Today we're going to talk about using improvement science to create a positive sustainable patient experience. So how many of you have used a Lean Project, or an A3 to solve a clinical problem, or a safety problem, or a quality problem. Well, we can do the same thing for patient experience. We want to approach it as if we were approaching the reduction in hospital acquired infections. We want to approach it like we would if we were looking at root causes and that's what I'm going to be talking about. So the first thing we need to do, and this was brought up at the Armstrong Institute with Dr. Peter Pronovost, is really engage all around a purpose and principles. So for the patient experience, it goes back to creating that environment where their cumulative evaluation of their journey is a positive one. He also says change progresses at the speed of trust, and we have to have trust with our staff, and our frontline staff, and our caregivers and providers, and our patients and families if we're going to change. We need to build trust by doing things with others and that means engaging others, and we'll talk about this. And finally, we need to leverage informal authority, and we find often that it's those folks that have informal authority that actually have the greatest influence on leading change. Strengthen your supporters and reduce your resisters. Approach improving the patient experience using improvement science. Think about it all the way down from the patient level, all the way up to the organizational level, and we'll use those same principles that we would use if we were fixing other issues in the organization. So this is a model that we use to the Armstrong Institute and this starts with declaring your goals. So around patient experience, we need to know how we've defined it and where we're trying to get to. In other lessons, we talked about surveys and that's one way to declare your goals, maybe is around reaching a survey target. You need to create an enabling infrastructure and this means that you need to make sure that people have the tools, maybe it's around carrying communication and we'll talk a little bit more about that. You need to engage and connect and that's with your improvement team and around patient experience. We want to make sure patients and families are on that improvement team, as well as those at the front line delivering the care. You have to have transparency and accountability, and that goes to how you report the data. So let's start with step one, declaring and communicating your goals. You need to link your goals to your overall organizational strategy. This creates alignments and it sets expectations for your staff. So a Johns Hopkins Medicine, one of the strategic priorities is patient and family-centered care and we have very specific goals about how we know we're getting there. You need to determine your patients expectations. This was talked about in another lesson, we talked about focus groups, interviews, patient comments, following your patients' and families' journeys, maybe doing journey mapping. You need to assess your people, your processes and your place. And from the definition, you know that how you people interact is an important piece, but are there processes that need to be fixed that are frustrating both your staff and your patients. Those need to be addressed as well. And you need to develop and share goals and targets based on the data, so communication is very important, where are we today, where are we trying to get to and how are we going to get there. So for us at Johns Hopkins Medicine, one of our goals was to identify and implement at least one Patient and Family Advisory Council initiated system improvement effort and one for the entity. So these are goals that our patients and families set at the beginning of the year just when we're doing our strategic planning. And then the other goal was to be a national leader in patient experience and this is evidenced by our HCAHPS in patient survey top box performance. We also have other goals set around our child CAHPS, our emergency department CAHPS and our medical practice CAHPS. The enabling infrastructure at the Armstrong Institute and Johns Hopkins Medicine, these group works together because we see things that are linked. Patient safety, the external quality measures, value, equity and diversity and population health all relate to patient experience. So by working together, we have the opportunity to improve things. Keys to creating an enabling infrastructure means that you have to have your executive leadership committed to understanding and improving the patient experience. Johns Hopkins Medicine, we have the chief patient experience officer and a team that works on these efforts. Although everybody owns the patient experience, so were coaches and mentors. You have to have key influential leaders assigned to leading this effort. Not only as the chief patient experience officer, but also your vice president for medical affairs, your clinical directors, these are all influential leaders. Your chief nurse, your human resource officer, we all play a role in leading this effort. You need to choose a framework or core service standards to train, coach and mentor your staff and providers. You need to select a standardized survey and commit to regular use and analysis. And from the analysis, you also need to commit to creating action plans. Having a Patient and Family Advisory Council is critical to your success, and I can't stress this enough, and you'll hear more about Patient and Family Advisory Councils. So for us, at Johns Hopkins Medicine, we share the always experienced best practices and we've created these based on the analysis of our data. I wouldn't recommend starting all of these at once but these are some of the ones that we've done. We've created purposeful rounding, and that means that we go in and we check with the patients and we make sure that their basic needs are being met. Bedside shift report, caring communication and that's for all staff, multi-disciplinary rounds, patient whiteboards being updated and clearly communicating and the patient oriented to them, executive roundings so that we understand the experience of the patients as well as the staff, and then truly an alignment and communication tool that we're working on with our physicians. We offer ongoing opportunities. You cannot train just once at new employee orientation and hope to be successful. We continually stress the importance of our caring communication and we run cohort classes. I would recommend that as you're looking at your strategies, that you have ongoing communication, marketing, education. We align this to our core values. So again, our service standards are not seen as standing alone. We have organizational core values, being open, being kind, being a role model and these are some of the being the best. These are some of the values