Author: Mark Zakowski, M.D.
ASA Monitor 03 2017, Vol.81, 14-16.
Mark Zakowski, M.D., is Chief of Obstetric Anesthesiology, Cedars-Sinai Medical Center, Los Angeles. He is President, California Society of Anesthesiologists, and First Vice President, Society for Obstetric Anesthesia and Perinatology.
Patient experience is the new Holy Grail. Just as patient satisfaction became king, scores are no longer sufficient. Like any business, a positive customer experience leads to brand loyalty, repeat business, referrals and social proof. Long ago, I incorporated the “business” aspects of running a busy obstetric anesthesiology service into my curriculum for obstetric anesthesiology fellowship. To thrive in 2017, you need to know, too!
Why should “patient experience” be important to every anesthesiologist? The speed of change has accelerated, and the new paradigm has arrived. The old paradigm: hospitals had predictable growth, steady demand and felt protected by relatively limited competition and regulatory agencies.1 Include onerous over-regulation and the old model led to a high-cost infrastructure that will not be financially viable. Market forces are likely to be accelerated by the new administration. While patient satisfaction currently affects reimbursements, the new emphasis on the overall patient experience reveals a more fundamental shift in hospital viability strategies. Expect to be rated by your patients in social media one day very soon.
A unique distinction exists between government (public sector) as a buyer of health care and the private sector. Government approaches Medicare/Medicaid as a high-cost per capita, chronic illness population by utilizing rate setting (i.e., payment to physicians, hospitals), regulation and accountability controls.1 Government financing covered 47 percent of all births nationally in 2015.2 The private sectors of employers and individuals generally are healthier, with episodic needs who value easy access, experience and convenience.1 The number of workers with employer health insurance plans with a ≥$2,000 deductible increased over four-fold in the last decade to 19 percent overall, and to 36 percent for smaller companies (<200 employees).1 The private sector consumer priorities include improved patient experience (not satisfaction!), customization and price. Improved transparency by hospitals and independent reporting websites combined with more high-deductible health plans create an increasingly consumer-driven marketplace. Don’t panic – opportunity exists!
Physician anesthesiologists and the entire anesthesia care team must help provide a positive experience to patients and build brand loyalty. Consumers are “choosing wisely” –based upon increased deductibles, improved transparency quality outcomes reporting by hospitals and, perhaps more important, by Yelp hospital reviews and social media. More than 72 percent of Americans use the Internet for health information, with Yelp having more than 140 million unique visitors per month. Yelp hospital reviews have 12 more areas of care than HCAHPS scoring, including compassion of staff, friendliness and rating-specific locations including labor and delivery; Yelp scores correlated strongly with HCAHPS.3,4 Social media was used by 41 percent of consumers as an aid in choosing hospitals.5
Patients want to be viewed as part of their health care team, and want to share in the decision-making and participate, not just be “done to.” While we standardize systems to improve clinical outcomes, we also need to customize to the individual. The physician, patient and hospital system are all in a relationship together. All parties need to help shape patient experience.
What can we learn from other industries? The entire spectrum of the patient experience needs to be seamless, easy and positive. We need to provide a high-quality, high-reliability product. Consistent service standards help drive patient loyalty. Patient experience accounted for 66 percent of the reasons for loyalty to their physician specialist – not influenced by a quality metric.3 Almost 60 percent of patients rate their doctor-patient relationship and physician personality as the most important factors.
Hospital systems desire building “brand loyalty,” and the obstetric service is one of the most common entry points for young women (who control the majority of purchasing decisions) into the health system.
Hospitals currently emphasize HCAHPS patient satisfaction scores because they affect payments – accounting for 25 percent of the up to 2 percent penalty for Hospital Value-Based Purchasing from Medicare.6 Hospitals consider a good introduction to the entire family as building brand loyalty via the obstetric experience, including anesthesiology services.
When choosing their yearly health insurance plan, many individuals consider their access to a desired hospital. Consumer loyalty no longer depends on satisfaction but on overall customer experience. So make your next parturient feel like a queen – or like a movie star! Having worked at Cedars-Sinai Medical Center in West Hollywood for 21 years, I’ve learned how to provide a premium experience while meeting a lot of well-known folks. So here are some of my “Tips from the Top”:
Personal Communication Style
Ask enrolling questions and listen to the patient with your eyes, not just your ears.
“Epidural” is not just one thing. Address their fears: assure them they can move their legs, will not be “paralyzed” from the waist down, that you can adjust their epidural,tailoring to their desires. Round on your patients to monitor their comfort and degree of motor block. When adjusting epidural analgesia involves finesse, offer the patient a choice so they subconsciously accept responsibility, e.g., either partial (say, 70 percent) pain relief or more motor block.
Expectation Determines Satisfaction
As nitrous oxide for labor “analgesia” shows, patient satisfaction scores are not equal to VAS pain scores.7 You need to set the expectation for the epidural experience. For instance, we offer a true “walking epidural” allowing ambulation, ask what type/degree of pain relief she wants, and modify or adjust the epidural “cocktail” or infusion accordingly. Be willing to go back and change what you are using based on clinical effect as well as patient desires. Labor analgesia is unique in anesthesiology as labor analgesia (pain reduction) differs from surgical anesthesia (a clear end point). Some women want 100 percent relief, others less so – but without major motor block in either case.
