do I start?

    Use your patient experience survey and/or feedback as a guide. Here are some examples of initiatives to improve patient care:

    1. Improve lab results reporting: Consider using your patient portal to automatically send a note about results being available to view along with your nurse's contact information in case the patient has questions. This provides patients with access to information as well as to the care team.
    2. Reduce patient frustration with wait time: Communicate delays to patients in a timely manner. Identify internal solutions to chronic bottlenecks and work with your team to address them. Some practices have a manager come out with coffee or vouchers when wait times are abnormally long.
    3. Reduce patient dissatisfaction with billing and insurance-related issues: It is unlikely that you will be able to eliminate all billing and insurance-related complaints, but training staff on basic insurance information and office billing practices can help them answer questions from patients. If you are consistently receiving patient feedback that their bills are hard to read or understand, consider putting together a team to reconfigure the bill layout to be more patient-friendly.
    4. Implement pre-registration: Collecting important demographic and insurance information ahead of the patient’s appointment can significantly expedite the check-in process and eliminate delays.
    5. Maximize in-basket management: Come up with a strategy to effectively manage patient messages coming through the in-basket and online patient portal to provide more timely responses to patients.
  1. 5

    Analyze feedback and determine impact

    You may choose to repeat patient satisfaction surveys as a part of your ongoing program strategy. Many surveys use similar measures that you can trend over time. If you are working with a vendor such as Press Ganey to distribute and analyze your survey or using the free CG CAHPS outpatient satisfaction survey, you can submit your practice data to a database for benchmarking.

    It is likely that you won't be able to quantify all parts of your patient experience program. Qualitative input can be just as valuable. Look for trends in the comments section of your patient survey. If you started a PFAC, ask how it's going. Is meeting attendance strong? Are patients engaged and happy to be participating? Are physicians and staff deriving value from the PFAC?

    If your practice has recently undergone a change or initiated a project aimed at solving a particular problem, look at patient visit statistics, complaint data and referral patterns to assess impact. For example, patients may have been particularly dissatisfied with the communication about wait times in your practice, so you recently put a process in place where the care team updates the front desk when the physician starts to run behind. That has allowed your front desk staff to let patients know about a delay at the time of check-in, which not only updates them immediately upon arrival, but also provides them with the opportunity to reschedule if they are not able to wait. You can track patient complaints and survey comments or complete leadership rounding to gauge the impact of this new communication strategy from the patient perspective.

  • Should I give group feedback to care team members other than the physician?

    Yes. It is surprising how many practices do not share feedback with their clinicians or teams. By sharing information, you create an environment of continuous quality improvement to keep employees engaged. During team meetings, you can use the results and patient comments to identify opportunities for improvement and highlight practice and staff strengths. Other ways to share this feedback include emails, daily huddles or displays/visual management boards in a common area.

  • What are some tips for approaching difficult conversations about satisfaction scores with clinicians?

    Reflecting patient comments back to individual clinicians can be a sensitive topic. Be sure to share positive as well as negative comments. When addressing negative feedback, it is important to give clinicians the tools they need to improve and to communicate efforts that are being made back to their patients. For example, if patients are frustrated and unable to find a parking space, be sure clinicians know that appropriate administrators are addressing this. This allows clinicians to respond to patients' concerns. If patient feedback indicates their physician seems to be rushed and distracted, relay this feedback to the physician and explore what might be leading to this response.

    If you are comfortable facilitating education to enhance communication skills, great. If not, there is tremendous value in simply exploring what clinicians think is the gold standard of communication in their practice. Ask them how they open and close visits. Collating the responses can benefit everyone in the group. Providing feedback generates discussion and helps identify strategies to improve the patient experience.

  1. 6

    Recognize accomplishments and improve over time

    Building a patient experience program can be a challenging process. Your team will continue to stay engaged if they feel the program has value. Make the program a key discussion topic in team meetings. Continue to ask for employee feedback and suggestions on ways to improve and enhance the program. Regularly share any results and positive affirmations gleaned from surveys. Share patient suggestions and stories from the PFAC or leadership rounding. Physicians and management should lead by example by participating in the various patient experience initiatives within the practice.

