Walking the talk of patient-centredness: Maximizing the value of the patient voice

Executive Director, Charlene McBrien-Morrison, comments on why listening to and acting on patient feedback and input is critical to “walking the talk” of a patient-centred healthcare system.

I greatly appreciated my colleague Kyle Kemp’s HQCAMatters piece about patient experience and how it is a wonderful complement to the suite of measures from which our health system should be reflecting. His perspective prompted me to probe further into the question:

Why do we survey patients on their experience in our healthcare system?

Like Kyle, I believe that listening to those we serve is invaluable. I want to take this a step further and assert it is central to assessing if we are a truly patient-centred healthcare system.

What does being a patient-centred healthcare system mean? The Institute for Patient- and Family-Centered Care (IPFCC) defines it as, “Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families.” The Institute goes on to say that, “Patient- and family-centered care leads to better health outcomes, improved patient and family experience of care, better clinician and staff satisfaction, and wiser allocation of resources.” It is crucial, therefore, to have those using our system tell us about their experience, and whether they really feel that “mutually beneficial partnership”. (1)

The Institute for Healthcare Improvement (IHI) speaks to the importance of actively learning from the patient and family by considering “the perspective of the individual as he or she interacts with the health care system (i.e., patient experience surveys)”.

The patient’s voice can be captured in many ways. Surveys (which Kyle mentioned), one-on-one interviews, focus groups, concerns/complaints, and resident and family councils are just a few examples. A cross-section of ways to capture experience is important, because “patient-centered organizations recognize that data is broader than numbers and includes the qualitative perspective of patients, families, and staff.” (2) The HQCA has also used qualitative methods to provide a more in-depth understanding of patient experience in specific sectors of the healthcare system such as our report about the experiences of seniors living in supportive living. “Qualitative approaches provide opportunities for dialogue, moving beyond the standard -always, -sometimes, or -never responses found on traditional surveys. The sharing of complete stories may very well shed light on areas for improvement not identified previously through the survey process.” (3)

This expanded train of thought led me to an even more important question:

Are we maximizing the value of the patient voice in moving us towards a patient-centred health system?

I’m not sure that we are; however, where organizations and teams are sincerely listening to and acting on patient feedback, the results are impressive and worth celebrating.

Just ask Westview Care Community, a long-term care centre in Linden, Alberta, where 100 per cent of families would recommend this care centre to others. “Propensity or likelihood to recommend” is one measure of the patient experience dimension suggested in the IHI’s A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. This would suggest that Westview is certainly demonstrating a patient- (resident-) centred approach in how they deliver care and identify improvement opportunities.

Being a patient-centred health system is not an end goal, but a continuous journey. “This journey approach also means that there are always opportunities for improvement, no matter how long your organization has been on the path to patient-centeredness. Sustaining a patient-centered culture demands adaptability and flexibility to meet the needs and expectations of your patients, families and staff―needs that will inevitably evolve over time.” (4) So, we need to continuously walk the talk of patient-centredness and never stop listening to, embracing, and acting upon the patient voice in all that we do.

To continue this conversation, I have posed a question to the HQCA’s Patient and Family Advisory Committee members:

How can we (healthcare leaders focused on improving healthcare quality) do a better job of “walking the talk” of patient-centredness by listening to and acting on the voice of those we serve?

I have invited our patient advisors to prepare a HQCAMatters article about their recommendations, and look forward to hearing their perspectives. Please follow us on social media (links at the bottom of the page), to see a notification when their response is posted in the coming months.

 

(1) Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. (Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012) (Available on www.IHI.org)

(2-4) Susan Frampton et al., Patient-Centered Care Improvement Guide. (Planetree, Inc. and Picker Institute; 2008)

HQCAMatters is published monthly and presents HQCA representative perspectives on topics or issues relevant to healthcare in Alberta.

The value of gathering patient experience data

Kyle Kemp, Senior Data Manager and Lead, HQCA, talks about the importance of patient experience surveys and how they can help capture the patient perspective to ultimately improve healthcare. 

You have just received a telephone call, knock on the door, letter in the mail, or an email asking you to complete a survey about your experience. You might get these requests after you visit your local bank, grocery store, fast food restaurant, or even healthcare clinic or hospital. Like many, you may ask, “Why should I do this?”, or “Why do they want this information?” These are important questions to ask and get answers to.

I may be a bit biased (part of my job is to analyze experience surveys), however I think there is tremendous value in getting feedback directly from customers. To illustrate this point, here is an example from my own family from earlier this year.