EMR detracts from the patient experience, takes longer, and worse, shifts your focus away from the patient and to the computer screen. A busy workload often forces us to save time, and many nurses and doctors ask questions as we type into computer. That’s actually poor personal communication – there is no eye-to-eye contact. Like talking to your spouse at the dinner table while checking your phone – it’s not oing to be earning you any experience points!
When first entering a patient’s room, introduce yourself as Dr. X or nurse anesthetist Y (not as “Anesthesia”!), view the EMR if you’ve not already done so, then say, “Now that I’ve reviewed your records, I need to double check a few items with you” – all the while focusing on patient and partner and answering all questions. Only then, turn back to completethe EMR. The patient’s experience and human connections have significantly improved.
Keep telling your patient what you will be doing, what to expect. You set the expectation of the experience of the current encounter. We all have different styles of placing an epidural/spinal – positioning, location and amount of local anesthetic, sequencing, technical skill level, as well as personalities and how we deal with the patient’s personality (and labor partner if allowed in room) and nurse who is helping, etc.
It’s O.K. to draw boundaries, but the best experience is if you give a reason (so it’s not a you-versus-them conflict). Having a sign posted – such as “No video recording of procedures allowed” – depersonalizes and de-escalates the exchange. The vast majority of people will acquiesce without further conflict. Better yet, add some explanation: you are performing a sterile procedure, please stay on the patient’s side of the bed, it’s distracting if you are watching me/recording me, are a few examples.
Body Language/Staff Attitude
Your body language conveys information about your attitude toward the patient. Sitting down, if you can, even for a brief period when talking to the patient is perceived as being more attentive. President Bill Clinton was infamous as a great communicator – he was able to focus on you entirely, making you feel as if you were somebody special.8 Remember, if you are tired or disheveled, it does not look professional. Positive (and negative) energy is contagious. So think about your energy/attitude before walking into the room.
Some anesthesia providers don’t like covering OB – so don’t! If you show up to work with a bad attitude, everyone knows. You will hurt the overall patient experience. As Han Solo said, “Women always figure out the truth. Always.”9
I emphasize the art of what I’ve termed “psycho-anesthesia” to my residents and fellows. Be an interested observer. When you walk into the patient’s room, what is the tension level? Is there underlying concern about the baby? About the way labor is going? Remind everyone in the room of our common goal – having a healthy baby and mother. Com-municate to the family at first chance during emergencies – you’ll take good care of their wife and baby, the baby’s O.K., and the current problem is under control. Exuding confidence during a crisis is very reassuring to patients. OB is the most demanding anesthesiology experience because the patient is awake in a high-expectation/high-tension environment. And be careful of the common (work or personal) chatter that often goes on among staff.
With an increasingly diverse patient population, we must stay attuned to women’s needs. More than 40 percent of women reported communication problems, and 24 percent perceived discrimination during hospital stay for birth.10 The golden rule, “Do unto others as you would have them do unto you,” has become the more expansive multi-cultural platinum rule, “Do unto others as they would want done to them.”
From the front door of labor and delivery, through discharge home, you are part of a team taking part of the patient experience. It’s important to the hospital, important to your group’s status and important to relationships.
Roades C; Health Care Advisory Board. 12 Things CEOs need to know in 2017: insights on competing in a consumer-driven health care market. https://www.advisory.com/research/health-care-advisory-board/white-papers/2016/12-things-ceos-need-to-know-in-2017. Published September 26, 2016. Accessed January 16, 2017.
Smith VK, Gifford K, Ellis E, et al; The Hendry J. Kaiser Family Foundation. Implementing Coverage and Payment Initiatives: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2016 and 2017. http://kff.org/medicaid/report/implementing-coverage-and-payment-initiatives-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2016-and-2017/. Published October 13, 2016. Last accessed January 16, 2017.
Egan Y; Health Care Advisory Board. Playbook for the consumer-focused Health System: 15 must-have features and tactical guidance for each. https://www.advisory.com/research/health-care-advisory-board/white-papers/2016/playbook-for-the-consumer-focused-health-system. Published September 26, 2016. Last accessed January 16, 2017.
Ranard BL, Werner RM, Antanavicius T, et al. Yelp reviews of hospital care can supplement and inform traditional surveys of the patient experience of care. Health Aff (Millwood). 2016;35(4): 697–705. [Article] [PubMed]
Cha AE. What Yelp can tell you about a hospital that official ratings can’t. Washington Post. April 5, 2016: https://www.washingtonpost.com/news/to-your-health/wp/2016/04/05/going-to-the-hospital-read-the-yelp-reviews-first/. Last accessed January 2, 2017.
HCAHPS Fact Sheet (CAHPS® Hospital Survey). http://www.hcahpsonline.org/Files/HCAHPS_Fact_Sheet_June_2015.pdf. Published June 2015. Accessed December 19, 2016.
Richardson MG, Lopez BM, Baysinger CL, Shotwell MS, Chestnut DH . Nitrous oxide during labor: maternal satisfaction does not depend exclusively on analgesic effectiveness [published online ahead of print December 19, 2016]. Anesth Analg.
Greene, Richard, www.richardgreene.org, personal communication.
Abrams JJ . Star Wars: Episode VII – The Force Awakens [DVD]. Burbank, CA: Walt Disney Studios Home Entertainment; 2015.
Attanasio L, Kozhimannil KB . Patient-reported communication quality and perceived discrimination in maternity care. Med Care. 2015;53(10):863–871.
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