    Celebrate the team members who are shining in this effort. Share uplifting or positive patient narratives, invite a patient to speak and present the highlights of mystery shopping to raise awareness of how the practice is moving towards its North Star.

I have had and continue to have excellent service from Dr. Smith's staff and excellent, professional and caring medical care from Dr. Smith herself. I am retired from the U.S. Army and I have had myriad experiences with medical doctors, civilian and military, national and international. Dr. Smith is by far, one of the most knowledgeable, professional and personally caring physicians I have encountered. She is never hurried. She listens and hears my questions and concerns with compassion. Most important to me, she gives me the best professional instructions and guidance, and leaves me with the confidence I need to take better and better care of my health. Dr. Smith is a stellar example of what physicians should be; she is pragmatic about her decisions to affect my healthcare courses of actions. I have and will continue to recommend her to professional and community associates, and friends.

—Anonymous patient comment about their experience
  • What if our first attempt at a patient experience program isn't yielding the results we anticipated?

    Assess accountability and don't give up. Take a step back and regroup with your team. Review the feedback you've received so far from patients, staff and clinicians. Allow this to serve as a guide to identify what's not working and how to move forward. If you started with service excellence training, but have found that staff behavior has not changed, consider trying leadership rounding. This can help keep your program moving in a positive direction, while setting an example for others in the practice. Keeping a patient experience program going is the same as maintaining momentum for any quality improvement project.

  • When should we consider adding to our patient experience program?

    Once you've implemented your first patient experience strategy and your staff and patients seem to be responding positively, you could consider adding another component. There really is no roadmap, which is both the joy and pain of improving the patient experience. The best approach is to work closely with patients and families to guide the evolution of your program.

Transform clinical care, enhance patient loyalty, and bring joy to patients and care givers #PatientExperience #STEPSforward

Conclusion

Building a patient experience program is a team effort that requires dedication along with an openness and desire for change. The voices of patients and their loved ones can provide valuable input on what a practice is doing effectively and where improvement opportunities exist throughout the patient journey. Using this information and partnering with patients allows practices and organizations to design services that transform clinical care, enhance patient loyalty, and most importantly, bring more meaning and joy to patients and caregivers.

This module is intended to advance the user's efforts to appreciate and improve the patient experience in practice. The AMA does not promote the use of survey results as a determinative measure of physician quality for the purpose of payment. Users seeking material on this topic as it relates to federal payment programs are referred to qpp.cms.gov for more information.

partnering with patients

I have learned so many skills that will not only aid me in teaching this curriculum but are highly applicable to leadership endeavors and professional interactions. Not only will it improve the patient experience but it has the potential to really restore a joy in patient care that so many physicians are lacking and desiring. I am happy to see that this initiative has such strong support amongst the leadership of this institution. It will be successful if we continue to model that support to our colleagues.

—Physician feedback about the patient experience program at the Cleveland Clinic

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References

  1. Agency for Healthcare Research and Quality. Compare survey data. Updated March 2016. Accessed December 1, 2016.
  2. Agency for Healthcare Research and Quality. Get the clinician & group survey and instructions. Updated June 2016. Accessed November 9, 2016.
  3. Agency for Healthcare Research and Quality. Service Recovery Programs. Published June 2015. Accessed March 24, 2017.
  4. Association for Patient Experience. Case studies & best practices. Accessed October 26, 2016.
  5. Association for Patient Experience website. Accessed December 12, 2016.
  6. Beaulieu-Volk D. Patient trust, perception of teamwork drives practice loyalty. FierceHealthcare website. Published September 1, 2015. Accessed October 26, 2016.
  7. Centers for Medicare and Medicaid Services. HCAHPS: patients’ perspectives of care survey. Updated September 25, 2014. Accessed October 26, 2016.
  8. Cleveland Clinic Patient Experience Advisory Group. Service excellence training. Accessed October 26, 2016.
  9. Frankel RM, Stein T. Getting the most out of the clinical encounter: the Four Habits Model. The Permanente Journal. 1999;3(3).
  10. Gibbons EJ, Graham C, King J, Flott K, Jenkinson C. Developing approaches to collection and use of evidence of patient experience below the level of national surveys. Patient Experience J. 2016;3(1):92-100. http://pxjournal.org/cgi/viewcontent.cgi?article=1118&context=journal
  11. Harvard Business Review. Employee Engagement Drives Health Care Quality and Financial Returns. Published October 30, 2013. Accessed March 24, 2017.
  12. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) website. Accessed October 26, 2016.
  13. Medicare.gov | Hospital Compare. Patient experience of care domain. Accessed October 26, 2016.
  14. Press Ganey Research Note. Consumerism: earning patient loyalty and market share. Published 2015. Accessed October 26, 2016.
  15. Sherwood R. Employee engagement drives health care quality and financial returns. Harvard Business Review website. Published October 30, 2013. Accessed October 26, 2016.
  16. The Beryl Institute. Defining patient experience. Accessed October 26, 2016.
  17. The Four Habits Model. Published 2011. Accessed January 5, 2017.
  18. The Sharp Experience. AIDET: Five Steps to Achieving Satisfaction. Accessed March 24, 2017.
  19. Windover AK, Boissy A, Rice TW, Gilligan T, Velez VJ, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Experience. 2014;1(1):8-13.