One night, in the rush between work, school, home, and the soccer field, our family stopped for dinner at a favourite fast-food restaurant. My wife and two young sons proceeded to find a table. After I placed our order, I was waiting at the counter when my attention was grabbed by a set of screens behind the counter, above the drive-thru window.

I quickly realized that these screens provided indicators about drive-thru performance. Staff were receiving information about things like time taken to serve each car, and the number of cars served in an hour. Data was displayed in red, yellow, or green, depending on how they were doing. Their own ranking was also compared with other drive-thrus across the city.

I received our order and returned to the table to tell my wife about these performance measures. She was quick to angrily reply that she had just had to clean up other people’s garbage, and wipe globs of ketchup off a table and chair, all while keeping our little ones out of trouble. Despite having one of the fastest drive-thrus in the city at the time, my wife’s experience was more strongly impacted by the lack of cleanliness in the restaurant. My wife’s experience wasn’t captured on that set of screens, but could have provided some important feedback to this hard-working team.

Like my example from the fast-food industry, there is a huge potential benefit in asking “customers” of the healthcare system (e.g., patients and their families) about their experience. Patient experience data is used to assess care processes and interactions with staff, through the eyes of patients and family members. This feedback can be a tremendous catalyst for change. It can also serve as a valuable teaching tool, and for giving credit when patients and family members have reported receiving great care.

Patient experience data can be a wonderful compliment to a hospital or organization’s existing set of performance measures, as patients and families can provide information not readily available with traditional performance measures. For example, a hospital may note that their emergency department revisit rate is high compared to their peers (a common performance indicator; a high rate is seen as an indicator of poorer performance). Patient feedback can be used to help determine why this is happening. Patients may report that they did not receive clear instructions on how to care for themselves when returning home from hospital, or that they did not understand how and when to take their newly-prescribed medications. Addressing these patient concerns may minimize additional burdens to patients, families, and the healthcare system, and may also improve the revisit rate.

As I mentioned before, it is my job to analyze and report the data gathered from experience surveys. At the Health Quality Council of Alberta, this means patient (primary care and emergency department), resident (supportive living), client (home care) and family (long-term care) experience surveys. By staying in touch with those we share our reports with, I also have the opportunity to see how this data ultimately helps improve healthcare for Albertans.

So, the next time you are asked to participate in a survey about your care, please consider saying “yes!”. Your voice makes a difference and the more voices and stories we can capture, the more impactful the data will be. To those of you who have already taken the time to provide feedback about the healthcare services that you or a family member has received, thank you. Whether it was by completing a survey, filling out a comment card, taking part in an interview or focus group, or by any other means, this information about your lived experience is invaluable! I hope that all Albertans continue to provide their feedback – good, neutral, and bad. It all helps improve the quality of care Albertans receive.

To learn more about the HQCA, our mandate, or our current surveys, please go to www.hqca.ca.

HQCAMatters is published monthly and presents HQCA representative perspectives on topics or issues relevant to healthcare in Alberta.

Re-imagine: Building a high-performing team

Kristina Watkins, HQCA employee and alumna Re-Imagine facilitator, shares a bit about the HQCA’s approach to building a high-performing team.

What an interesting time to be asked to write about the HQCA’s approach to building a high-performing team. I am feeling anxious and overwhelmed by my workload, stretched in quite a few directions. It is in these cycles of stress and intensity when my attitude lacks its usual pep and polish. My flexibility turns rigid. My olive tree has (a lot) less branches. This makes adhering to the HQCA’s social contract (the document at the core of our approach, below) difficult.

HQCA social contract – launched in February 2016.

In January of 2015, we (HQCA employees) started a process called “Re-imagine”, initiated by our executive leadership.  Re-imagine was introduced as a way of learning to connect and become more effective communicators with one another. It is meant to help us function as a high-performing team.

A team of five internal employee facilitators from across departments and levels of the organization guides this work. The facilitators’ first task was to help employees collectively develop a social contract. This social contract would be agreed to and signed by all employees to set core expectations about how we work together.

When you read the outcome of this work, the social contract above, it sounds pretty easy, right? Address issues so they don’t fester, celebrate good work, and respect your co-workers. Common sense.

I think this is easy to understand, but really hard to practice consistently. Especially the part involving feedback. What an important activity, but I have to agree with this article. Our “nice” and “kind” culture makes delivering and receiving feedback HARD.

So, we use a “balanced feedback” model developed by an external expert to overcome barriers to resolving differences and crediting accomplishments.

