Shannon Phillips, MD: I'm Shannon Phillips, and I'm here with Anne Pendo, one of my colleagues at Intermountain. Anne, why don't you tell everybody a little bit about yourself?
Anne Pendo, MD: Thanks, Shannon. I am a practicing internist, and I am also Medical Director, responsible for about 180 clinicians, physicians, and advanced practice clinicians that have primarily hospital based practices in the central Salt Lake Valley.
Shannon Phillips, MD: All right, and we started working together probably six or seven months ago.
Anne Pendo, MD: Yeah.
Shannon Phillips, MD: You want to tell people how we ran into each other?
Anne Pendo, MD: Yes, I would love to. When Shannon's engagement, or employment with Intermountain was announced, I was especially excited to have, as your responsibility, patient experience, for two reasons. One, because that's an area of work that I'm passionate about, and believe is important. And also, because I thought we could be doing better. The clinicians that I work with are excellent, outstanding, and caring. But our scores, our measurements, weren't really reflecting that. There was this disconnect between what I'd observed of how they talked about their experiences with patients, and what those metrics showed. It didn't match, and in trying to figure out how to bridge that gap, move things forward, I thought-
Shannon Phillips, MD: Give me a ring.
Anne Pendo, MD: I know just the person to call, and so asked you to come visit us at the Avenues Specialty Clinic, which is where I practice Internal Medicine, and get to know some of our team, and help us think about ways that we could improve.
Shannon Phillips, MD: Yeah, and I think what became, what was obvious to me, was that people were very focused on that number, that measure. How do we make provider ratings better? How do we make our patients like us more? We were maybe losing the opportunity to step back from that, you think? Or, that people were so caught up in the number, and the graph, that they were almost paralyzed to think about what was behind that.
Anne Pendo, MD: Yes, that's, I think, a great description of that. We had posted the data on our huddle board, and so people could see…clinicians could see where they were being measured. It was really a bit demoralizing, and paralyzing I think is a good word. Because nobody really knew what to do. Then we had the issue with, it was a physician rating. But it wasn't just the physicians that were involved in the whole visit. How do you bring the team, every touch point that the patient encounters with someone on our team, how does that all get brought together into the experience. And also, helping them understanding why we were even measuring this.
Shannon Phillips, MD: Right, so I think it ... I heard when I came to visit, some frustration with the measure. When we sat down to talk, there was an opportunity in teaming, right?
Anne Pendo, MD: Yes.
Shannon Phillips, MD: Everybody comes into Avenues Clinic every day, and they had a job, and they came in and did that, and they did it a bit independently of the things around them, right? We had a conversation, for instance, about the front desk.
Anne Pendo, MD: Yes.
Shannon Phillips, MD: And how not only is there a door and a wall between the front desk of course, and where we give clinical care, but it was not just literal, it was figurative a bit, right? Metaphorical. Talk a little bit about how people have addressed, how you all have thought about teaming, and the alignment of everybody together.
Anne Pendo, MD: One of the things that we did the day you visited the office, is we started on a patient journey.
Shannon Phillips, MD: Right.
Anne Pendo, MD: We walked-
Shannon Phillips, MD: We list it, exactly the steps they take.
Anne Pendo, MD: Yes. That was particularly helpful, because it pointed out to us, even though we knew what those steps were, I don't think we had a really good picture in our mind of what that felt like to our patients, and your description of everyone had these independent jobs. So yes, you waited in line to be greeted by the person at the front desk, then you sat down, then you were taken back to an exam room by a medical assistant, and then seen by the physician, and then came back out to the front desk to finish your visit, and reschedule your appointment.
We did a couple things that were really simple, and we shifted our focus from the number, to what do you think our patients are experiencing or feeling when they come in to the office. The way we did that, is we used our huddles. We have a weekly huddle on Fridays, where our physicians attend, and we had everyone participate. We talked at the beginning really, about why we were getting everybody together. I think that, that...those conversations really laid the groundwork for our whole group, to feel like they had a role in taking care of our patients.