STEPS in practice

Case 1

How’s it working in New York, NY?

Northwell Health is a large, integrated organization that performed a baseline patient experience assessment in 2014. They concluded that although pockets of excellence existed, inconsistencies in processes, resources and accountability were impacting the patient experience across the organization. To address these fundamental challenges, the Northwell Health Office of Patient and Customer Experience (OPCE) was created. Led by Chief Experience Officer Sven Gierlinger, the office is tasked with standardizing strategy, spreading best practices and advocating for customer-centric standards. Specific areas addressed by the OPCE based on the 2014 assessment included physician and nurse communication, patient and family partnership councils, real-time feedback, first impressions and patient experience data transparency.

To improve the patient experience, Northwell Health also made an effort to improve the employee experience, in parallel with the OPCE program. Northwell Health systematically implemented a cultural transformation that follows the Connectedness, Awareness, Respect and Empathy (C.A.R.E.) framework, with the goal of becoming the health care provider of choice in their geographical area. The culture of C.A.R.E. mission, vision and expectations were communicated to all employees through a cascade of experiential courses, sustained by processes such as weekly huddle messaging and recognition and solidified by policy, competency and performance evaluation measures.

One OPCE process that best exemplifies the goal of connecting with patients is the Immediate Service Recovery (ISR) tool, which allows physicians to obtain and act on real-time patient feedback. This effort is led by Peter Costantino, MD, Chairman of the Department of Otolaryngology at Northwell Health. His team became very engaged in the patient and customer experience program and developed this innovative approach to service recovery. Dr. Costantino and his team recognized that the patient experience survey being used by their office only provided a retrospective understanding of the patient experience, and didn't allow the team to address patient concerns in real time. To overcome this gap, they developed the ISR tool, a short, six-question survey that patients could quickly complete following their visit with the physician. The ISR tool captures patient feedback on the physician interaction and office processes such as ease of scheduling and wait times. Below is the process that was followed with the initial launch of the ISR tool:

  • Medical assistants (MAs) hand-delivered the survey to patients while they were still in the exam room. Once complete, the MA would visually scan the survey responses for any crucial or negative feedback.
  • If there were responses that required attention, the physician was notified and returned to the exam room to address patient concerns in real time.
  • Patients were reminded that they may receive a larger patient experience survey at a later date.
  • Office management collected, reviewed and analyzed ISR responses to identify trends within the practice.
  • Results, trends and concerns were communicated to the physician and their support team.
  • A plan of action was developed and implemented to improve areas of concern.