Our Re-imagine model incorporates elements from some of these well-known practices and models:

The team develops and maintains awareness to help us see opportunities to use this model to check assumptions and then deliver balanced feedback, if needed. However, as I mentioned, I’m writing this during one of those cycles of self-doubt and frustration. I am less likely to deliver or ask for feedback because I know there is a risk I might not be in the best position to give or receive it in a “nice” or “kind” way. I worry about the potential risk to my long-term relationship with the person I need to check assumptions and discuss feedback with. I have always lived by the adage, “Treat people the way you want to be treated.” This week that just might not be possible.

Here’s the thing I’ve learned, though. That is not an excuse to avoid feedback. If your professional environment is practicing feedback regularly, delivering or receiving it should be no more difficult than your other to do’s. Feedback does not have to create anxiety. It guides our behaviour and allows us to change our approach. Reframe a challenge. Hit a target more successfully. These feedback interactions add up and, if consistently delivered in a respectful way, can create a working environment where psychological safety is real and innovation can thrive. These are excellent reasons and incentives to embrace feedback.

While absolutely logical, I am not there yet. I don’t “walk the talk” as consistently as I should and still make awkward mis-steps that could be avoided with more practice.

The great thing about Re-imagine is that it is a process, not a goal. I make time and have the space and support to do this work. And, as the organization and individual relationships change and evolve, there will always be new opportunities to improve my practice and ultimately, our team’s performance. I welcome this personal and team development opportunity and am proud to work for an organization that makes this work a priority. Turns out taking a moment to acknowledge this at a time when I am channeling more Maleficent than Wonder Woman is part of that ongoing self-awareness and self-improvement.

For HQCAMatters updates, follow @HQCA on Twitter.

HQCAMatters is published monthly and presents HQCA representative perspectives on topics or issues relevant to healthcare in Alberta.

The Goldilocks philosophy of healthcare administration – What size is “just right”?

Andrew Neuner, Chief Executive Officer, HQCA

Recently, there has been quite a heated discussion in Ontario (more on this herehere, and here) about whether healthcare bureaucracy costs (i.e., costs related to administration; not costs related to delivering front line care) are unreasonable or “bloated”. This conversation is not Ontario-specific and made me think about this in the Alberta context, given we are often criticized for our comparatively high healthcare costs, which includes administration, and see this topic pop up regularly in the news. It is also important to note this is not a 2018 issue. This has been simmering for some time now (see here and here).

Maximizing how we spend public funds on healthcare is critically important. Healthcare is often the largest segment of a provincial/territorial budget, Alberta being no exception to this rule.

As a voter and tax payer myself, I am also personally invested in and care about how our money is being spent.

As a leader of a government agency in healthcare who is both responsible for managing some of that spending within my own organization and recommending ways to improve the quality of healthcare in Alberta (improving quality very often leads to decreased costs), I am truly aware of the weight of this issue and feel a responsibility to champion opportunities to address this every day.

So, before we listen to more pledges about how healthcare spending can and should be reconsidered, especially related to administration, I think there are two important questions to answer:

What do we want our health system to achieve?

What does it take (realistically) to achieve that vision?

As a system, we need to answer these questions and make sure our system is designed to support the desired outcomes.

As health reporter André Picard stated, “Complex systems such as health care don’t run themselves. Oversight and management is required.” Thoughtfully structured bureaucracy supports an efficient and effective healthcare system or, as the famous saying goes, form follows function.

So, before wildly targeting administrative costs, or any other costs within our health system, let’s first consider what we want our health system to achieve (a clearly articulated strategy), followed by important resource mapping to support the realization of that strategy. Or, more simply: Set a goal, then plan and position every part of the system, including administration, in a deliberate and cost-conscious way to support the achievement of that goal. This may require new partnerships and/or innovative approaches and understanding how other health systems outside of Alberta and Canada are achieving the same goals. This could also require asking people to try new roles or challenges. However, answering these questions and then taking actions that focus on outcomes and working to get the vision and structure of our healthcare system “just right” sounds to me like the best way forward.

Follow Andrew on Twitter @HighNeun

HQCA Matters is published monthly and presents HQCA representative perspectives on topics or issues relevant to healthcare in Alberta.

Protecting civility in healthcare

I recently posted a piece about the ideal conditions to pursue improved healthcare quality, which included ‘protecting civility’ as one of those essential conditions.

Civility describes an interaction that is respectful, transparent and inclusive. In the healthcare context, Don Berwick from the Institute for Healthcare Improvement (IHI)said (1), “everything possible begins in civility” and in the absence of civility, dialogue is eroded. He suggests approaching conversations about healthcare improvement as if we are at the dinner table, not in the boxing ring.

