How My Medical Group Improved Patient Satisfaction
Thursday, July 29 2010
By William Faber, MD, MHCM, Medical Director, Chicago Region, Advocate Medical Group
When Jim Skogsbergh, the president and CEO of Advocate Health Care, told a large gathering of system leaders in 2006 that within a year every group within the Chicago-area system needed to achieve a patient satisfaction score of at least the 50th percentile, I doubted that our group could attain the goal. For years, I had been a medical director in one of the large medical groups within Advocate where patient satisfaction scores had traditionally hovered in the single digits. Members of our team wondered how practices at the other end of the spectrum did it. Through a focused pursuit of high patient satisfaction, we got some interesting answers … and results.
My former medical group, Advocate Health Centers (AHC), merged with several other Advocate physician groups in January 2009 to form the new Advocate Medical Group (AMG), which now employs more than 800 physicians.
In 2006, the annualized Press Ganey patient satisfaction score for AHC was near the 9th percentile, and the score for the older, smaller AMG was near the 19th percentile. Over the following three-year period, however, a remarkable transformation occurred, with these groups achieving average scores at the 73rd and 89th percentiles, respectively, in 2009.
There is no doubt in my mind that Skogsbergh’s publicly stated goal for the organization was vital to our eventual success. His declaration provided a burning platform for us to find and implement effective strategies. Support for such an initiative as a top priority, from the top of the organization, is necessary for achieving this kind of change. Skogsbergh has raised the bar each year since.
Vision is necessary but not sufficient. Our management teams devised strategies and tactics and ensured that each tactic was executed. The goal engaged every member of the team, from facilities to operations to medical management. Everyone looked at how his or her own division could contribute to a better patient experience.
Two important incentives were established to support success. Our management teams structured their own bonus plans to reward achievement of specific patient satisfaction targets. This applied to the CEO and all the vice presidents and directors, not just to some. We also engaged physicians by putting a portion of their compensation at risk for hitting specific patient satisfaction targets. Tiered incentive dollars are distributed to physicians according to their individual Press Ganey scores (based on at least 30 responses), and the highest performing physicians can earn a bonus above the amount reserved from their biweekly compensation. Because effective local group functioning affects physician satisfaction, this incentive supports physicians to use their role as team leaders to improve quality and service at their sites.
In addition to aligning incentives, we embarked on a number of specific tactics to increase patient satisfaction. We found the most fruitful tactic to be a disciplined process of having a nurse telephone a patient on the day after an appointment. Some of the staff predictably challenged this tactic because they already felt overextended. As it turned out, the time spent proactively calling patients probably saved an equivalent amount of time that would have been spent responding to calls initiated by patients. Patients who are not doing well greatly appreciate further advice and those who are doing well take these calls as an expression of our care.
Patient satisfaction became an item of discussion at every meeting, and whole meetings were devoted to the subject. We became internally transparent with site-specific monthly patient satisfaction reports, then shared best practices across all practice locations and used Press Ganey data to evaluate new initiatives and PDSA (plan-do-study-act) cycles. We provided scripting and behavioral expectations for our associates and encouraged patients to respond if surveyed. We responded to each patient comment made on a survey. We used feedback from Press Ganey surveys to improve our access, throughput and messaging. The Press Ganey client improvement manager was a useful resource behind the scenes, pointing us to Solutions Starters and helping us to better understand and accurately report the data.
Physician scores were also tracked. Medical directors personally coached physicians on their communication skills and bedside manner. AHC and AMG invested significantly in a professional coaching program for low-performing physicians. Approximately 10% of the physicians in the cohorts described here took advantage of the program. Physicians who participated showed significant improvement in their individual scores.
As patient satisfaction started to steadily climb, so did morale, which created a positive feedback loop of a better patient experience. Going through a merger did not slow the improvement of either group. The wider sharing of best practices further enhanced improvement. As just one example, the practice of patient calls by nurses the day after an appointment was quickly expanded from one site to all others.
There is a very important epilogue to this success story. At AHC there was a marked drop-off in performance during early 2010, and we are pained to admit that this trend has persisted into the second quarter of 2010 for both groups and AMG as a whole. In the fall of 2009, AMG shifted focus to the huge initiative of rolling out an electronic health record to hundreds of physicians and associates. Although the EHR will ultimately serve patient service, rolling out an EHR decreases patient access because throughput is slowed for a few months as users learn the system. At first, we assumed that this was the cause of our fall-off in patient satisfaction.
An honest look at the data, though, provides an important insight. It turns out that patient satisfaction scores have dipped across all of AMG, even at sites where the EHR was already established or where the rollout has not yet begun. Our management team agrees that the more rational and accountable conclusion is that the EHR rollout replaced patient satisfaction as our No. 1 priority. Analogous to the performance of an athlete, high patient satisfaction cannot be simply checked off a list, but rather requires the ongoing pursuit of specific behaviors that produce results. That is the good news. We know how to do it.