that we stress, and for each of these we have service standards that are linked to those core values. When you engage your staff, your providers, and your patients, and families, and improve their work, you're more likely to get a sustainable execution of the positive patient experience. So what we have are Comprehensive Unit-based Safety Programs called CUSP. And these teams review patient experience data. Again linking safety, quality, and experience together means that you'll have a better outcome. We've used high reliability principles and applied them to the patient experience. And finally our Patient and Family Advisory Council's work in small groups on identified priorities and you'll see a couple of these. So let's talk about some of the high reliability principles that are applied to the patient experience. If you look at their preoccupation with failure as a high reliability principle, for patient experience that means identify ways that the next patient may have a poor experience and then work to prevent it. The reluctance to simplify is the next principle. So we use tools to investigate scores, complaints, grievances, and consider the complexity of our system. You can use a root cause analysis again with a grievance to help you understand what went wrong. People, process, place, and how do we address those. Sensitivity to operations. So this agenda refers to the wisdom of the frontline staff, the providers, the patients and the families. The commitment to resilience means continually seeking ways to protect patients from a poor experience. And you can do this through secret shopping, observation, coaching, mentoring, and looking at your survey tools. And deference to expertise. So engaging members of our multi-disciplinary care team and our patients and families in the analysis and the efforts that we put forward. Everybody has a different perspective so whether your patient experienced professional, you're bringing one lens, a physician, a nurse, a respiratory therapist, an environmental care worker, a nutritional person, a patient, and family. They all have different lenses in which they can help to make things better on a daily basis. So at Johns Hopkins Hospital, the communication approach that we're starting to work with is called Connect, Partner, Reflect. And this model that I'm going to show you right now is something that we're using with physicians. What does connection mean? Introducing yourself, identifying others in the room, being present, minimizing distractions, and focusing fully on the patient or the family, and acknowledging the feelings and concerns of the patient and the family. Actually, not only can physicians do this but everyone can do this. And when we talk to our Patient and Family Advisory Committees, our Pediatric Committee said, "Well, actually before you even come in the room, what I want you to do is connect with the previous provider and come in and tell us what the plan is for the day or what you know." For partnership, be an information gatherer, set an agenda for the visit if appropriate, show your care non-verbally, ask open ended questions, and wait for the patient to stop talking before speaking. And we know that patients get interrupted quickly. Usually it doesn't take very long for them to say what they need to say. Engage others in the conversation with the patient's permission. So maybe the spouse or the daughter or the son or the parent in the room can tell you what they're observing and so you should engage them if the patient is comfortable with that. Finally, it's reflection. And for reflection, you need to determine if the agenda that was set has been accomplished. Did we cover everything that you had hoped we would cover? Are there additional concerns that you have that need to be addressed? You can use teach back to ensure understanding. But again we don't want to quiz the patient. We want to say- a great example is with a physical therapist and you're showing how to put a brace on. You might say, "Let me have you now put the brace on so we can make sure that you know how to do it appropriately." Use positive intent to reinforce your actions and thank the patient and family for their time. And what our parents said to us was, "Tell us that you're going to go talk to the next care provider and talk about what you discussed with us so that we make sure that there's continuity in the care that's being provided to us." I would recommend that you take this type of a model and you bring it to different patient and family advisory councils. We found that what's important to adults, it differs if you're just getting general care versus care in our Cancer Center versus our teens and children's Council. So again everybody has a slightly different perspective on this and you can learn a lot by starting with these basic tools. One of the components that we added is The Warm Welcome and The Fond Farewell. And these really came from our Patient and Family Advisory Committees and from observation, we realize that patients didn't know how to use things in their room or how different things worked. How did you order your food, how do you use the television, where are my educational videos? The Warm Welcome covers this and this is a standardized tool that we use for all new in-patients. The Fond Farewell, make sure that the patient knows where they're going next, that everything has been set, and we asked them if they've gotten a survey, we hope that they'll complete it. So measuring the patient experience is really only the beginning. You have to improve the experience before the scores will change. It's about the "always" experience. Again, we have a lot of "usuallies", we have more "always" and we want to move those "usually" experiences to "always" experiences. Using high reliability tools will help you get to that. It's about how the staff always work together to care for the patient and family and we know through data analysis that team effort is what really can make or break the entire patient experience. That handoff from one provider to the next, whether it's a physician to physician or nurse to nurse or even environmental care worker to environmental care worker. It's about always being patient and family centered in all we do, it's about being the owner of the experience and I would also add engaging the patient's families and activating them. So for us, the Patient Experience Strategy again incorporates many different roles and is a continuous cycle of improvement from setting goals to hiring the right people to building capacity to setting service standards using root causes and applying best practice, engaging your staff, your clinicians, your patients, and families in problem solving. Hearing the voice of the patient throughout their cumulative journey and responding with empathy. And this is an ongoing cycle. It's something we do every day. This is a journey, not a destination.