Adding further clarity to this dinner table analogy, I read a recent piece (2) that stated, “Fundamental to, and governing the practice of, civility is the principle of reciprocity: your place at my table implies my place at yours.

This analogy resonates for me and after thinking further on the idea, protecting civility in a discussion or debate about how to improve quality in healthcare in Alberta means:

  • Inviting and welcoming diverse perspectives and opinions to the table,
  • Checking egos at the door,
  • Making sure everyone has an opportunity to speak and to be heard,
  • Creating a safe place for differing opinions to be shared and considered, and
  • Listening with openness and a willingness to reshape perspective or position.

I highly value these five principles when I engage with others, however have to challenge myself to keep them top of mind and apply them consistently. It can be particularly hard when the topic of discussion is one I’m passionate about or consider it an area where I have expertise. I also find it difficult if everyone at the table and especially the “host” does not apply these principles, because it risks making decisions with incomplete information or leaves participants feeling their voices were not heard.

Deliberately engaging in and leading conversations with civility encourages broader expertise and views to be voiced and leadership and followership responsibilities to be shared; creating a flexible or, in some cases, non-existent hierarchy. All of this ultimately fuels innovation and helps a team or system pursue change with more confidence and strength because all perspectives, risks and opportunities have been tabled and considered.

It is also important to clarify that civility benefits all “tables” in healthcare; whether a governance or leadership table, care team huddle, design sprint, project team, etc. Any time people, including those we serve, are brought together to talk about improving how care is delivered is an opportunity to apply these principles.

So, as we continue to protect civility to advance healthcare quality in Alberta, I challenge our health system to:

  • Take a look at your table and invite others you may have overlooked or omitted to pull up a chair;
  • Find opportunities to let your table mates lead, and hone your expertise as follower; and
  • When followers or the most vulnerable among us are brave enough to ask for a seat or opportunity to lead, find a way to say ‘YES’ and make sure their voices are heard.

 

(1) On this page (http://www.ihi.org/resources/Pages/Publications/Era-Three-for-Medicine-Health-Care.aspx), under ‘Related Information,’ there is a link to watch Berwick’s complete keynote speech (recommended). This requires you to register for an Institute for Healthcare Improvement login, which is free.

(2) https://www.newyorker.com/culture/cultural-comment/sarah-huckabee-sanders-and-who-deserves-a-place-at-the-table

Follow Andrew on Twitter @HighNeun

HQCA Matters is published monthly and presents HQCA representative perspectives on topics or issues relevant to healthcare in Alberta.

In pursuit of quality, let’s be more like geese

Andrew Neuner, Chief Executive Officer, HQCA

In reading Dr. Greg Powell’s recent Quality Matters piece; Quality, cost and continuity – A reflection on Falling Through the Cracks: Greg’s Story, I whole-heartedly agree that when we have conversations about improving the quality of healthcare for Albertans, the Alberta Quality Matrix for Health dimensions of quality: acceptability, accessibility, appropriateness, effectiveness, efficiency, and safety should be our compass or ‘North Star’.

Before we forge ahead toward this common destination of quality in healthcare, what conditions create an ideal and trusted space to pursue these dimensions? Here are some of my thoughts.

Take turns leading, placing equal value on leadership and followership.

I have often used the analogy about geese in flight and their relevance to this cooperative relationship between leadership and followership – particularly in a large and complex system like we have in healthcare.

Leadership and followership are complementary skills to appreciate and develop. Knowing when to be a leader or follower, and when to let others lead or follow, allows for more effective and efficient movement together, as a team or system, to maximize collective impact.

Geese fly in a V formation because it:

  • Conserves energy. By staying in formation, they can travel up to 70% further than going off on their own.
  • “Allows them to keep visual contact with one another so they are orientated in the right direction.”

In my experience, the idea of working together to maximize effort and resources is already a shared value in healthcare. However, I think the opportunity here is to become better followers, recognizing when it is time to “let go” and let someone else take the lead position.

With respect to keeping visual contact to maintain formation and correct orientation, geese do this so they are not crashing into each other or getting lost. The parallel in healthcare is the importance of keeping one another informed of respective priorities, plans and activities to reduce the risk of duplicating or pursuing irrelevant work and finding opportunities to share knowledge and/or resources.

Also, geese know it is time to migrate (change) when the weather (conditions, priorities) shifts. And, even though each goose might take a slightly different course or approach when they lead the V, they are all flying to the same destination (clear objective or vision).

By taking cues from our feathered friends, there is an opportunity to be more efficient, increase alignment, and work as a team or system toward the same well-defined goal. I believe that if we can create the right environment by sharing leadership and followership accountabilities, the sky is the limit when it comes to advancing healthcare quality.

