Delighting Patients and Families Antonio Quiros, MD, FAAP Amy Richburg, MSN, RN Rebecca Harper, Lean Six Sigma Black Belt

Waiting for the doctor Patient satisfaction scores were below target – especially for moving through the visit Efforts had been made in some of the clinics to improve flow, but this did not help the scores Observed patient movement in clinics; talked with parents about their wait; did not gain much insight Needed to dig deeper to understand why patients and families were frustrated with their wait Feeling that our patient satisfaction scores were not where they could be, Antonio Quiros and Andrew Savage asked for assistance from the Value Institute. The Value Institute observed how several of the clinics operated. While they saw patients waiting to be called for triage, no one seemed particularly upset about the wait time. It was almost as if they expected to wait. And, most of wait times were not unusually long. The question then became: how do we keep our patients happy while they are waiting? We decided to conduct a Kano survey. This type of survey is designed to determine what customers see as basic requirements vs. what they value vs. the unexpected things that will delight them. The survey was distributed on RT 4, RT 3B and RT 3. A total of 86 surveys were completed by patients and families.

Kano Survey - + DELIGHTERS (Excited Quality) PERFORMANCE (Desired Quality) Didn’t know I wanted it, but I like it! Communication about length of visit. My satisfaction increases as performance increases. Friendly, helpful, professional staff Service Performance - Service Performance + We decided to conduct a Kano survey. This type of survey is designed to determine what features of a product or service customers see as basic requirements vs. what they value vs. the unexpected things that will delight them. The survey was distributed to patients and families on three pediatric clinics. A total of 86 surveys were completed. Delighters: unexpected features that when present cause a positive or excited reaction Performance: a feature that is expected but can increase satisfaction if we provide more of it or decrease if we provide less of it Must Be: expected by patients and families; if we don’t provide it, then patients see it as incomplete or not good; these are basic expectations – more of these types of features does not increase satisfaction -- like chairs to sit in while waiting – if we don’t provide chairs, our patients will be very unhappy but if we provide more than is needed, it won’t have an impact on their satisfaction Indifferent: these are features that don’t make a real difference in satisfaction or dissatisfaction We didn’t have an extremely low scoring feature that fell into the must be category. MUST BE (Expected Quality) Cannot increase my satisfaction, but can decrease it.

Sample Questions

Focus: Communication, Perceptions

Opportunity Statement Improve our communication with patients and care team members about delays, waiting time and what to expect during the visit. We reviewed the survey results, and through a prioritization exercise we selected communication with our patients as families as the focus to help improve our scores for moving through the clinic visit. Then we brainstormed potential solutions. Again, we prioritized our solutions so that we would focus on only those that could have a significant impact on our scores.

Brainstorming Multi disciplinary team – scheduling, registration, nursing, providers

Opportunities to Communicate with Patients and Families The team decided we needed to create a process map showing the many communication touchpoints that occur during a patient’s visit from the time of scheduling an appointment through follow-up communication with patients about lab results. The orange squares below the line indicate all of the opportunities we have to communicate with patients and families about their visit.

Keep us informed/communicate delays Solution: Daily team huddles Patients – how many and types Need to know information How to handle late patients Staffing For each of our solutions, we would try it in between team meetings and come back with feedback on how it went. Respondents said they would like to know what to expect during the visit. For example, if there was going to be a delay once they were roomed, they would like for us to tell them. The team realized that often staff may not know exactly how many patients are in the waiting room, in triage, roomed, etc. One solution is a daily huddle at the beginning of the day to understand how many patients are scheduled, if there are any extenuating circumstances, what the staffing level is and how to the physicians want to handle late patients. With a game plan in place each day, the staff will be better prepared to handle any delays that may occur during the clinic’s operating hours. A team huddle set the stage for the rest of the day.

Keep us informed once we are in a room Solution: Use dots in Epic Patient is in triage. Patient is ready to be seen by provider. Patient in the lobby because no rooms available. (Provides visual indication to provider that they may be running behind.) Meds/orders/ancillary testing (patient in x-ray, patient in PFT). Discharge. (May indicate time for nurse to complete discharge or that the provider has discharged the patient for those areas where nursing does not do the AVS.) Open (can be used if clinics needs another dot.) Another solution to help facilitate knowing where patients are throughout their visit was to utilize different colors of dots in the electronic medical record. By standardizing what each color means, it would be easier for everyone to quickly look in Epic (the EMR used at MUSC) and know where patients are in the clinic – especially anyone floating to one of our clinics. This will also make it easier to communicate with anyone who is waiting for the next step in the their visit. We left one dot – the black dot – open in case a clinic has a special need not accommodated by the other five colors.

Update white boards in a timely manner Solution: Designate a communicator in the unit each day Check flow Update Registration and white boards Talk with patients/families Create a script to ensure consistent message Each waiting room has a white board to indicate the wait time for each provider in the clinic. Respondents to the survey said they would find it attractive (have a great influence on their satisfaction) if the white boards were updated regularly to reflect an accurate wait time – even if the wait time increases. During observations of the clinics, we noticed that the times on the white boards did not change over the course of the day. Team members confirmed that they do not change the times because they are uncomfortable having patients and families see the time being changed to a longer wait time. After piloting this solution, the team decided they needed to write a script to help nurses and registration feel more comfortable talking with patients about the wait time.

What you can say to a Patient and Family WHEN THE PROVIDER IS BEHIND SCHEDULE Good morning/afternoon. I am (NAME), the CMA/RN working with (PROVIDER). (PROVIDER) is currently running behind because of a difficult circumstance. It will be about 20 to 30 minutes before we bring you back to a room. In the meantime (NAME), the CMA/RN working with (PROVIDER) will bring you back for vital signs/triage. Once the room is available, we will be right out to get you. Thank you for your patience. Is there anything I can get for you while you’re waiting? Example of what to say when the provider is behind schedule.

What you can say to a Patient and Family WHEN THE PATIENT HAS ARRIVED EARLY We wanted to let you know we see you have arrived early for your (TIME) appointment, and we greatly appreciate that. (PROVIDER) has other patients scheduled right now, but we will try to get you seen early if possible. Please let us know if there is anything we can get for you while you wait. Example of what to say if the patient has arrived unusually early for the appointment and has to wait a long time.

Goal: Delight our customers (patients/families) Customer service training will help us: Optimize patients’ experiences Boost staff confidence and morale Improve staff knowledge and skill set Improve MUSC’s reputation Create MUSC’s uniqueness Increase customer loyalty Who? EVERYONE! Physicians, RNs, CMAs, Registration, Scheduling For all of this to be successful, the team recognized that we all need customer service training. Relaying bad news – such as a delay in the visit – can be stressful for staff as well as for patients and families. The nurse educator piloted a six-week customer service training program – using the daily huddle and email to provide customer service tips to staff. Because of personnel changes and moving clinics to off-campus locations, the project has been put on hold. Once all of the changes have settled, we plan to pick back up with the customer service training. Everyone knows this is the cornerstone of our success with improving patient satisfaction.

Patient Clinic Experience Project Results

Lessons Learned PDSA helped the team test solutions and make changes quickly before rolling it out to everyone Change is inevitable – can disrupt a project – don’t give up! Multi-disciplinary team is a must

One last thought… Airline passengers want more than a flight. Hotel guests want more than a room. Restaurant patrons want more than a meal. Healthcare Patients want more than just somewhere to get well. Taken from Healthcare Warriors’ Customer Service Standards