Over time, Dr. Costantino and his team were able to turn the manual ISR tool workflow into a digital process by using "digital pen" technology. The digital pen is a ballpoint pen with a small camera at the tip. Through a partnership with Waiting Room Solutions (WRS), Northwell Health initiated a focused pilot study at Dr. Costantino's practice using the digital pen with the ISR tool. WRS provides a web-based portal that patients are registered in prior to their visit. This allows the team to print a survey that is compatible with the digital pen. When patients use the pen to complete the ISR survey, a digital image of the completed survey, detail from the individual fields on the survey, and all pen strokes are immediately transferred to the web-based portal. "The beauty of the digital ISR is that our patients can feel comfortable providing us with feedback using a standard pen and paper survey tool, while our administrative team can analyze the responses digitally, eliminating the time-consuming tallying that a manual approach requires," said David Zeman, MBA, Administrative Director, Otolaryngology-Head & Neck Surgery.

Patients have not reported any reservations about completing the survey in either format. They welcome the opportunity to provide feedback and continue to share their comments regardless of anonymity because they appreciate Northwell Health's efforts to improve their experience.

The new digital process eliminated the cumbersome manual analyses of paper surveys to identify trends and areas of opportunity. Additionally, it has provided a more secure means for collecting information, reducing the risk of patient health information (PHI) disclosure. The greatest feature of the program lies in its simplicity. While iPad or tablet-based survey tools may be useful, the digital pen offers patients a familiar method to provide feedback without introducing confusion that often comes with learning how to use new technologies. The digital pen IRS tool also helps physicians and care teams mitigate and resolve patient concerns immediately. "This is a game changer. The ability to combine real-time feedback with service recovery and digitize data capture for review and analysis with one seamless tool is extremely useful and efficient," said Dr. Peter Costantino, Chairman and SVP, Otolaryngology-Head & Neck Surgery at Northwell Health.

Incorporating digital pen technology into patient care delivery is still early and its impact is currently being reviewed and monitored. However, the "likelihood to recommend practice" measure for the Otolaryngology service line has seen a 28 percent improvement since they started using the digital pen with the ISR tool. This represents a mean score improvement of 2.9 points. Rank performance was benchmarked against Press Ganey's national database within the Otolaryngology specialty peer group. This significant increase, along with favorable patient feedback, suggests that the digital pen innovation has had a positive impact on the patient experience. Northwell Health is dedicated to providing its community with quality, patient-centered care and continues to seek ways to leverage technology and innovation to support this overarching mission.

Watch a 2-minute video on how Northwell uses a digital pen to improve efficiency and the patient experience.

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Case 2

How’s it working in New Haven, CT?

Dr. Michael Bennick has worked at Yale New Haven Hospital (YNHH) for decades. It was only recently that his own health scare and emergent bypass surgery turned him into a patient. Small acts of kindness outside the surgical suite profoundly affected him and led to an epiphany about what influences how patients perceive YNHH. As a result, Dr. Bennick and colleagues created a formal patient experience program. He now serves as its Medical Director and is working towards creating a single care signature for all YNHH.

"It was an eye-opening experience going from walking the halls to laying down staring up at the ceiling. The Section Chief of Cardiology happens to be a friend. He came in on his day off to perform my coronary angiography. But what made an equal impression was when a food service worker, Marlene, whom I have said hello to for years, happened to pass by as I was waiting to go into the surgical suite. She stopped and touched my knee and told me 'get well soon.'' That kindness made me feel as safe as knowing such a talented cardiologist was coming to the hospital to care for me on his day off," said Dr. Bennick. "Then, a nurse heading home after her shift came to an end, reminded me that I had cared for her 17 years ago and she still remembered how that had changed her life. Her expression of gratitude, and saying that he'd be praying for me during surgery, made me feel both cared for and about. It was then that I realized just how many elements go into the experience our patients have everywhere in the Yale New Haven Hospital System."

YNHH agrees with how the Beryl Institute defines patient experience as "the sum of all interactions, shaped by an organization's culture that influences patient perceptions across the continuum of care." This is the mandate that guides how we seek to improve the experience of our patients and is becoming firmly rooted in the culture of YNHH.

