Summary
As highly trained practitioners in the practice of patient care, at times we may not emphasize the art of the patient experience. Multiple studies have shown that patients’ attitudes and expectations have an effect on their outcomes after surgery. Our patients’ perceptions of their care, through proxies like respect, courtesy, compassion, emotional connection and listening, may be as important to them as the actual care received. In this discussion, I review the importance of measuring patient experiences through patient-reported experience measures, and I describe our practice at Oakville Trafalgar Memorial Hospital with mass surveying using an Internet-based survey tool. Oakville Trafalgar Memorial Hospital is a 469-bed facility in Oakville, Ont., in which 13 401 surgical procedures were performed in 2016.
Feedback, according to my wife, is the reason that I am still married after 20 years. Her feedback often leads me to the Home Depot, where after each purchase I am asked by the friendly cashier to rate their service online. Do we do that in medicine? How well do we do what we do, and how do we know it?
The godfather of the National Surgical Quality Improvement Program (NSQIP), Ernest Codman, at the turn of the 20th century, pioneered the idea that all hospitals must analyze their results, compare them with those of other hospitals and publicly report their successes and failures. This was considered heresy at the time. Have things changed 100 years later?
As specialists affiliated with the Royal College of Physicians and Surgeons of Canada, we’re mandated to complete 400 hours of continuing medical education per 5-year cycle, but we are not trained in customer service, the patient experience, or health care communication skills. We are trained to focus on outcomes and on patient care.
What is a good patient experience, and why is it important?
What is the patient experience? The Beryl Institute defines it as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.” It encompasses physicians’ manner, timely compassionate nursing care, clean surroundings and respectful and courteous treatment.
In his seminal book, Service Fanatics, Dr. James Merlino detailed the journey of the Cleveland Clinic from the lowest ranks in patient experience scores as determined by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to the 92nd percentile in 5 years.1 The Center for Medicare, understanding the importance of patient satisfaction, withholds $1.8 billion per year as part of their value-based purchasing program; how hospitals do on their HCAPS scores determines the payment of huge resources.
Function versus purpose
As caregivers and staff in a hospital, we need to understand the difference between our function and our purpose. We all have different functions, such as administration, computer support, nursing care and provision of surgical services, but we need to understand that we all have the same purpose — the reason why our job exists — in our hospitals. At Oakville Trafalgar Memorial Hospital, our vision is “exemplary patient experiences always,” and that is our collective purpose. These 4 simple words have a profound meaning in modern health care. At times, caregivers forget their purpose and perform only their function. Why should surgeons, who are traditionally taught to focus only on outcomes, care about patients’ attitudes, expectations, or experiences? Because it is clearly demonstrated that patient attitude affects patient outcomes. The COST trial,2 which looked at open versus laparoscopic colon resections, surprisingly identified the fact that a low quality of life score before surgery predicted surgical complications.
Expectations and outcomes
Many studies are now showing that patients’ expectations affect their outcomes after surgery.3 What’s more important: the patient’s care or the patient’s experience of care? Is it better to receive optimal care or to believe that you did? Most patients, for example, will never see an elegant bowel anastomosis or the care with which their surgeons close the abdominal wall. They may not understand some of the complexities of modern surgical care, but they do know respect, courtesy, caring, emotional connection and listening, and we have to understand that, to them, these are proxies for quality of care.4
Despite what we were taught in medical school, physicians need to connect with patients and show empathy and compassion. Why is paying attention to the patient experience important? Because it’s the right thing to do; it’s how we would want to be treated, it’s how patients perceive quality, and it’s the basis of the patient-centred care model.1
Maya Angelou said, “At the end of the day people won’t remember what you said or did, they will remember how you made them feel.” After completing a colonic resection for cancer several weeks ago, several days after the surgery the patient told me, “Doctor, I honestly don’t remember everything you told me in the office, but I do remember I felt I could trust you.”