Shannon Phillips, MD: Right, so I remember the huddle board, and right, it had some of these big numbers, operational, and experience, and such that people looked at, and there wasn't that next level down. Yes, there's a provider rating, and what are we doing, what's behind that? What is the patient feeling and seeing. Where we could make a difference, one of my favorite stories from you all, was something as simple as picking a function that happens in the day that made a difference. For example, I'm trying to remember, but I think we're going to answer all...We're going to fill all medication prescriptions by the end of the day.
Anne Pendo, MD: Yes.
Shannon Phillips, MD: To me, that was such an amazingly simple example, because not only was it very clear what people needed to do. We're not going to leave, we're not going to close for the day until we've filled every prescription. And, in doing that, we could reliably tell a patient, "We've got this no matter who took it, we would have it done," so you could always tell them it would be done. And furthermore, it then decreases the amount of calls, and inquiries from patients who say, "Is it there yet, is it there yet? Have you done it?" And that gives people back time to serve patients. That was just a simple example, but I bet there are others.
Anne Pendo, MD: The key thing with that project, and I'm going to use the word project. But it was very simple, someone just kept track on a sheet of paper, how many were left at the end of the day. But what it did was, it allowed our medical assistants to own a problem. Before it would have been, "The doctors want us to do this." It got switched from, "The doctors want us to do this," to, "This is how we take care of patients."
Shannon Phillips, MD: And you bet the patient...I mean that's caring for a patient, right?
Anne Pendo, MD: Right.
Shannon Phillips, MD: Yes.
Anne Pendo, MD:
The other thing that we did was, we started the process of in-room scheduling for follow up visits, so that the patients didn't have to go back out and wait in another line. They could-
Shannon Phillips, MD: That's impressive, right? And simple.
Anne Pendo, MD:
Yes, and simple. I mean it was so elegant in its simplicity. We did have teams that were not sure that, that was going to be doable for them in their flow of their patient day, and having a physician or two try it, find out that it really was workable in the process. The patients were actually saying to our medical assistants, "This is so great. Thank you so much." Then what we were able to do with our metrics, is we could see that our experience scores were rising, climbing in a positive way, and that seemed to coincide with the in-room scheduling. I don't know if that was really directly a result of that, or really kind of a shift in the culture of our practice.
Shannon Phillips, MD:
So as I say, talk ... because I think these are a series of small things that are making a caregiver’s life at work better, and are completely centered on what's right for the patient. Talk a little bit about how that changed the work environment, the culture in the practice.
Anne Pendo, MD:
I would say initially we were really very siloed, as we talked about at the beginning of our conversation. It changed the feeling of ownership, and ability to solve problems for all the staff. Not just ... It didn't need to come from the physician, or administration. It was really that sense of ownership. It was almost as if administration, or operations folks needed to say to the staff, "Try us. Come up with a solution to something, and we're going to implement it." As we came up with ideas, and they were implemented, people kept moving forward.
One of the other small things is the language that we use. We use. So-
Shannon Phillips, MD: You know I really like the word, "We," right?
Anne Pendo, MD: ...Yes.
Shannon Phillips, MD: I'm all about that word.
Anne Pendo, MD: We do.
Shannon Phillips, MD: What did that mean in the practice?
Anne Pendo, MD: What that meant is that we were a team together. The front desk part of our team brings the patient, gets them registered, and then says, "I will let Amanda know that you're here." Who's the medical assistant, so using that individuals name instead of, "Have a seat," they'll-
Shannon Phillips, MD: And I'll let them know you're here. Them.
Anne Pendo, MD: ... And I'll let them know you're here.
Shannon Phillips, MD: Yeah.
Anne Pendo, MD: Exactly. It allowed for the clinician, or the medical assistant to say, "We are so happy you're here today, and your immunizations are going to be given by my assistant, Vicki." Again, using a name. It became clear to our patients that we functioned as a team. Each of the individuals was a part of the team, were all linked to that providers name.
Shannon Phillips, MD: I could imagine for the patient, that feels like a warm handoff.
Anne Pendo, MD: Yes.
