Mark Briesacher, MD: I'm Dr. Mark Briesacher, the Chief Physician Executive at Intermountain Healthcare. Today we have a guest host, Dr. Shannon Phillips, who's our Chief Patient Experience Officer, and she's talking with some of our caregivers about this very important topic.
Shannon Phillips, MD: Good afternoon, this is Shannon Phillips. I'm the Chief Patient Experience Officer at Intermountain and I am here today with two colleagues who lead our Experience of Care initiatives in the Office of Patient Experience.
Anne Pendo, MD: I am Anne Pendo. I am a practicing internist, and the Medical Director for Experience of Care in the Office of Patient Experience.
Korby Miller: And I am Korby Miller, the System Director of Experience of Care operating out of the Office of Patient Experience.
Shannon Phillips, MD: So ladies, we had a vision here at Intermountain to set up the Office of Patient Experience, and that's not necessarily a new gig in hospitals. Lots of them have that today, and then they have an Office of Quality and what not. And so, we took the bold move of saying that a patient's experience is all of that, right? So it's personalized and caring, it helps you stay healthy, it delivers great outcomes and is free froham harm. And that's a bit of a mind shift, I think, for people. How's that going, you think, so far? Just that big picture first; we'll get into experience of care.
Anne Pendo, MD: Well, I'm going to say that it's going well, being the optimist that I am. I think that one of the things that has been particularly useful is that we've got some data to support that, where we really have done some things in medical settings and we're focused on what's getting in the way of caring for our patients. When we focused on those things, and not our percentile rank or the national metrics, but we really focused on what's in front of us, what's right there that we can impact, we saw that there was an improvement in safety, and our quality metrics improved, and our experience metrics improved.
Shannon Phillips, MD: The trifecta.
Anne Pendo, MD: The trifecta, exactly.
Shannon Phillips, MD: Korby, what are your thoughts?
Korby Miller: Yeah, I've always thought that quality and safety and experience were two sides of the same coin, and I really, really bought into the vision initially, right off the bat. And as I've been out there in the field and we've been building our teams, they do too. And they all feel like all of it is the patient experience, so I think from a visionary standpoint, from setting the stage, everybody gets it. I think how that work comes together and how we really make that reality is a work in progress, but I do think we're off to a good start and that everyone believes in it. Everyone believes that when they come and have a harm event happen, that it's not a great experience, even if we are smiling at them when it's happening.
And the converse of that is true, we might diagnose them properly and completely cure them of whatever they came in for, and if we don't deliver that in a human way, with that connection, they leave feeling like it wasn't a great experience even though we delivered on those clinical outcomes. So, I think the foundation is there, and I think that everyone buys into, I think, how it comes together fully, we've got our...
Shannon Phillips, MD: We're paving that road.
Korby Miller: We are. We are.
Shannon Phillips, MD: So, someone who's a little cynical might say, experience of care, that's just the flavor of the month, right? Yeah, you're just going to tell me to smile and thank people and whatever, right? So, pull together for me why it is so much more than that.
Korby Miller: To me, having a truly healing environment leads to better outcomes. Our patients are more engaged when they're feeling like they're in a safe environment to be able to speak up, to be able to share all of their concerns, and if we don't create that atmosphere for them—and that comes through trust—it comes through compassion and truly feeling like the care team around them cares about what's happening to them, it leads to literal better outcomes. And it's not just about, did they fluff my pillow? Did they bring me water? It's bigger than that.
Anne Pendo, MD: And I think those cynics out there know, deep in their hearts, that why we went into medicine and why we are choosing this career is to make a difference for patients, and I would propose that it's thinking about patients a little bit differently than we were trained to do in medical training; that it's really thinking about what is the goal for the patient. And maybe what is my goal, too, and then how we can work together to get either the desired outcome, or at least create a treatment plan that everybody is on board with.