The first step to implementing patient satisfaction programming was to break down two types of silos:

  1. Those that were a result of training and the job titles.
  2. Those that were a result of walls separating functional domains within the organization, such as safety, quality, engagement and experience

They accomplished this by creating 'dyads' or leadership teams composed of a nurse and a physician who would oversee the patient experience in their domain. Next they encouraged clinical leadership to address all issues concomitantly rather than sending pieces of the issue off to a functional group to be rectified. The clinical endorsement of the dyads on the front lines helped encourage staff to support behaviors that were enhancing patient experience and adjust those that weren't. Endorsements from this group ranged from requiring communication skills training for physicians and nurses to standardizing how central lines were to be maintained. Combined with a direct line to administrative leadership, this proved to be a much more effective method to promote change than senior level administrative mandates and oversight.

Like many groups, they identified areas for improvement with patient satisfaction survey data. In addition, they encourage staff from all areas, including environmental services, spiritual care, food and nutrition and human resources to share their experiences as patients or with patients. Each team meeting is kicked off with a patient story that helps ground the group in the reason that they're a part of Yale New Haven Hospital. A recent patient story exemplifies this:

"There isn't a single person I have encountered that hasn't been wonderful. They all come in the room smiling, remember the back and forth banter from the prior visit. They always ask if they can get me anything and if I ask for anything, they take care of it immediately. I watch as my roommate gets the same caring treatment as well. I don't recall all the names but Nurse Britney has been wonderful, the young man that draws my blood at night, Fernando who cleans the rooms, the young lady delivering my meds, I am sure there are a couple more. I am a manager of people as well and I am sure you would appreciate knowing this."

Patients and families are consulted as part of a formal advisory group and often sit with front line staff to review issues in their service area. This approach has uncovered ways to improve patient experience with billing, visiting hours and procedures, and accessibility of visit notes. In addition, there are no staff meetings scheduled from 9 a.m. to noon each Friday. This is to encourage leadership rounding. Administrators are supposed to be out on the floor talking with staff or patients in a way that they don't often get to experience in their role. While YNHH acknowledges that this will be a challenge to roll out system-wide and to all staff members, it is something that is greatly valued and yielding positive results for culture and patient experience.

Excellence is recognized and rewarded every month with the Patient Experience Award for Caring and Excellence (PEACE) statuette of a hand holding a heart. This award is given to staff who go above and beyond for patients. Storytelling, rewarding and recognition have become a part of YNHH's culture.

"'Patient' means 'I am suffering.' And our goal is not to add suffering to those doing the work while alleviating the suffering of the patient at the same time," says Dr. Bennick. His partner and colleague, Susan Haufe, Executive Director of Patient Experience, offers these words of advice to those starting a program of their own: "Leadership connected to the top is a must for a patient experience program to thrive and evolve. The teams need to work together with quality and safety, with employee engagement, and with each other to improve the experience for providers and patients. Identify those specific behaviors that reflect your values every day into elements of care."

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Downloadable tools

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The tools and resources here can offer implementation support for your practice. You can download and modify them to fit your specific needs.

Complete Building Patient Experience toolkit

Access all the tools and resources in the toolkit.

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Module Completion

Individual tools

  • Building a Patient Experience Program

    Download a printable PDF version of this module.

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    PDF, 397 KB

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  • Building a Patient Experience Program PowerPoint

    Use this PowerPoint presentation to review this module with your team.

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    PPT, 1,169 KB

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  • AIDET tool

    Use this service excellence training tool to teach your team how to apply Acknowledge, Introduce, Duration, Explanation and Thank you (AIDET) in their daily work.

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    MS WORD, 46 KB

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  • CG CAHPS survey

    Sample patient experience survey

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    MS WORD, 66 KB

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  • Patient experience survey

    Sample patient experience survey

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    MS WORD, 52 KB

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  • Focus group guidelines

    Tips for conducting a focus group, a sample protocol and examples of questions that can be used to spark dialog.

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    MS WORD, 45 KB

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  • REDE model skills checklist

    A guide created by The Cleveland Clinic to teach effective and empathetic communication between physicians and patients.

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    MS WORD, 51 KB

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  • Employee engagement survey

    Sample survey to help determine how employees feel about their work environment.

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    MS WORD, 37 KB

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  • Ways to celebrate

    Creative ideas to consider when celebrating your team's success.

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    MS WORD, 53 KB

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  • Leadership Rounding Template

    Use this template as a way to track interactions during rounding.

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    MS WORD, 33 KB

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