Shannon Phillips, MD: And that there's not, "Oh, they couldn't get that done," or, "The nurse is backed up." It's, "We are, and Amanda is," and that sense of connectedness is important. How does it make the team feel? The people in the office? What's changed there?
Anne Pendo, MD:
I'm going to say that, I would say more of a sense of comradery, and working as a unit. Even if we've got our groups, one MA, one physician, or APC working together, it really felt that there was a shift in not only ability to problem solve, but really somewhat feeling safe to bring an issue up, or to make a suggestion. Whereas before, they may have been afraid that somebody would shoot that idea down, or say, "That's silly, why would we even think of it?" It's allowed for more conversation amongst the team.
Shannon Phillips, MD: People willing to speak up?
Anne Pendo, MD:
People willing to speak up, and it goes back to that feeling safe. Feeling safe to point out an error, or feeling safe to say, "I've been thinking about how we might be able to do this better. What would you think of trying this?"
Shannon Phillips, MD: So that human connection, something as simple as your name, is followed by opportunities to share differently than you have today. Whether it's to help problem solve, or bring up something maybe nobody else but you sees, and that really changes the dynamic, I think, of how people work together. I imagine that, that feels different to the patient. Well, if we fast forward, it all started with a visit to talk about provider rating, and it's not working, and nothing we're doing is making a difference. How are we doing, how are the results today?
Anne Pendo, MD: Well, we just saw our October satisfaction data-
Shannon Phillips, MD: And?
Anne Pendo, MD: ...And we are at 91%.
Shannon Phillips, MD: Drum roll. Wow.
Anne Pendo, MD: Wow is right. We continue to post our data, but the discussion wasn't around that. It wasn't around the number, it was around the things behind the number, as you said.
Shannon Phillips, MD: That is, those are things that are tangible. People can get their hands around, and any one of those small things that are made better, are collectively reforming the culture, and the teaming that, that office is doing.
Anne Pendo, MD: Yep.
Shannon Phillips, MD: Great. Patients perceive our caring differently today. Do you have any comment as to whether, because some people will say, "Okay, they like it better." It also matters that we deliver great outcomes to our patients, right? It's an and, it's not a but, right? It's an and. Comment to how this teaming in your office is impacting the outcomes for patients?
Anne Pendo, MD: And I am so glad you asked that, because two of our quality measures are around high blood pressure and diabetes care. Our metrics on both of those are above our goal. I would venture to say that the reason those measures are so much better is our staff, our caregivers understand the why behind when they're looking at a report and seeing that somebody's blood pressure last time was high. They understand the reason behind double checking it, to make sure that it is in the normal range. Or, if someone hasn't gotten their urine sample checked for their diabetes, to take ownership of that and saying, "Let's get that urine today, before we put you in an exam room."
We haven't looked specifically at safety, but I would venture to say as well, that our ability, our self-reporting of errors is ... I'm going to say it's improving, because we're having more self-reported errors. There was a huddle not too long ago, where we were, as a team, frustrated because we were having difficulty getting the correct immunization, to the correct patient. We came up with a process to fix that, and it took all of 30 seconds.
Shannon Phillips, MD: And people, at the front line, it sounds like dug in for the solution on that, right?
Anne Pendo, MD: Yep.
Shannon Phillips, MD: It didn't need a committee, it didn't need approval, all those layers up the organization. But people are at the front line, meeting patients where they are, fixing those things, those small things that make all the collective difference to patients.
Anne Pendo, MD: Exactly.
Shannon Phillips, MD: Very, very powerful.
Anne Pendo, MD: Exactly.
Shannon Phillips, MD: So, we learned from the opportunity, I think the Avenues example to me says, "We need to move past those big seemingly untouchable things. We talk about together, what matters most to the patient, and what's getting in the way of serving the patient." Whether it's changing immunizations, in-room scheduling filling all the prescriptions before we leave, answering all the phone calls for the day. The sum of those small things have made an incredible difference for our patients. The extraordinary experience of care is clearly there, because they're telling us it is. Because of all of those little things that make the cumulative difference. That's a very powerful story.