Shannon Phillips, MD:: So I'm going to play off of that a moment. So when we think about the goal or the treatment plan, I think we haven't maybe done as good a job of actually identifying what the goals are of the individual sitting in front of us, right? So, we think about number needed to treat and which oncology protocol and the pathway for community acquired pneumonia. We have all this evidence base and clinical best practice that swirls and we need to be competent in, are we fitting in the patient's voice? The patients are what matters most. Are we doing that well enough?
Korby Miller: I love the what matters most—even just the tagline, if we were going to call it that. If I were a caregiver and I walked into a patient room at a clinic or in the hospital setting and the very first thing I ask them was, "What matters most to you?" I would be willing to bet that a lot of the time it's not what we think it is. And it might be something that is arbitrary to why they're even in the hospital, and yet, they're concerned about it. It could literally impact the treatment plan we give because if their goal is to be skier, you know, I've heard this example before, we might literally choose a different path to healing. And that is twofold if I may just elaborate a little bit on that.
We talk about our caregivers needing their well filled, too, and that simple question of asking a patient what matters most to them could open a dialogue of a really meaningful conversation between the caregiver and the patient and or family to where they actually have their well filled in that moment and bring them back to purpose and why. So I think there's a lot of reasons to ask the “what matters most” question at the very beginning of that dialogue.
Anne Pendo, MD: Yep. You can't see me, but I'm shaking my head as Korby is speaking with a smile on my face. My addition, in addition to what Korby said is, as I think about our work, and you brought that up, we're so really focused on the find it, fix it, get the data right and in our work around communication, recognizing that if we don't engage and create a safe and empathic environment for our patients, we won't create that safe space for them to share with us what's most important, what matters most to them. And that find it, fix it may not meet their goals at all. And I often remind myself when I'm in with a patient talking to them, we keep in the same conversation, that's my moment to pause and say, "I have not done the listening, the engaging, with them. So stop, reset. Go back to engage and empathize and create that connection, that relationship, that partnership because if I don't do that, I'm not going to get to that outcome, whatever that is."
Shannon Phillips, MD: I think I'm feeling in both of your descriptions, be present and be together.
Anne Pendo, MD: Yes.
Shannon Phillips, MD: Maybe, right?
Anne Pendo, MD: Yes.
Shannon Phillips, MD: And it's an “and,” right? I don't think patients...I wrestle with the, I don't wrestle with, the concept of patients centered in that. I think patients of course, I mean we're in a healing profession, they should be in our, I think, they're looking for a relationship, right? They're looking for trust, respect so that when they have to make decisions about quality of life, choice of treatment, that they feel like they have an ally in their caregiver.
Anne Pendo, MD: They feel safe.
Shannon Phillips, MD: They feel safe. There you go, safe.
Anne Pendo, MD: Safe.
Shannon Phillips, MD: Present and together.
Anne Pendo, MD: Exactly.
Shannon Phillips, MD: All right. Right? So, that connection, I mean I think it's innately human that you're looking to feel somebody has your back, they're with you, they're walking your journey...
Korby Miller: At their most vulnerable time. I mean really when we think about that, they're coming to us in most cases and they don't know what diagnosis that might alter the rest of their lives is coming their way and...
Shannon Phillips, MD: So, careful for us, it's interesting we built Bricks and Mortar, patients come to us, we see them in transactional experiences, right? You come to the clinic, you're into the hospital, you go to X-ray and we are trying to think about the continuum, right? We're trying to be intentional in the Office of Patient Experience to set up our work across the continuum to try and force ourselves to be a little less transactional. Are we going to get that done, do you think? Is that pie in the sky? Because it's almost...It's a counter current, right? It's very easy to set up in a hospital, set up in a clinic, and the patient's journey is never one of those things alone. So, is that reality? Do you think we can hit that?
Anne Pendo, MD: Well I think that's an excellent aspiration, and with some of the reorganization at Intermountain, what I'm observing is that we are having groups of people talking to each other about patients and what they're care is like in different settings across the continuum, and that wouldn't have happened a year ago. So, we don't have it right yet, but if the conversations of the people that are coming together to have the discussions, the example I'm thinking of is medication reconciliation.
