Why improving the patient experience with advanced care options matters

1. Why Improving the Patient
Experience With Advanced Care
Options Matters: Patient
Satisfaction Scores and More
James N. Kirkpatrick, MD
Assistant Professor
Cardiovascular Medicine Division
Department of Medical Ethics and Health Policy
Physician Co-Chair, Ethics Committee
Hospital of the University of Pennsylvania

2. Disclosures
 None relevant to this presentation
 Employed by University of Pennsylvania
 No “transfers of value” from any commercial entities
 Am. Soc. Echo (ASE) Bylaws and Ethics Committee
 Honoraria for ASE educational products
 Salary support from NIH and NASA

3. Outline
1. Context: Patient satisfaction
assessment (HCAHPS)
2. Meaning: Patient satisfaction as
marker of quality
3. Reframing: Patient satisfaction
and communication in Advanced
Cardiac Care

4. Caveats
• Extensive literature review
• Risk Management
• Conflict Resolution
• Bad Outcomes
• Family Experience
Most patients want to live longer and
feel better.

5. Patient
Satisfaction/Experience
• “…measure of how services or products of a
company meet or exceed the anticipated
expectations of the customer.”
• Customer retention, loyalty, and repeat
business.
• Value of the process by which services are
delivered.
Kupfer, JAMA, 2012;308 (2): 139-140

6. Patient Satisfaction
Procedural Outcomes Cardiology Process
• Plastic Surgery
• Orthopedics
• Urology
• Gramegna L, et al. In-hospital follow-up
of implantable cardioverter defibrillator
and pacemaker carriers: patients'
inconvenience and points of view. A
four-hospital Italian survey. Europace.
2012 Mar;14(3):345-50
• Kraai IH, et al. Heart failure patients
monitored with telemedicine: patient
satisfaction, a review of the literature. J
Card Fail. 2011 Aug;17(8):684-90.
• Glaser R, et al. Patient satisfaction is
comparable to early discharge versus
overnight observation after elective
percutaneous coronary intervention.
Invasive Cardiol. 2009 Sep;21(9):464-7.
• Kamphuis HC, et al. ICD: a qualitative
study of patient experience the first year
after implantation. J Clin Nurs. 2004
Nov;13(8):1008-16.

7. Hospital Consumer Assessment of
Healthcare Providers and Systems
(HCAHPS)
2001: IOM
Report-Patient
Centered
Medicine
2002: Hospital
Quality Initiative
2007: Inpatient
Prospective
Payment System
(IPPS) annual
payment update
provisions
2010: ACA
includes
HCAHPS to
calculate value-
based incentive
payments

8. HCAHPS=Quality
Improvement
• “create incentives for hospitals to
improve quality of care.”
• “enhance public accountability in
health care by increasing
transparency.”
www.hcahpsonline.org.

9. Public Reporting and Pay for Performance
Clinicians and
Hospitals
CMS

10. HCAHPS=Informed
Consent
“…comparable data on patients'
perspectives of care that allows
objective and meaningful comparisons
among hospitals on topics that are
important to consumers.”
www.hcahpsonline.org.

14. T
TJU Hahnemann HUP PA avg. USA avg.

15. How do I decide?
• Nurses Communication:
o TJU and HUP
• Doc Communication:
o Hahnemann and HUP
• Quietness:
o Hahnemann
• Given
information/understand:
o HUP
• Cleanliness:
o Find another hospital!

16. • What do the
numbers mean?
• Sample Size at HUP
o HCAHPS: 15%
o Press Ganey: 23% RR
• Variability?
?

19. Patient
Satisfaction
What does it/should it mean?
Correlate or outcome?

20. Chang, Ann Intern Med. 2006 May 2;144(9):665-72.

22. Communication
• Placebo Effect?
• Therapeutic Personality?
• Reduction in malpractice claims?
Hall MF. Healthc Financ Manage. 2008;62(10):76-80

23. Means or End?

26. Joynt KE,JAMA Intern Med. 2014 Jan;174(1):61-7

27. Reframing:
Patient
Experience
and
Advanced
Cardiac Care

28. Allen L, et al. Circulation. 2012;125(15):1928-52.
Good
Communication
Clean, Quiet
Room

29. You, et al. CMAJ. 2014 Dec 9; 186(18): E679–E687.

30. Preferences for care in event of life-threatening illness
Values
Prognosis
Express fears/concerns
Additional questions

31. You, et al. CMAJ. 2014 Dec 9; 186(18): E679–E687.

32. 2
Patient Engagement-What Works?.
Coulter, Angela
Journal of Ambulatory Care Management. 35(2):80-89, April/June
2012.
DOI: 10.1097/JAC.0b013e318249e0fd
Table 4 . Promising Interventions to Improve Care Processes

33. Quality Communication
About Tough Choices
• Comfort
• Emotional support
• Education
• Patient’s perspective
Kupfer, JAMA, 2012;308 (2): 139-140

34. VAD-me!
Cr. 5.0
Cirrhosis
No caregiver
Active substance
abuse

36. Conclusions
• Patient satisfaction is a different type of
quality
• Means AND Ends
• Why not be nice, informative, quiet and
clean?
• Increase CEO Pay!

