PROVIDER FOCUS

JANUARY 2015

Blank Children’s Hospital Hematology/Oncology Patient Satisfaction Study

Improving patient satisfaction in a mid-size pediatric hematology-oncology outpatient clinic. Nicholas J Fustino, MD,1, Justin Kochanski,2. 1Blank Children’s Hospital, UnityPoint Health Des Moines, Iowa, 2Drake University, Des Moines, Iowa.

Background: The study of patient satisfaction is a rapidly growing area of importance within healthcare. High levels of patient satisfaction are associated with exceptional doctor-patient communication (Williams S, et al., 1998), improved patient compliance (Zolnierek K and DiMatteo M, 2005), and reduced likelihood of medical malpractice (Stelfox H, et al., 2005). Furthermore, physician reimbursement and pay-for-performance measures will imminently be tied to patient satisfaction metrics. Despite its emerging significance within the medical community, a relative paucity of data exists with regards to improving patient satisfaction, and no reports have evaluated methods to improve the patient experience for the unique population served by the pediatric hematology-oncology (PHO) outpatient clinic.

Aim: To improve the PHO outpatient clinic overall patient satisfaction score to an 75th percentile nationally, and improve collective provider score to the 90th percentile nationally by the end of year 2014.

Methods: Patient satisfaction was measured using returned Press-Ganey® surveys at Blank Children’s Hospital PHO outpatient clinic (UnityPoint Health, Des Moines, Iowa), a mid-size practice consisting of 4 physicians and approximately 50-60 new oncology patients per year. Scores from year 2013 were analyzed and several provider and staff-initiated interventions were implemented in January 2014, including:

1)Distribution of published written strategies to address areas most likely to drive improvement in 2014

2)Weekly review of all returned surveys by physicians and clinic personnel

3)Review of year-to-date patient satisfaction results, goals, and progress at monthly staff meetings

4)Transparency of scores among providers

5)Devotion of additional efforts to address less-satisfied demographics (first-time patients)

6)Implementation of service recovery modalities

7)Offering of optional web-based patient satisfaction training modules to all providers

Results: Comparing pre-intervention patient satisfaction data from the year 2013 (n= 108) to year-to-date post-intervention data from year 2014 (n=98), overall patient satisfaction improved from 56st to 96rd percentile (all scores are national percentile rank). Collective provider scores improved from 70rd to 98th percentile. Among patients at their first appointment in the clinic, overall satisfaction improved from 27st to 92st percentile, and satisfaction with providers improved from 29th to 98th percentile.

Conclusions: Patient satisfaction can be improved in a mid-size PHO clinic through implementation of multiple strategic provider and staff-driven initiatives. It is unclear which interventions are most associated with improvement or if progress will be sustained as further post-intervention data is acquired. As the importance of patient satisfaction continues to grow within the medical and economic communities, further study is necessary to better address the needs of the distinctive PHO patient population.

Doctor Communication

Quint Studer, former hospital CEO who owns a very successful organization called The Studer Group has co - written a great book called “The HCAHPS Handbook”. In Section Two: “Doctor Communication”, Quint takes three questions on our patient satisfaction survey and divides them into 3 chapters:

  1. During this hospital stay, how often did doctors treat you with courtesy and respect?
  2. During this hospital stay, how often did doctors listen carefully to you?
  3. During this hospital stay, how often did doctors explain things in a way you could understand?

We will focus on the second HCAHPS question in this issue:

During this hospital stay, how often did doctors listen carefully to you?

According to Dr. Jerome Groopman, author of How Doctors Think, physicians interrupt their patients within 18 seconds of the start of the conversation. Listening counts. It counts even more than having access to the latest technology and most sophisticated equipment. It is through listening to what the patient is saying that we provide the best care and create a meaningful patient/physician relationship.

…And the tactics that make “ALWAYS” responses more likely=

Tactic 1: Reflective Listening (Paraphrasing)

Reflective listening, also known as parallel talk and paraphrasing, is a critical physician skill. It involves paying close attention to what you are hearing, so you can repeat it back to the speaker. When you practice this skill, you convey to the patient that you are listening and that you care about getting the story right.