Shannon Phillips, MD: Oh, that's a small topic.
Anne Pendo, MD: It's a small topic.
Shannon Phillips, MD: Mm, it is.
Anne Pendo, MD: And as I'm looking at the...It started with somebody saying we've got a problem, and it came from patients transitioning from the emergency department back to their physician and that's a quality metric that we're measured on. And so the room last week was pharmacy. Inpatient, outpatient, physician, critical care physician, outpatient physician. We had nursing, inpatient, outpatient pharmacy, home health, all in one room, and as I looked around the table I thought, this never would have happened. People would have said, "Oh no, that's my piece, I just take care of that." And I should show you the white board, because there was writing that covered it, all over it, and it was really following the patient from place to place to place.
Shannon Phillips, MD: And you wonder how it ever gets done right? How could they possibly get the right medication?
Anne Pendo, MD: Yes.
Shannon Phillips, MD: It's just daunting.
Anne Pendo, MD: Sometimes it's entered here and sometimes it's entered there, but these two systems don't speak together, and the end result was, what's the gold standard for med reconciliation? And I thought, maybe we should have started there, right? But I don't think we would have known that if we hadn't done that exercise of really demonstrating how complicated it is.
Korby Miller: Yeah, I agree with the restructure. More people are having the conversation even about what is happening over here versus over there. You asked whether or not we feel like it's a possibility or if we're just reaching out there and I do think it's possible. I think a lot of what we do, just as part of the nature of the work, is we have certain things we have to meet during care. I can't choose not to do a physical exam. I can't choose to not do some quality and safety elements of care, and I think we can introduce a culture of empowering our caregivers to deliver on extraordinary experience, no matter where they're at in the process.
Where they're at along that journey, and I think just having a culture where people feel empowered in their work to be able to deliver for that, or help the patient and family get what they need and exceed those expectations, because we talk about meeting expectations a lot, and I would like us to exceed them, where they leave one of our facilities or an event, or some education and they feel, wow, I left with my expectations blown out of the water. I think that's what we should strive for, and I think it's possible. I think that's a culture shift. We still have to medically and clinically do what we need to do, but I think we can get there.
Shannon Phillips, MD: Sure. I have been known to say more than once, that we can only take care of our patients as well as we care for each other. Your reflections as experts in this space on the importance of caregiver, provider engagement, and how that connects to the experience of care.
Korby Miller: So, it's huge. It's foundational. Without that engagement, we will not get where we need to go. I think we have segments of our caregivers that don't ever interact with a patient physically during their job. And I think it's important for all of us to empower them to also deliver on extraordinary in their space, because even if they never see a patient during the day, or evening, they are absolutely impacting what's happening at the bedside or in the clinic. And I think, through stories and constantly bringing those to the forefront so they can see how the work is impacting real people, is really important. I also think that really helping them to know that they're all part of that experience and they're all caregivers—it's one of the things we adopted here at Intermountain—is the term caregiver for all of our staff members for that reason. And I really like that, and I think we have a lot of room to grow on that even still.
Anne Pendo, MD: Yeah, I would agree. I would agree we have room to grow in that and as I speak with nursing and physicians feeling overwhelmed by all the tasks that are required of them, and as we talk about the work we're doing and initiatives, really be mindful of, how does this improve care for our patients? And what can we do to make it easier for the caregiver to do whatever that work is? Now to think if we can't answer those two questions, we need to go back to the drawing board before we really share that. We were talking, one of the Intermountain Medical Group, the employee physician group, has a board committee on caregiver engagement, and as a person that attends that meeting really in the role of a staff person rather than a board member, listening to the frustration and, really, the pain of the physicians, it reminds me how mindful we need to be in what we're asking, what we ask people to do.
And you can tell that, as the conversation starts and ends, as it's ending, or we've got some ideas in place where we think, okay, we can really make a change here or do something different here, you can sense the decrease in anxiety. The people, they're sitting up a little straighter and they're sounding much more optimistic, and I'm imagining that when they go to work the next day, they've got a little bit of extra...
