Preparing for Success: Penn medicine's Thoughtful Approach to Transparency

Added on Oct 20, 2016

Preparing for Success: Penn medicine's Thoughtful Approach to Transparency
By Audrey Doyle
From Industry Edge October 2016

A world-renowned academic medical center based in Philadelphia, Penn Medicine has a rich history of “firsts.” Pennsylvania Hospital, founded in 1751, is the nation’s first hospital. The Perelman School of Medicine, which opened its doors in 1765, is the nation’s first medical school. The Hospital of the University of Pennsylvania, established in 1874, is the nation’s first teaching hospital.

And according to Craig Loundas, Penn Medicine will continue its pioneering tradition on November 15 when it becomes the first medical center in Philadelphia to make its provider ratings and unedited comments— positive, negative and neutral—available to the public.

“We’re very excited about provider transparency and the benefits it will offer,” said Loundas, who serves as associate vice president of Penn Medicine Experience, a department within Penn Medicine that focuses on organizational change, employee engagement and patient satisfaction. “Patients want to make educated choices about how they’re going to spend their health care dollars. Being transparent about our provider ratings and comments will give our patients accurate data they can use to make informed decisions about their care.

“We feel that quality, safety and the patient experience are interrelated— the more you focus on patients’ perceptions of their care, the better the quality of that care will be,” Loundas continued. “In this way, transparency will benefit our providers as well, by giving them an accurate picture of their patients’ perceptions of the care they received, which will help them advance care quality and the patient experience throughout the organization.”

Time for a Change

Although provider transparency certainly has its advantages, Loundas knew that getting stakeholders to embrace it could be challenging if the initiative was rushed or inadequately explained. “That’s why we took our time planning this out,” he said. “We wanted to make sure we rolled this out in the best way possible to ensure success both externally and internally.”

For Penn Medicine, that meant taking a careful and methodical approach to preparing executives, managers, department leaders and providers for the organizational change that was going to take place. As Loundas explained, Penn Medicine—a $5.3 billion enterprise consisting of the University of Pennsylvania Health System and the Perelman School of Medicine at the University of Pennsylvania—has been expanding medical frontiers in areas that range from dermatology and ophthalmology to radiology, neurosurgery and organ transplantation for decades.

“But while we’ve been enthusiastic about developing or embracing the latest in medical procedures and technologies that advance patient care, we are a 250-year-old institution, and we knew an organizational change like this might not come as easily as we’d like,” Loundas said.

Because change can be overwhelming and stressful at times, and can even elicit such emotional reactions as anxiety, apprehension and fear, Loundas said it was important that Penn Medicine take the time to introduce and implement its transparency initiative systematically, likening the process to fashioning an intricate quilt by hand and “making sure every thread lines up perfectly.”

As he explained, Penn Medicine had been working with Press Ganey to collect patient experience data for about 10 years, so having access to accurate, verifiable, measurable data wasn’t going to be new to anyone internally. What was going to be new was the idea of star ratings, and making the ratings and unedited comments made by patients about Penn’s providers publicly available. “We knew this would be one of the most personal things our providers would ever go through, so we had to make sure everyone understood that doing this was going to help them,” he said.

Realizing that any type of change, if poorly introduced or managed, likely will fail, Penn Medicine chose to embark on its transparency journey by basing its process on an established change management model.

“The five main steps of the model are to identify the change, prepare to change, plan the change, implement the change and sustain the change,” Loundas said. “By basing our approach on these steps, our hope was that people would have the time they needed to understand and embrace the initiative. We didn’t want them to feel like it was being forced on them.”

The organization’s first step was to introduce the initiative to internal stakeholders while making sure the reasons for and benefits of online posting of ratings and unedited comments were clearly understood—a task requiring close collaboration among three Penn Medicine departments: Clinical Operations, the champion of the initiative; Penn Medicine Academy, the learning and development arm of Penn Medicine; and the Marketing department, which oversees providers’ online profiles.

Toward that end, the team began their journey in November 2015 by holding a series of high-level meetings during which they introduced the initiative and gained executive buy-in. Then, in March 2016 they presented the idea to Penn Medicine’s board of directors; once they received approval to proceed, they continued to socialize the idea through meetings with managers and department leaders.

A number of key milestones occurred in the months that followed. The first took place in June, when each department leader chose a physician champion to reinforce the providers’ role in nurturing and sustaining a culture of service throughout the organization.

“The department leaders identified about 25 champions who they felt would be a great resource for providers to turn to for guidance if their ratings didn’t turn out as good as they could have,” Loundas said. “Some of the champions are quite seasoned health care providers and others are fairly new in their careers, but all of them were chosen because they’re passionate about advancing the patient experience, they’re well-respected within their departments and by other faculty members, and they’ve got the skills to provide feedback and assistance to fellow providers should they need to improve.”