Patients are concerned about a lack of respect. They want to be treated as individuals and want a personal connection so that they get better health care. They want health care providers to communicate with each other; they don’t want nursing staff asking patients, “What did the doctor tell you?”.
Assessing patient experiences using SurveyMonkey
Our surgical program has started to use a readily available Internet-based survey tool, SurveyMonkey, and we endeavour to assess every single patient encounter in every single division, including surgical day care, ambulatory care, and the inpatient units, every single day. We use this information to guide training in great patient customer service. We participated in the development of the Ontario Hospital Associations Ontario Day Surgery Experience Survey. A group composed of the chief of surgery, surgical program director, patient care manager for the OR/PACU, and all surgical division leads excerpted a portion of the questions for our hospital. We have already started surveying patients coming through our surgical day care unit (Fig. 1, Fig. 2, and Appendix 1, available at canjsurg.ca/ 006618-a1). The survey is completely anonymous and we do not, at this point, identify the surgeons involved in the patients’ care.
Surgical Day Care survey card.
First page of the survey.
Bias is always a concern with an anonymous survey such as ours. The survey is also open to manipulation owing to its anonymous Web-based access. As such, we are not looking for statistical significance; rather, we are looking for trends to follow and address. This technique provides a very cost-effective way for smaller institutions to assess patient care experience.
Our early results point to a number of issues for us to consider: postoperative nausea and pain control, varying wait times and lack of communication thoughout the surgical experience, and inadequate information provided to patients about their surgical procedure. As a result, we have tasked our pain control service to address postoperative nausea and vomiting, and we have started implementing a multimodal day surgery pain protocol for hospital and discharge. An upgrade to our operating room booking and patient information system is underway to streamline care and provide real-time information to patients and their families through short message service (SMS) and a Web portal. To address communication about patient surgical procedures, we are developing a postoperative day one program modelled on suggestions from a colleague to improve patient satisfaction, where the attending surgeon calls or has a video visit with patients the day after surgery. Our surgeons discuss the anonymous survey data at our departmental meetings to provide us with further insight on how we can improve.
We can measure staff satisfaction in the same way, because numerous insights will come from our front-line employees. Our caregivers want to be heard, to contribute, to be appreciated and to be on the winning team.
Dr. Codman’s original statement, “If you can’t measure it, you can’t improve it,” has now evolved; in the words of Professor James D. Perkins from the University of Washington, “If you don’t show it, it doesn’t matter.” We need to post all of our quality-improvement survey results, regardless of whether they are positive or negative, on our hospital’s website in order to control the narrative and give people a voice.
All caregivers who have contact with patients need training in great customer service and need to be engaged and believe in their purpose. A focus on improved patient experience has been shown to reduce medicolegal costs and to improve the efficiency of health care delivery. We need to have a purpose-driven relationship mindset, not a functional task mindset. Patients need and want to be a part of their health care experience.
Once surveys of patient experience have produced results, how can we act on the results and create meaningful change? There are many organizations dedicated to improving the patient experience, including the Beryl Institute, the Association for Patient Experience and the Institute for Healthcare Improvement. We need to be a part of the evolution of patient experience to the forefront of care and use data to improve what we do.
Conclusion
As physicians move into leadership positions, the importance of measuring performance and value becomes increasingly clear.5 We must understand that the loss of autonomy leads to the strengthening of team performance, and the importance of measuring this performance and using these metrics will become increasingly clear and will lead to more cost-effective and efficient care. Our patients want to be a part of their health care teams, and as we organize their care around them, they will inevitably, and rightly, become the centre of what we do.
Acknowledgements
The author thanks Julie McBrien, program director of surgery at Halton Healthcare Services, who has been an invaluable colleague in the development and implementation of our feedback strategies. Without her support we would not have been able to sustain the pace or success of our initiatives.
Footnotes
Competing interests: None declared.
- Accepted July 27, 2018.
In this issue
Article tools
Related Articles
Cited By...
- No citing articles found.