Shannon Phillips, MD: Something, something.
Anne Pendo, MD: ...something, something. Yep.
Shannon Phillips, MD: Awesome.
Anne Pendo, MD: Yep.
Shannon Phillips, MD: Intermountain is one of a very few healthcare organizations that has a Chief Consumer Officer. A great partner to us, Kevan Mabbutt, and I wonder, we, for a long time as healthcare professionals, bristled at the idea that a patient could be called a consumer, a customer, and so forth. And I wonder, because I'd like to be a cup half full kind of girl, is, what can we leverage about the fact that before any of us is a patient we are consumer, right? So, every day, I hope I'm not on Amazon every day, oh my goodness, but we're out there being consumers in our lives and so, how do we not see that as a bristle but say, "We're all consumers and our patients are consumers," and where could that help us be extraordinary?
Anne Pendo, MD: So since Kevan started here at Intermountain, I've become much more aware as I go about my day to day. Yes I'm on Amazon more often than I should be but pay more attention to what goes well, what didn't go well and, how do you apply that to the healthcare setting? I was speaking to a patient who had an unsatisfactory interaction with our phone system, and yes...
Shannon Phillips, MD: That could not happen.
Anne Pendo, MD: Shocking, and as we were chatting, that's his field is consumer service, consumer experience, in his setting. So we engaged in a little bit of a conversation about how he would do this if this were his business and I'm like, "That makes sense. That makes sense. That makes sense." And I'm going to say that this thought about being a consumer before you're a patient is changing the way I look at things in that I'm looking at it more from the patient. So whether you call them a patient or a consumer or a customer doesn't really matter, but the idea that we're focused on the experience has heightened my awareness both outside of the office and the clinic and as I see things that I think, "Oh that worked well." How could we implement in our clinical setting?
Korby Miller: Great. I don't have a ton to add onto that other than to say people have a choice where they go for healthcare and where they buy things and where they choose to spend vacations, and we're in that mix. We want people to come to Intermountain because we know we can produce and deliver on quality healthcare for them, and when you consider how everyone is bombarded today with things they have to do, people with parents, working and raising kids, and other people just having a lot on their plate. Making it easier to enter our system to get the services that they need is important. And I think we have a responsibility to do that, and that brings in that consumerism conversation, absolutely.
Shannon Phillips, MD: Yeah, go ahead.
Anne Pendo, MD: I want to add one more thing to what Korby said, and it's something that you said earlier about patient-centered, and people bristle at that as well. Physicians, in particular, because the way it's perceived is, I'm supposed to provide whatever is asked for; the customer's always right. And I always like it when I get asked that question, because it gives the opportunity to really have a conversation about it. It's not about giving somebody the large quantity of narcotics that they're asking for, that to me is not patient- centered, that would be harmful. So, when I hear that, I think it's important to distinguish, we're not saying that the goal is to deliver care that isn't appropriate just because it's asked for. But it does require a different set of skills and I'm learning those skills and practicing so that I can be more proficient at having those difficult conversations.
Shannon Phillips, MD: And managing those expectations, right?
Anne Pendo, MD: Yes. That's really true.
Shannon Phillips, MD: So I'm going to tease back to something you said in the beginning when we talked about the definition of patient experience and that you really can't have an extraordinary experience without the whole thing being safe, great quality, and caring, if you will. If I recall when I was here just a couple months, a nice doctor named Dr. Pendo rang me up and said, "Well you know Shannon, my doctors are just demoralized. They don't like these survey results, they don't like being confronted with the fact that they're not extraordinary, and it's just making them feel bad about themselves and the care. That's not what we're about, right? No, of course we're not, and why don't you come out and see if you can't push us along?" And so what a great experience for me to come out and visit Avenues.
Anne Pendo, MD: Turned out great for us, as well as our patients.
Shannon Phillips, MD: And maybe if you would summarize kind of what's transpired there and how maybe it is emblematic of patient experience.