I end, by the way, it made the quality of care better. You are one of our seasoned experts at Intermountain, in Communication. I also want you, if you wouldn't mind, to reflect on the fact that we could probably go about changing some of these things in a very dogmatic, and hierarchical way. And/or, we could use Communication at its best. Interested in your reflections on how attention to communication has helped in the office, and then maybe we'll turn to providers specifically. Where has that played in?
Anne Pendo, MD: I think that one of the things that we talk about in communication is asking the how and what questions, and not asking the why, because the why seems to have judgment around it. Using that communication technique of how and what allows, again, for that safer environment with our team, with our group, that works together. Not just with the physicians, but in our huddles. "What do you think of this?" Or, "How do you think that's going to impact our call center?" Using those tools, I think has been helpful.
Shannon Phillips, MD: Keeps a respectful, your voice matters, in the work, in this problem solving.
Anne Pendo, MD: Yeah.
Shannon Phillips, MD: I think that's a very powerful, and maybe second nature to you. But I think people could take that, and think about that. If you think about the provider, so imagine that they ... How much do they care about filling prescriptions by the end of the day, or that the handoff from the front desk to the rooming person goes differently than it does today. How has that mattered for them, or does it?
Anne Pendo, MD: Well, I'm going to suggest that the smoother that process at the beginning goes, then when you enter that exam room, you are not spending time apologizing, or attempting service recovery with an unhappy patient. It allows for more time to get to the heart of the issues, that the patient has come to the office for.
Shannon Phillips, MD: So they can see immediate feedback potentially for that going better, because their visit starts in a different place.
Anne Pendo, MD: Yeah, exactly. Exactly.
Shannon Phillips, MD: Okay, okay. They are busy, and overwhelmed, and charting, and charting, and charting, and whatever else is on the plate. How have you connected with your team to be present?
Anne Pendo, MD: I typically share this when I'm talking to groups of people, that one thing that I have found particularly helpful is the pause and be present. What I've found was I had so many things going on in my head, I'm running behind schedule, and "I've got all of these messages to answer, and I didn't get milk so I've got to remember to pick that up on my way home. Oh shoot, I forgot to call this child who was having a mini crisis about something." My head was so jumbled up with all of those things, that I would often enter an exam room completely disconnected from the patient because I was so focused on all those other things that just kind of go along with being a physician and a parent.
In one of the trainings that I attended, there was a recommendation to try pause and be present. I'll get the chart, I'll look at the name, and I will take a deep breath, and let it out. I will put a smile on my face, knock, and walk in the door engaged, present with them, welcoming, and what I've found is that I like my work better, I'm happier in my work. And, I think that my patients also sense that I'm there for them. I had somebody comment not too long ago, that, "You not only care for me, but you care about me." I thought that was so eloquent, and it just reinforced why I-
Shannon Phillips, MD: Right.
Anne Pendo, MD: ...Do what I do, and I don't know if it's completely pause and be present, but certainly not having those other things roaming around in my head, allows me to be focused on the individual that's in front of me.
Shannon Phillips, MD: Right, and I think very ... Wouldn't we all aspire to having the bar be set at, "You care about me." That is very powerful, and in doing that you're getting all the things that have to get done, done, and it's probably a little bit about how you're choosing to engage. When we talk about resilience, and the impacts of Physician burnout, and all the things that are upon us in healthcare today, finding a way to fill your own cup in this, while serving a patient I think is really powerful. That's a great example.
I look at primary care, where you are, and say, "You guys are out saving lives." Right?
Anne Pendo, MD: Thank you for saying that.
Shannon Phillips, MD: It's funny, not funny, but we think of all the work done in hospitals, and emergency rooms, and ICU's, and it is of course saving lives. That's not to ... But, let's focus on, we're in the ambulatory space today. The work of engaging patients as partners in their own health has to start with that human connection, has to start with about me, caring about me, and not only for me. Your story around blood pressure screening for example. If we can engage patients in their own care and wellbeing, and their blood pressure comes down, that's saving lives, right? You all are now ... Talk me out of that, right? You're on the frontline of saving lives.
