Orthopedic surgeon Kathleen Gartke prides herself on getting patients in and out of her clinic at the Ottawa Hospital on time. “It was something my patients always spoke favourably about, and it was nice feedback to hear,” she says.
So when patients began grumbling about delays and lengthy waits in the “plaster room,” where casts or splints are outfitted, stitches removed or dressings changed, Gartke decided to take a closer look, eventually compiling a report and list of recommendations that might help speed things along.
There were some easy fixes: the practice of referring all emergency department patients to the orthopedic specialist on call was retooled so that new patients coming in through the ED could be distributed throughout the team, rather than piling up on a single individual.
A phone tree was also further refined to determine how to deal with incoming calls, making it far more likely that patients would connect with a live responder or alternative call choices or numbers, rather than only an answering machine. Surgeons were also asked to update their booking schedules to better match their speed of practice.
“These were all things that were frustrating to patients,” she says.
It was a first step toward using patient experience feedback to focus improvement efforts.
Driving quality improvement
Patient experience surveys are meant to go beyond whether patients are satisfied with their care to understand where their experience points to gaps or places for improvement. They’re now mandatory as part of requirements for Accreditation Canada, the non-profit that affirms standards of care in health facilities across the country, and required by legislation in some provinces.
In 2011, the Canadian Institutes for Health Information (CIHI) was asked by several jurisdictions to develop a standardized patient experience survey for use by hospitals. It became available for use in 2015 and includes questions on courtesy and respect, whether care was adequately explained, control of pain, cleanliness of the facility and delivery of medications, among others.
It is now generating data in Ontario, Alberta, Manitoba and New Brunswick. British Columbia uses the tool but hasn’t submitted data to CIHI, while Prince Edward Island is implementing its use now. The data are not yet publicly available.
“We’re hopeful that we’ll be able to get at least a reasonable pan-Canadian perspective of what acute care patient experience looks like,” says Kira Leeb, Director for Health System Performance at CIHI, adding that this type of data can be combined with administrative and clinical data, allowing hospitals to look more closely not just at when and how care was provided, but how it was experienced by patients.
“That’s a very powerful way of starting to look at quality improvement,” says Leeb.
Putting patient experience data into action
Alberta piloted the CIHI survey and is already producing deeper-dive analytics, including a recent study that found a link between patient dissatisfaction with discharge instructions and higher rates of unplanned readmissions to hospital.
Notwithstanding early results from the data, Stafford Dean, Chief Analytics Officer for Alberta Health Services, says the true power of patient experience surveys comes from merging their data with cost data and clinical and patient-reported outcome data.
“If I have all that data, I can start to evaluate which practices lead to better outcomes,” he says, adding that the data is really only valuable if it’s acted upon.
“Bottom line, we’re not actively managing or trying to move these patient experience measures,” Dean says. “We’re doing a lot of reporting and there’s quite a bit of variation but the business side isn’t really taking it and designing interventions to improve. In some places they are, but it’s not being mandated. It’s all passive improvement.”
One of Gartke’s earliest accomplishments was making patient experience data more widely available – it had once been restricted to department and division heads and hospital administrators. She started by taking printouts and charts to rounds, including statistics from surveys, readmission rates and infection rates and then arranged for surgeons in her division to have access and training to use the data dashboards that show their performance metrics. This has since been rolled out to all medical staff, who now have access to an online dashboard that allows them to see how they’re doing, by department or as an individual.
“If you give them the information, they’ll come to consider the need for change organically,” she said.
A discussion of one’s patient experience dashboard was built into the re-credentialing process for the hospital’s orthopedic team, which Gartke says brought two types of benefits: physicians were forced to become familiar with the results of patient experience surveys and bring a plan to address problem areas to the discussion. The discussion also resulted in physician leaders becoming aware of potential issues needing to be addressed.
“In the beginning, there will always be some grumbling: ‘the data are flawed, this doesn’t apply to me, I’m different.’ But what we found was that some of the weaker performers self-identified and came up with projects to move ahead,” she says. “You don’t really know where to focus your actions or energy until you know how you’re doing.”
Physicians have a high degree of interest in responses that relate directly to them, she says, including their communication style, but also have a great deal of influence over responses to general questions, such as “did you get enough information about…” or “did someone explain to you…” or questions about understanding new medications. Improving their own approach to talking a patient through medication changes can have a powerful effect on how they respond to these survey questions.
In the span of a year, one hundred percent of orthopedic surgeons have accessed their data and the number of hits on the patient experience dashboard originating from orthopedics far outnumbers all other programs. In the first year the patients’ overall rating of their experience in the orthopedic surgery program improved 5.9 percent when compared to the same time period the previous year.
Cultural change
A recent study looking at how patients perceived their care following a visit to the emergency room found a distinct divide between the aims of the ED – to diagnose or treat life-threatening conditions – and the concerns of patients. Patients were mainly concerned with four areas: symptom relief, understanding the underlying causes of their health concern, seeking reassurance and leaving equipped with a plan for further care or tests.
Consider a patient who arrives at the emergency department with chest pain. While ED staff may feel they’ve delivered good care when a heart attack has been ruled out, the patient may feel differently about the experience if they’re left wanting more information on possible causes and instructions on what to do – and how urgently to do it – if the pain returns.
