The Patient Experience:
Changing the Culture
Patty Ledbetter, BA, CHAM
Manager, Revenue Cycle Management,
Tucson Medical Center
Presented by:
Patty Ledbetter, BA, CHAM
Manager, Revenue Cycle Management
Tucson Medical Center
Tucson, Arizona
1.
2.
3.
4.
5.
6.
7.
Define the problem
Identify the root cause(s) associated with patient
dissatisfaction and the problems associated with
our poor patient satisfaction scores
Analyze various approaches and obstacles to
affect a change within the organization
Develop and implement a model to change the
culture and behaviors within the organization
Monitor and maintain the culture climate
Measure benefits as reported in our HCAHPS
scores
Plan for organizational integration





Largest single level facility in the country
Established as a community hospital in 1943
Buildings and grounds spread over 120 acres
Nearly 27 miles of combined hallways, TMC's
campus also serves as home to the Tucson
Orthopedic Institute, the Cancer Care Center of
Southern Arizona and the Children's Clinics for
Rehabilitative Services
Licensed for 615 adult, pediatric and behavioral
health beds serving more than 38,000 inpatients
and 115,000 outpatients annually.
How do TMC Scores compare to the US Top Box scores at the
TUCSON MEDICAL CENTER
Title
75th percentile?
Note: Where s cores a ppea r to meet target, but col or i ndi ca tes otherwi s e, i t i s a
res ul t of mi s s i ng a t a deci ma l poi nt l evel not s hown.
Jan
Feb Mar Apr May Jun
'11
HCAHPS - Nurses Always communicated well
77
79
76
81
78
HCAHPS - Doctors Always communicated well
79
80
76
81
78
82
HCAHPS - Responsiveness of hospital staff
57
63
58
65
60
HCAHPS - Pain was Always well controlled
72
70
72
75
HCAHPS - Staff Always explained meds to Patients
61
66
63
HCAHPS - Room/Bathroom were Always clean
69
66
HCAHPS - Always quiet at night
51
HCAHPS - Discharge information given
Jul
78.6 78.5
Aug Sep Oct Nov Dec
81
81
77
78
77
79
81
82
79
76
78
63
61
72
64
61
64
61
72
74
75
77
73
72
74
71
65
61
65
67
71
67
67
66
63
66
73
68
73
66
71
75
67
71
71
50
50
49
51
52
49
55
62
47
51
45
84
86
89
87
87
89
87
89
88
90
87
86
HCAHPS - Overall rating for this hospital (9 or 10)
63
70
63
71
66
64
71.7
74
77
63
70
66
HCAHPS - Would definitely recommend hospital
72
74
70
77
74
73
79
80
81
71
77
76
CMS
US at
75th
%ile
79
84
69
72
63
76
64
85
72
76
*(TMC benchmark for 2010 is based on US Top Box reported by CMS for Apr'08-Mar'09)
(TMC benchmark for 2011 is based on US Top Box reported by CMS for Jul'09-Jun'10)
Composite Scores & Benchmark (at far right):
68.3 70.3 68.2 72.3 69.5 71.3 71.4 75.2 74.8 69.4 71.4 69.3
74.0
HCAHPS-Hospital Consumer Assessment
of Health Plans Survey (or Hospital CAHPS®).
A nationally standardized survey developed
by CMS and AHRQ for measuring how
patients perceive the care they receive in
hospitals.
TMC HCAHPS: Cleanliness Scores
Score
MEAN Score
UCL
LCL
HS 75%ile Score
85.00%
80.00%
75.00%
70.00%
65.00%
60.00%
Nov-11
Sep-11
Jul-11
May-11
Mar-11
Jan-11
Nov-10
Sep-10
Jul-10
May-10
Mar-10
Jan-10
55.00%
TMC HCAHPS: Quietness Scores
Score
MEAN Score
UCL
LCL
HS 75%ile Score
Nov-11
Sep-11
Jul-11
May-11
Mar-11
Jan-11
Nov-10
Sep-10
Jul-10
May-10
Mar-10
Jan-10
80.00%
75.00%
70.00%
65.00%
60.00%
55.00%
50.00%
45.00%
40.00%
35.00%
30.00%
TMC HCAHPS: Nursing Communication Scores
Score
MEAN Score
UCL
LCL
HS 75%ile Score
90.00%
85.00%
80.00%
75.00%
70.00%
Nov-11
Sep-11
Jul-11
May-11
Mar-11
Jan-11
Nov-10
Sep-10
Jul-10
May-10
Mar-10
Jan-10
65.00%
TMC HCAHPS: Overall Rating Scores
Score
MEAN Score
UCL
LCL
HS 75%ile Score
80.00%
75.00%
70.00%
65.00%
60.00%
55.00%
Nov-11
Sep-11
Jul-11
May-11
Mar-11
Jan-11
Nov-10
Sep-10
Jul-10
May-10
Mar-10
Jan-10
50.00%
TMC HCAHPS: Willingness to Recommend Scores
Score
MEAN Score
UCL
LCL
HS 75%ile Score
Nov-11
Sep-11
Jul-11
May-11
Mar-11
Jan-11
Nov-10
Sep-10
Jul-10
May-10
Mar-10
Jan-10
85.00%
83.00%
81.00%
79.00%
77.00%
75.00%
73.00%
71.00%
69.00%
67.00%
65.00%
To achieve the 75% percentile or top 25% of
all hospitals is our goal.
Buy it versus make it?
 Contract with an outside company to design
and implement a plan
 Researched examples of organizational
success how companies created the “wow”
factor for their customers
Champion and vision from our COO
We began with a few initiatives