Anne Pendo, MD: Yeah.
Shannon Phillips, MD: And what we as Intermountain are going to learn from that.
Anne Pendo, MD: Yeah. Thanks. Thanks for asking. So I was a little embarrassed that when Shannon, Dr. Phillips, said, "Well why don't we walk through the office as if we're a patient?" And it was as if the light bulb went off, because we hadn't thought of doing that. I mean, we believed we were providing extraordinary care it was hard to get an appointment, our patients told us we were doing a great job and we were really kind of stuck with how could we do better? So, as we walked through the office in the patient's shoes, we realized there were a couple things that were getting in the way of providing the care we would want. One of those was getting the prescriptions called in at the end of the day, and the other was asking the patients to come back out to the front desk and wait in line again at the end of a visit to schedule their follow-up appointment.
So we implement two small changes, simple ways to measure. We used our huddle board to visually track how we were doing. We did in-room scheduling and tracked how many follow-up appointments were being scheduled in that way and how many prescriptions were left over at the end of the day. So it was simple. We measured it, we had buy in from the physician leaders and our staff, our caregivers, our practice director, our care guide, our care manager and a couple MA's. They were really on board, and we kept going with this even though there were some people thinking, some caregivers thinking, that this was silly or maybe not what we should be focusing on.
And the lovely thing about this was that, at the end of a couple months, it was demonstrated that safety events decreased, our quality increased, our experience of care patient experience scores increased from to %, and it really proved to the clinic, the group, that this was something that was really good. And since we did that, it was about a year ago, we've shared those learnings across the clinic I work in as a multi-specialty clinic and shared that in general surgery. Same thing. Implemented a couple simple things, things that were getting in the way, not just for the patients but also for the caregivers, which I thought was just so elegant that these were things that we focused on that were bothersome to both groups and to the physician and APC's and again, increase in experience.
Shannon Phillips, MD: So you found the secret sauce?
Anne Pendo, MD: Yeah.
Shannon Phillips, MD: Maybe?
Anne Pendo, MD: I'd like to think so. I mean I'd like to think so.
Shannon Phillips, MD: Ah, for sure.
Anne Pendo, MD: So much so that our Medical Group, which is our employee physician group, retreat focused a good part of that retreat on our continuous improvement process. It's doing just that work that I described, now sharing it more broadly, and hopefully then sharing it even more broadly with hospital, home care, really any setting to kind of take charge, take ownership, of what's getting in the way.
Shannon Phillips, MD: Mm-hmm (affirmative). And I think people need a sense of control and working on something that's lagging and very far out there and doesn't have a specific answer so getting to what's getting in the way, what matters most. I think what happens in those circumstances is you change the way you team, because you weren't specifically working on the ACL measure for blood pressure, diabetes, what not, not that you were ignoring it, but what was happening is the way you all teamed on behalf of the patient changed, and so you got a lot of unintended consequences that are sticking today.
Anne Pendo, MD: Yes, and I would say now that as we're looking at how we provide our care differently, we've changed how our staffing is and how our...It was one physician to one medical assistant but we've reconfigured that because we think this will work better, our new configuration will work better. So I'm going to say it's changed a little bit, the way people show up at work. As I was seeing patients today before we got together, I was working with Dulsay but I needed somebody to have a follow-up appointment scheduled. Cassie just stepped right in and took care of that; because she was rooming somebody else, I thought that would not have happened. It would have been, this is my doctor, this is what I do, I don't step in other places, but it's really been a shift...
Shannon Phillips, MD: Extraordinary teaming.
Anne Pendo, MD: Yes. I love it. I love it.
Shannon Phillips, MD: I love that too. No, and I think we're onto something there so...
Anne Pendo, MD: I'd like to think so.
Shannon Phillips, MD:...we'll have lots of good stories to share. All right, before we close, you get one word to describe an extraordinary experience of care. Ready, go.
Anne Pendo, MD: Trust.
Korby Miller: Empathic.
Shannon Phillips, MD: Thank you, ladies.