Reflective listening can accomplish all of the top six attributes patients want in physicians (Harris Poll. 2004). These attributes are listed in order below. I want my physician to:

  1. Treat me with dignity and respect
  2. Listen carefully to my health concerns
  3. Be easy to talk to
  4. Take my concerns seriously
  5. Truly care about me and my health

Tips for using Reflective Listening:

  • Pay attention to the tone of your voice (calm, even tone, unrushed, interested)
  • Use open ended questions (invite patients to explain symptoms and pain using their own knowledge & feelings)
  • Follow the two minute rule (allow the patient to talk for two minutes uninterrupted & maintain eye contact)
  • Paraphrase with key words (“I want to make sure I heard you correctly…….I care about how you’re doing…..”)

Tactic 2: Demonstrate Empathy

Physicians certainly feel empathy for their patients. Unfortunately, many rarely demonstrate it. When patients believe you feel their pain, so to speak, they also believe you’re hearing them. The two go hand-in-hand. Demonstrating empathy takes virtually no time, and can make a big difference in the patient’s perception of whether the physician is listening. Empathy diffuses tension and fear. It says, I understand. I care.

Tips for showing Empathy:

  • Imagine yourself in the patient’s shoes (Picture this happening with you and your family. How would you feel?)
  • Say “I’m sorry” (even if you don’t understand, you can always say you’re sorry for the situation, the pain, the loss)
  • Actively listen (completely engage yourself; listen 60% talk 40%; hear the words and try to feel the emotion)
  • Offer help or a suggestion (“Let me start by helping to reduce the pain you are feeling.”)
  • Recognize the impact of family (remember to listen to family and include them in the patient’s care)

When we listen and show empathy, we not only build stronger relationships with our patients, we gain clues that help us provide proper diagnosis and better care.

Infection Prevention

UnityPoint Health Des Moines’ Role in Iowa’s Tiered Ebola Plan

The Iowa Department of Public Health (IDPH) has set up a detailed care structure for persons under investigation for Ebola Viral Disease (EVD). This system:

  • Identifies at-risk individuals
  • Monitors individuals under health orders
  • Provides safe transport
  • Provides healthcare services to rule out and/or treat individuals with suspected or confirmed Ebola

Hospitals in Iowa have been identified and defined utilizing the following tier structure:

Level / Definition / Center
Tier 1 / Biocontainment Treatment Centers / University of Nebraska Medical Center
Tier 2 / Hospitals in Iowa capable of providing definitive treatment for a confirmed case of Ebola for up to one month / The University of Iowa Hospital and Clinics
Tier 3 / Hospitals in Iowa capable of providing care for up to 5 days during rule out/ rule in phase for a suspected case of Ebola / Iowa Methodist Medical Center
Mercy Medical Center - Des Moines
Tier 4 / Any hospital, ambulatory, urgent care or clinic in Iowa capable of verbally screening and temporary isolation of a suspected case of Ebola for up to 6 hours / Iowa Lutheran Hospital
Methodist West Hospital
All other Iowa hospitals and clinics not listed above

Extensive readiness efforts are now in place at IMMC to provide Tier 3 level of care. Our care is based on two guiding principles:

  1. Provide prompt evaluation and care of patients with possible EVD while protecting the safety of staff and providers.
  2. Fully evaluate and provide care for other treatable conditions (e.g. malaria, sepsis, intra-abdominal processes).

By necessity, the entire care process is fully and carefully choreographed. A Special Response Team has been formed to care for these patients until EVD has been either ruled out or confirmed.

Summary of a few critical aspects of care for persons under investigation for EVD:

  1. All HCW involved in care are fully trained in use of personal protective equipment (PPE). Prompt and full adherence to PPE along with use of a buddy system is required.
  2. Inpatient care will be provided in 1 of 2 locations:
  3. South 2, specialized care unit.
  4. CCU when a negative airflow room is required.
  5. Number of healthcare workers providing care will be controlled.
  6. The Special Response Team along with adult and pediatric critical care and infectious disease physicians will provide care to possible EVD patients.
  7. No trainees to be involved in patient care.
  8. A log of all persons entering the room and the tasks they performed will be maintained.
  9. All patient laboratory testing will be performed in the South 2 auxiliary lab by a specially trained lab team.

Although the likelihood of treating a patient under investigation for Ebola at IMMC is low, members of our community do travel to countries with Ebola transmission. We are prepared to care for them.

Please call Infection Prevention at 205-4658 with any questions.

Measles Vaccination for Adults

Question: How do I know I am immune to measles?