Say Hello
Image
Caring for the environment
Discharge rounds
More teams grew from there and focused on key areas
aimed at improving communication and physical
impressions in the facility. Including:












Way finding
Lunch with Linda
Say Hello
Points of Entrances
Communication Expectations-Excellent Customer
Service
Adopt A Hallway
HCAHPS
Service Recovery
Dress Code
Mission Moments
Be the Nicest
Quiet at Night





Quality objectives were developed
Best Practices (HealthStreams) were studied
Ownership and Accountability were
identified as essential pieces of the project
Acknowledged that our Volunteer
population played a key role and must be
included
Right the wrong-value in immediate service
recovery


We lacked the combined focus and other key
elements that kept the project organized and
making a bigger impact.
We needed to reorganize our efforts for a
more unified approach and delivery of a
stronger message.



The Project Team was updated
Guidance Council was created
IHI bundle model
Who is IHI?
 The Institute for Healthcare Improvement (IHI)
Development of Behavioral Bundles to
address target areas of greatest need
outlined above
A bundle is a small, straightforward set of
evidence-based practices — generally three
to five — that, when performed collectively
and reliably, have been proven to improve
patient outcomes.


Care bundles are groupings of best practices
with respect to a disease process that
individually improve care, but when applied
together may result in substantially greater
improvement.
The bundle is an effort to design a standard
approach to delivering these core elements of
care.
 Capture
improvement
measures
 Track improvement measures
over time
 Develop & implement data
collection tools
 Communicate success!



Putting it all together
Current efforts
Councils : A familiar structure that has been
successful at TMC
◦ HCAHPS Bundle Teams
◦ Patient Experience Bundle Teams
◦ Patient Experience Guiding Council

Fresh new look with interdisciplinary team

Bundle Teams Responsibility:
◦ Review the care experience from data collected
by the Shadower
◦ Define Touchpoints
◦ Build bundles to improve care experiences

Team make-up:
◦
◦
◦
◦
◦
HCAHPS Bundle Leader
Patient Experience Bundle Leader
Shadow Team
Facilitators
Members

Guidance Council make-up:
◦ Administrative Champion
◦ Care experience champions
◦ Data expert
◦ Facilitator

Guidance Council Responsibilities:
◦ Review care experience requests
◦ Charter teams
◦ Assign Bundle Leaders and assists in
selecting Team members and shadowers as
needed
◦ Review Bundle Team’s progress
◦ Assist in removing barriers, makes
suggestions
◦ Communicate Team’s work to organization


We were way off the mark in Cleanliness
and Quietness
Addressing the communication piece
We wanted to infuse feedback from patients
and families into the process.
 Shadowed patient experiences
 Interviewed patients and volunteers
 Voice of the Customer-third party patient
surveys
Uncovering opportunities to deliver
exceptional patient and family care
experiences.