Samuel Vaillancourt, an emergency department physician at St. Michael’s Hospital who authored the study, is working with patients and others to develop a set of key performance targets that reflect patient concerns when receiving emergency care. They’re also developing a survey to administer to ED patients within three days of their visit, one that would help tease out areas for improvement in encounters that are often brief and unlikely to be repeated.
“Measuring patient experience would make it visible and would make it a worthwhile thing to pursue in health care quality. By not measuring it, we don’t know what concerns exist and we don’t know how to address them,” he says.
Finding the right time
It can be a challenge to find that sweet spot where patients feel motivated to provide feedback, but still have enough time to reflect meaningfully on their experience. In Ontario, response rates to hospital surveys are low, and vary significantly.
“For most people, we expect they’re very busy and they’re inundated with surveys – not necessarily from hospitals but from all other sectors, especially retail. There may be come cynicism – but for many, we believe they may not respond because they generally trust the system and are relying on the experts to know what to do,” says Anthony Jonker, Director of Innovation & Adoption at the Ontario Hospital Association.
Hospitals need to do a better job of showing patients how their feedback has prompted change, says Brian Clark, chair of the Patient Advisors Network.
“The most powerful driver of the return of those questionnaires is demonstrable results and change in the system,” he says. “I think a lot of patients see themselves filling out questionnaires which don’t seem to go anywhere. Even if the institution does make the changes, often they’re not getting around to communicating that to people who fill out the questionnaire. What everyone needs is feedback. If you get feedback it makes it all much more meaningful,” he says.
Gartke points to programs throughout her hospital that are directly connected to patient feedback: noise monitors that resulted from patient feedback about wards being too loud at night, for example, and a new #hellomynameis campaign meant to encourage better communication between care teams and their patients.
“There are whole programs in place to make these things happen, and that’s because patients filled in these surveys,” she says.
Better capturing patient concerns
Almost everyone agrees that an online patient experience survey might prompt more responses, but so far, privacy concerns have stalled the sending of surveys electronically.
Care Opinion, a website run out of the UK, circumvents that. Patients or family can submit feedback to the site on health care experiences that are posted publicly and passed on to the institutions where care was delivered. It was inspired by e-Bay-style seller reviews, receiving 1,500 submissions when it was first established in 2015, and has since spread to Ireland and Australia.
RateMDs and OntarioDoctorDirectory also allow patients to leave anonymous Yelp-type reviews.
But it’s not scientifically rigorous, meaning some health care facilities don’t take it seriously.
“What you have is those who chose to go to site because they’re motivated for whatever reason. What you end up with is the extreme: it’s either really good or really bad,” Jonker says.
“We’re actively thinking about how do we continue to advance the art of this and do it in new and different ways,” he says, noting that “as technology and preferences change, we need to evolve the ways we survey patients to allow them to share their perspective.”
Still, he says there is concern that paper surveys miss people without a mailing address, English literacy or a willingness to mail back their responses.
Gartke predicts the next big focus for improving patient experience will be on communication and sharing of information, as that’s where patient experience surveys point to the most frustration and the most room for improvement.
Survey questions around communication include whether a patient’s understanding of their condition improved, whether they understood what would happen after they left the hospital, including what symptoms to look out for and where to go for help, as well as whether care providers explained treatments, procedures or new medications.
“It seems to be the next big area where we can get traction and make a difference,” Gartke says.
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I’m not sure when Medicine became such bureaucracy. I fill no papers out, I know exactly what happens. It is a pretend process, we know this because those ratings have been around for a long time and things actually get worse. Medicine has become a sort of belief system where every employee joins the church, and even if they have different beliefs, in order to belong, you discard your own beliefs, quit or get fired.
I remember trying to get heard by a ‘patient representative’ and after just a few words I could feel the built up defenses in the representative, and I knew exactly who paid her wage and who she was representing.
It’s would be laughable, but it is so real and powerful that it is unbelievable such power exists in todays supposedly more enlightened world.
I just keep wondering what mental malady afflicts persons that turn the other way, and hide behind power, to the cost of patients. Who employs doctors? The government. Where does that money come from?
It would be wonderful to see an enlightened country such as Canada to change the existing status quo. I am not just a patient, I am your equal as a human being and I am also well informed.
Let us save paper and ink, all it might lead to is a 40 year study on the subject of patient satisfaction, with meetings and coffee and possibly a patient speaker (just to make it look real) :)
Oh I do sound disgruntled and lord knows, medical staff have a tough job, I do not envy it.
But don’t we all wish that our children and grandchildren would not have to feel a need to fill out a commentary letter?
Does medical staff wish their offspring would get the care that they themselves give to their patients?
I think a good restaurant is one in which the cook makes the kind of food with the kind of care that he himself would like to eat. And a good restaurant is also one that reacts to dissatisfaction in a manner that makes the customer want to come back. But then restaurants are not in business because of starving people.
Business based on need, often result in greed.
Good to see people looking at patient survey issues, and the lack of effect that we often notice after filing these out. I do notice one error though. Brian Clark is the Chairperson of Patient Advisors Network.