There are two other important conditions I think help create that ideal and trusted space to pursue quality improvement and will write about as part of our HQCA Matters series: protecting civility and learning from others. I hope you will stay connected as this conversation continues.

Quality, cost, and continuity – A reflection on Falling Through the Cracks: Greg’s Story

Dr. Greg Powell, O.C., MD FRCPC

The business of any healthcare system is that of helping people. When people think about their healthcare experience, they reflect on the care they received and what happened to them, or the outcomes of that care; these are the core features of healthcare quality.
Healthcare Quality and Safety Management: A Framework for Alberta, July 2017

Last week, I had the opportunity to attend the premiere of the short film Falling Through the Cracks: Greg’s Story. This film tells the story of a young man, Greg Price, and his journey through the healthcare system that ultimately ended in his unexpected and tragic death.

I have extensive experience with the Canadian healthcare system, both as a patient and provider. My expertise lies in emergency medicine, so I am all too familiar with unexpected and tragic loss. However, Greg’s story is not about a sudden accident. Greg’s story is about getting a diagnosis and treatment, and the gaps in communication along the way that prevented him from receiving timely, quality care. The film does an excellent job of showing us what his care journey felt like and unfortunately, it feels uncomfortably familiar and relatable. Even with limited experience with the healthcare system, it is very easy to see how Greg was able to ‘fall through the cracks’.

Last week’s film screening also included a panel discussion about the implications of this film for Albertans and Alberta’s healthcare system. What an impactful conversation among the panel members and with the audience. I hope that others, like myself, walked out of the theatre thinking perhaps progress is possible if we put our shoulder behind it.

That is the catch, though. What should ‘putting our shoulder behind it’ look like? And, do we have the courage to push?

With respect to the second question, I say yes. There is an increasing appetite for innovation in healthcare in Alberta, making this an opportune environment to put time and energy into this. Also, we are not doing this alone. One of the questions posed by the film audience was, “Is this problem uniquely Albertan?” The answer to this question was simple: No. Making improvements to continuity of care* is a priority for many jurisdictions, across Canada and internationally.

So, we are in this together as we consider, develop, and implement solutions to improve continuity of care. As we do this, we should be considering the foundational work done by the Health Quality Council of Alberta (HQCA) in their 2013 and 2016 reports that identified and then followed up on recommendations on how we can stimulate the greatest improvement in continuity of care for the greatest number of patients. Now, as we engage further in this work and revisit those recommendations, there were three points from the panel discussion worth raising to make sure they stay top of mind and are not sidelined or lost in the hustle bustle of our day-to-day responsibilities.

It’s not about public vs. private

Rather, as stated by one of the health experts on the film discussion panel, “It is about a blend of public and private healthcare that is well-regulated.”

I appreciate that creating this balance and accountability structure would be complicated. However, we (Albertans and Canadians) should feel more urgency to try and simplify the steps to get there and make this goal achievable.

Manage your own healthcare information

Until we have an integrated health system, patients must become partners and advocates to proactively manage their own healthcare. This includes managing healthcare information. Alberta does not have a clinical information system (CIS) that allows providers to access all of our healthcare information. So, patients need to be prepared to ask questions and provide answers to their care team. Additionally, patients can and should feel confident to ask for copies of their healthcare information (e.g. test results) and help to understand that information.

We should focus our conversations and actions less on cost and more on quality

When we sit down to have conversations about how to improve healthcare for Albertans, the Alberta Quality Matrix for Health dimensions of quality: acceptability; accessibility; appropriateness; effectiveness; efficiency; and, safety should be the North Star. This common language for quality was agreed upon by Alberta’s health system leaders more than a decade ago and still resonates.

However, in my experience, current conversations about healthcare quality get derailed by a preoccupation with cost. This opinion was reinforced during the panel discussion at the film screening.

So, it begs repeating until we can reprogram our thinking and reactions to proposed change—

Improving healthcare quality does not equate to increased costs. In fact, just the opposite. Cost savings are actually realized by addressing the six dimensions of quality.

In closing, I strongly encourage you to see this film and consider what you can do, both individually and in your community, to ‘put your shoulder behind it’ and make quality a priority in healthcare.

Dr. Greg Powell, O.C., MD FRCPC, is Vice-Chair of the HQCA Patient and Family Advisory Committee

 

* Continuity of care can be defined as “the degree to which a series of discrete healthcare events is experienced as coherent and connected and consistent with the patient’s medical needs and personal context”. 2013 Continuity of Patient Care Study