37. “For the secret of
the care of the
patient is in caring
for the patient.”
F.W. Peabody

39. Extra slides

41. Dugdale DC, J Gen Intern Med. 1999 Jan;14 Suppl 1:S34-40.

42. Symptom
class
Specific symptoms
Physical
Dyspnea, chest pain, edema, fatigue,
exercise intolerance
Gout, pruritus, muscle cramps, pain,
anorexia, nausea, constipation
Psychological/
Spiritual
Panic attacks, anxiety, depression,
cognitive impairment, insomnia, loss of
confidence, feelings of uselessness or
hopelessness, low spiritual well being
Social /
Functional
Falls, incontinence, trouble walking, loss of
independence in performing activities of daily
living, isolation
McKelvie, et al. Canadian Journal of Cardiology 27 (2011) 319–338

43. Kaufman, Social Sci and Med, 2011
Fuchs, 1968
IRONIC
TECHNOLOGIES
Moral
Imperative
Technological
ImperativeNot Static
New Challenges
Extends life
Shifts goals

44. Public Reporting
• 4 consecutive quarters
• 4 times per year
• www.hospitalcompare.hhs.gov
• adjust for factors that are not directly related to
hospital performance but which affect how
patients answer HCAHPS survey items
• quality oversight activities
o survey administration procedures
o statistical analyses
o site visits of HCAHPS survey vendors and self-administering hospitals

45. HCAHPS Content and
Administration
• Random sample across medical conditions
• 48h-6 weeks post discharge
• Mail, telephone, mail with telephone, active
interactive voice recognition (IVR)
• 18 core questions
• 4 questions to direct patients to relevant questions
• 3 items to adjust for the mix of patients across
hospitals
• 2 items that support Congressionally-mandated
reports
• English, Spanish, Chinese, Russian, Vietnamese
www.hcahpsonline.org.

46. HCAHPS: CMS and
AHRQ 2002
• 2002: development and testing
• 2005: endorsements and approval
o National Quality Forum
o Hospital Quality Alliance
o Office of Management and Budget
• 2006: implementation
• July 2007: Inpatient Prospective Payment System
(IPPS) annual payment update provisions
• 2008: first public reporting
• 2010: ACA includes HCAHPS among the measures
to be used to calculate value-based incentive
payments (October 2012).

48. Meaning
“Biofixtures”
Substitutive vs.
Replacement Therapy
“Integral Device”
Paola et al, South Med J. 2000;93:20–3
Sulmasy, J Gen Intern Med. 2008 23(Suppl 1):69–72
England, et al. J Med Ethics. 2007 Sep;33(9):538-40

49. Living with LVAD-DT
• Gratitude
• Incorporation of LVAD into self
• Device anthropomorphization
o “Sidebar”
o “Hearty”
o “The Brain”
o “Gizmo”
o “Timothy”!?

50. Dependent on a machine

51. Grace, et al. Journal of Evaluation in Clinical Practice 15 (2009) 634

52. Survey topic Survey question
1) How often did nurses
communicate well with patients?
During this hospital stay...
•How often did nurses treat you with
courtesy and respect?
•How often did nurses listen carefully
to you?
•How often did nurses explain things
in a way you could understand?
2) How often did doctors
communicate well with patients?
During this hospital stay...
•How often did doctors treat you with
courtesy and respect?
•How often did doctors listen carefully
to you?
•How often did doctors explain things
in a way you could understand?
3) How often did patients receive
help quickly from hospital staff?
During this hospital stay...
•How often did you get help as soon
as you wanted after you pressed the
call button?
•How often did you get help in getting
to the bathroom or in using a bedpan
as soon as you wanted?
4) How often was patients' pain well
controlled?
During this hospital stay...
•How often was your pain well
controlled?
•How often did the hospital staff do

53. Akingbola , Journal of Health Organization and Management, 2015;29(1): 111

55. Joynt KE, JAMA Intern Med. 2014 Jan;174(1):61-7