The next major milestone occurred on August 1, when the team launched an internal pilot program with its neurosurgery and radiation oncology clinical practices, and two of its large primary care practices—one each in Woodbury Heights, N.J., and Bala Cynwyd, Penn. During the pilot stage, the team decided that quantitative star ratings would be reported on the following nine questions:

  • “Friendliness/courtesy of the care provider”
  • “Explanations the care provider gave you about your problem or condition”
  • “Concern the care provider showed for your question or worries”
  • “Care provider’s efforts to include you in decisions about your treatment”
  • “Degree to which care provider talked with you using words you could understand”
  • “Amount of time the care provider spent with you”
  • “Your confidence in this care provider”
  • “Likelihood of your recommending this care provider to others”
  • “Wait time at the clinic”

They also determined the conditions under which patients’ qualitative comments regarding their care experience would be included or excluded in the providers’ online profiles.

One of the conditions concerned a starting date for comment inclusion. “We began advising patients about the possibility of their comments being included in providers’ profiles in our surveys sent after May 20, so that became our line in the sand,” said Loundas. “Comments made before that date won’t be included, and comments made after that date will be posted for a rolling 12-month period.”

A second condition concerned the comment exclusion criteria, which the team identified as follows:

  • Refers to issues that are unrelated to the provider or team (e.g., parking, food, travel time) or refers to another provider or department
  • Consists of an incomplete response or indecipherable words
  • Uses profane, offensive, abusive, discriminatory, slanderous, libelous or malicious language
  • Contains patient identifying information

A third condition concerned the procedure by which questionable comments would be vetted. According to Loundas, comments that meet one or more of the exclusion criteria will go through two review stages. First, Penn Medicine Academy’s Patient Experience Team will conduct an initial review of questionable comments. Then a Governance Board consisting of two senior physicians, two junior physicians, the Clinical Operations COO and a practice administrator or manager will meet on a monthly basis to make a final determination as to whether the questionable comments should be published or redacted.

The Governance Board also will oversee provider improvement strategies, should the survey results and comments indicate there is room for a provider to improve. These strategies will be delivered through Penn Medicine’s Scaffold of Support, a support system that will be offered in the following four stages.

  1. Awareness—The provider is informed about the area that needs to improve.
  2. Informal Intervention—Peer coaching or shadowing opportunities and self-directed learning through videos and journal articles are provided.
  3. Group Meetings—Annual or semiannual workshops for identified low performers, department workshops led by an external physician or consultant, and Patient Experience Grand Rounds meetings led by the provider’s department chair and the Penn Medicine Academy Patient Experience Team are offered.
  4. 1:1 Coaching—Formal counseling, external coaching, internal coaching and provider-patient interaction simulations are conducted.

“We feel this approach meets our goal of being there for our providers in giving them the data and the support they need in order to improve,” said Loundas.

Throughout the months of August and September, the team met with Penn Medicine’s providers to ensure that everyone understood the benefits of online posting of ratings and comments and to answer questions. Loundas said that although the providers agreed the survey results would tell them whether they need to alter their practice or style in order to provide an optimal patient experience, some were a bit apprehensive about the posting of unedited comments because they felt negative comments may inaccurately or unfairly describe past interactions they had with patients.

To alleviate this concern, Penn Medicine will give providers the opportunity to appeal the posting of negative comments that concern them. Although the team determined that the comments won’t appear in providers’ profiles during the appeals process, they haven’t decided yet whether providers will be able to review their comments before or after they’ve been posted.

“We talked to other organizations that are doing this, and around 80% allow their providers to review comments before they’re posted,” Loundas said. “Until we go live on November 15, we’ll track the number of negative comments our providers receive, and if it’s a significant amount, we’ll let them see the comments beforehand; if not, we’ll let them see the comments once they’re online.”

Coming Out on Top

On October 3, Penn Medicine began internal reporting of provider ratings and comments for all departments. According to Loundas, from May 20 to June 30, 2016, 2,161 of the organization’s 2,300 providers had at least one patient experience survey returned. As of October 10, 1,072 of those providers (50%) had received more than 30 returned surveys and an additional 164 (13%) had received between 20 and 30 returned surveys.

Of the 1,072 providers with more than 30 returned surveys, 14 received between 4.0 and 4.3 stars; 1,043 received between 4.4 and 4.9 stars; and 15 received 5 stars. “Overall, our mean score was 4.75 and our median score was 4.77, which isn’t a bad place to start in our transparency journey,” Loundas said. “Plus, about 28% of our providers have consistently scored in the top 1st percentile nationally in patient experience, so we know we have top performers.

“All of this was new territory for us, and it took a year of planning and testing and preparing for it, but it was worth it,” he added. “We want to make sure our patients can make the best choices about their care, and we want our providers to have what they need to deliver high-quality care. We anticipate that this will be an important tool on both fronts.”