Anne Pendo, MD: Well, I often use that phrase in my Administrative work, when I have to leave a meeting to go to the office, and see scheduled patients, I will often say, "I'm going to go save some lives now."
Shannon Phillips, MD: I like that.
Anne Pendo, MD: Yeah, it kind of reminds us of why we do what we do. When I think about that, I think that I may not be saving a life in an hour, but over the next six to 12 months. And I've had the luxury, or the luck of having cared for patients over many, many years. What I've observed, and heard is that there were moments that didn't mean anything to me, but when patients come back and say, "You saved my life." Or, "Oh yeah, you've saved my life." It was finding a cancer that they were able to get treatment for, or, "You took that few minutes to listen to me, and I had a plan to kill myself, and I didn't do that." I couldn't-
Shannon Phillips, MD: Because you cared about me, right?
Anne Pendo, MD: ...Yes. I think of that patient in particular, that I wasn't doing anything differently than my regular work, but obviously that interaction had a huge impact on that individual.
Shannon Phillips, MD: That's very powerful.
Anne Pendo, MD: Mm-hmm (affirmative).
Shannon Phillips, MD: I think I've heard you talk about a couple things today. We all own it, so no matter how little the task, or big the conversation to have, everybody owns it. That attention to those small things matter. That the cumulative of small things is something pretty awesome, and big. That you all have found camaraderie in walking that journey together, and so there's no little idea, and everyone's participation makes things better. And, we all have, if we changed nothing about process, if we put, again, a little bit of attention to communication to avoid the why-
Anne Pendo, MD: Mm-hmm (affirmative).
Shannon Phillips, MD: ...And focus on the what and how, that collectively our patients will probably feel that we care about them.
Anne Pendo, MD: Yes.
Shannon Phillips, MD: That's really powerful. If I put you on the spot for a last moment-
Anne Pendo, MD: Yes.
Shannon Phillips, MD: ...And asked you, what does an extraordinary experience of care mean to you. What would you say?
Anne Pendo, MD: I think I have shared this with you before.
Shannon Phillips, MD: That's all right, I'll listen again.
Anne Pendo, MD: You'll listen one more time. Those experiences revolve around the thank you. Not maybe in the way you might think. Often the thank you comes from just doing our jobs, but it's that the connection in the thank you. When someone takes the time to say thank you to me, I want to be respectful of them taking that time to say thank you, to acknowledge it in a meaningful way.
Shannon Phillips, MD: Be present.
Anne Pendo, MD: Being present. What I've found instead of saying, "Oh, that was no big deal. That's just part of what I do." Or, "Oh, don't think twice about it." It kind of minimizes their experience. Being able to acknowledge that thank you. I'm thinking about a patient whose wife I was caring for, and she's having some issues with dementia, and he has some medical problems, and he is her primary Caregiver. We spent actually most of the visit talking about how he could care for her, and not become too tired. We had some strategy around what things he could do to make it easier on himself, and still help her. At the end of the conversation he said, "Thank you so much. I am just at my wit's end. I didn't know what to do, or who to ask." And he started to cry.
I mean, this is a big, strong, not the crying type man. It was at that moment where I realized that if I had said, "Oh, no big deal." He would have really been embarrassed that he had done that. Instead, I got up from my chair, sat down next to him, and held his hand, and had that moment of, "This was my pleasure, and I'm confident that you're going to be able to go home, and do some of the things that we've talked about."
As we ended the visit what I realized as I walked out of the room, I probably stood up a little straighter. And I had a more ready smile on my face. I thought, "That was an extraordinary experience for both of us."
Shannon Phillips, MD: Right. You were present in his suffering.
Anne Pendo, MD: Yeah.
Shannon Phillips, MD: You met him where he was.
Anne Pendo, MD: Yeah.
Shannon Phillips, MD: And, cared about him.
Anne Pendo, MD: Yes.
Shannon Phillips, MD: Beautiful, thanks for sharing.
Anne Pendo, MD: You are very welcome.