Answer: Proof of immunity includes:

  • U.S. laboratory confirmation of disease-not provider diagnosis.
  • Laboratory confirmation of immunity (positive IgG on serology).
  • Birth prior to 1957- Those born prior to 1957 are likely to be immune as measles infection occurred commonly then. This does not apply to HCW(Health Care Workers).
  • 1-2 documented doses of age appropriate MMR vaccine, appropriately spaced.

Question: How do I handle adult patients with concern regarding measles?

Answer: For adults who are not HCW:

  • Born during, or after 1957 - 1 dose of MMR recommended.

If planning international travel or a student in post-secondary institution, 2 doses are recommended.

  • Born before 1957 – were likely infected with measles and therefore have presumptive immunity.

Question: What is the recommendation for MMR vaccination for HCW?

Answer: IDPH recommends all HCW, regardless of year of birth, should have 2 documented doses of MMR vaccine, proof of immunity (positive IgG result on serology) or laboratory confirmation of disease.

Question: What if serology was tested and returns as negative to 1 or more antigens?

Answer: With 2 documented doses of MMR, this person is considered immune regardless of the results of subsequent serology tests. This is because commercial tests may not be sensitive enough to reliably detect vaccine-induced immunity. Serologic tests interpreted as “indeterminate” or “equivocal” should receive 2 doses of MMR if they do not have documentation of MMR.

Clinical Informatics

Physicians who need PT care STAT

When patientsmay beheld in an area until they can get admitted or transferred to a hospital unit (high census), review the signed and held orderswith nursing staff.Signed and Held orders are not generally reviewed by the sending unit or emergency department so providers need to communicate with nursing staff if there are things that need done immediately or sooner rather than later. Remember, individual orders can be released if needed and the rest can remain signed and held.

Accepting Order Set changes

In your Epic inbasket, check for order sets needing to be updated/accepted. If you click the “Order Set/Preference List Notifications” folder, there will be a list of order set changes that need to be accepted. Click a row once to open a reading pane and view the changes (in red). Click the “Accept Changes” button to update your order set. If you do not click this button, your order set will not update and could cause errors.

Non-violent Restraint orders

This is a reminder that if you have a BPA firing because of restraint orders that will be expiring soon, please use the link in the BPA to modify the current restraint order. Once you click the link, it will open Manager Orders for you. Find the restraint order and click the modify button. If you create a new order, it does not stop the BPA from firing. If you are not the provider responsible for the restraint order, click “Not Ordering Provider” and the BPA will not fire again for three (3) hours. If you would like additional information, there is a tipsheet available within Epic.

Build Freeze

As of Friday, January 16th, a build freeze was in effect for Epic. This freeze went into effect so that the build team could begin transitioning Epic to the 2014 model. Any changes you made after January 16th until the freeze is over, anticipated to be January 29th, will not be saved once the freeze ends. This means, if you changed your user order sets or preferences during the freeze, you will need to re-save those changes again.

New ACR selection tool within Epic

Beginning February 17, 2015, we will begin using a tool called ACR (American College of Radiology) Select in Epic. With ACR Select, when you order an advanced image, (e.g. MRI, CT or Nuc Med scan) for your patient, you may see a pop up screen that, based on ACR criteria, shows the appropriateness of that imaging with the indication you have entered and suggests other testing if more appropriate. You may choose the suggested testing or continue with the imaging test you initially selected.

You may also get calls from nursing and radiology techs if they place the order for you. More information will be coming as it becomes available.

Isolation orders

If you have a patient that you believe needs to be in isolation, place an order in Epic. When placing the order, you can select the type of isolation.

Consulting Diabetic Educators

Diabetic Educators are not being consulted for of some patients with the DKA order set.

This pre-checked order is a Nursing Intervention for patient education. It does NOT include the consult to the diabetic educator.

This consult needs to be checked to consult the Diabetes Educator.

UnityPoint Clinic – Cardiology to Implement In-Patient Service at IMMC

UnityPoint Clinic – Cardiology – Methodist Plaza will implement an in-patient cardiology service beginning Monday, February 23, 2015. The inpatient service will be covered by Dr. Eduardo Antezano and Dr. SushmaKoneru.They will be assisted by locums tenens cardiologists, Dr. Hugo Koo and Dr. Rocque Arteaga who will provide weekend coverage two out of four weekends until newly recruited cardiologists arrive.