Process in which a Shadower follows the
patient and family through the entire care
experience





Focus on patient’s & family’s point of view
alone.
Provides timely information
Enables patients & families to become
partners in care
Allows us to map the patient flow
Enables us to view interactions at each
touchpoint
1.
2.
3.
4.
5.
6.
Define the care experience
Select the patient and family Shadower
Gather information for the project
Connect & coordinate with the patient &
family
Observe, Record, Evaluate the experience
Report finding

Example: Emergency Department
◦ Parking to point of entry
◦ ER Admitting
◦ Registration/Triage
◦ Exam Room
 Lab, radiology
 Physician interaction
◦ Discharge process

The Shadower should:
◦ Be a good observer and listener
◦ Have a positive and supportive attitude
◦ Approach shadowing with “open eyes”
◦ Be empathetic, compassionate & reliable
◦ Have good verbal and written
communication skills






Identify the patient
Know the current flow of the care experience
Know what other patients & families have
experienced
Identify an ideal time of day
Communicate shadowing to caregivers
Tour the area prior

Make arrangements with patient and family in
advance
◦ Reduces anxiety
◦ Helps ensure success


Explain your role to patient and family
Let them know how their participation will
benefit others

Observe, Record and Evaluate!
◦ Who are the caregivers?
◦ What are the touchpoints?
◦ How long does each process take?
◦ What are the comments and concerns?
◦ What are your impressions and
observations?


Collect:
◦ Comments, questions and suggestions
◦ Touchpoints
◦ Amount of time spent at each touchpoint
◦ Quality of interactions with all caregivers
Observational Report:
◦ Include highlights, bottlenecks,
redundancies
◦ Include a time study





Many issues identified with physical space
Snacks and beverages in surgery waiting
areas need to be improved
Poor eye contact and communication from
staff with patients and visitors
Many patient conversations easily overheard
by others
Better maps and signs needed
The first bundles were identified to address:
 Communication
 Quietness
 Cleanliness (after the kick off)


Mandatory Educational Meetings were
planned and organized to orchestrate the
delivery of this new bundle information.
The first two bundles were completed to
address:
◦ Communication & Quiet


The Team held the meetings (it was a
marathon!) and participated in the delivery of
the information to all staff.
Personal accountability and on going
expectations were communicated.



The project and background were
communicated.
The Scores were examined and new goals
explained.
The first two Bundles were explained in
detail.
Senior Leadership delivered an inspirational
message about the importance of these steps
and their integration into our organizational
culture. The development of our new
performance appraisal tool to develop
behavioral expectations and measurements
was communicated.
The importance of recognizing and rewarding
the new positive behavior bundles was
explained and emphasized.

For the two months following the kick off, our
scores rose! We noticed that there was an
obvious buzz in the halls.
◦ And we noticed that the excitement created was
quickly fading
◦ We developed an assignment calendar to ensure
rounding on the units
◦ We revised our Service Recovery policy



Keeping the momentum has been our biggest
challenge. While we continue to feel the
positive effects from the project today, clearly
people change and programs lose their
strength over time.
How to keep this behavior alive is our current
focus.
New bundles are in the works and new teams
have been developed to continue
communication efforts and keep the project
alive.
In celebration of the work we do every day at
TMC, staff members, patients, visitors and
physicians are invited to share examples of
extraordinary care and kindness. These
stories are reflections of how Tucson Medical
Center brings compassion, healing and hope,
to those we serve.
I went to Wal-Mart this morning and was wearing my scrubs that say
TMC HealthCare on them and the associate noticed that I worked
there. She told me that her husband was at TMC for about 2
months (he was passing away) she told me the staff were
wonderful to both her and her husband. They made her feel
comfortable and welcomed and took excellent care of her
husband.
She decided to do home hospice and before he was discharged TMC
handled all the arrangements for a home health nurse to come,
gave her grievance counseling to prepare for his passing. She took
the names of everyone they encountered during the hospital stay
to thank them and make sure those employees were recognized
for excellent care. The home health nurse was very kind to them
and she told me TMC even gave her pamphlets on funeral
arrangements and support groups to attend after her husband
passed.
She told she will always go to TMC and recommends TMC to
everyone because of the staff. Even though her husband passed
over 2 months ago she still remembers the great care she received.
I told her thank you for letting me know. It is nice to hear
wonderful comments from the public.
Patty Ledbetter
Patty.ledbetter@tmcaz.com
520.324.3331