Turning Feedback into Action at Martinsburg VA Medical Center.

What process did you use to develop a solution?

1. Compared the facility’s patient satisfaction results across 12 clinical sites of care within the organization to the Veterans Health Administration (VHA) national average and top 10% performers.
2. Identified significant areas of underperformance including both positive and negative drivers of performance.
3. Mapped the entire patient experience and identified key points of patient-staff contact in which the patient’s perception of the visit was or could be impacted by behavioral changes.
4. Structured point of care questions to address those key points of patient experience such as clinic responsiveness to phone requests, impression of the front desk interaction, care provided by the nurse at triage for the scheduled visit and the care received by the clinic provider. Additionally, we targeted an overall rating of the visit, impression of the clinic cleanliness, timeliness of the response to call or messages, the provider’s inquiry regarding any current mental health concerns/issues and the ability to schedule both urgent and routine visits. To assist the facility’s infection control monitoring, we later added questions regarding hand hygiene.
5. The data was collected via patient responses to a questionnaire offered at check out. The questions were made available to the patient via email link or text message. We tracked invites daily by clinic location.
6. The data was summarized by the contractor and shared at an appropriate frequency; invites daily, outcome data on weekly, monthly, quarterly and rolling 12-month basis depending upon the specific measure.
7. The contractor/consultant formatted the data and provided coaching during a scheduled monthly call in addition to an “as needed” basis.
8. In response to the data analysis, end user feedback and changing targeted areas, the patient experience question set were adjusted.

What specific steps did you take to address the problem?

1. Met with the established Primary Care Service Leadership Team to review the current VHA patient satisfaction survey results (SHEP = Survey of Healthcare Experiences of Patients) to identify sites of care and underperforming areas.
2. With the understanding of the underperforming areas, identified the points of patient contact within the service (phone, email, front desk, nurse visit, provider visit, environment) which may contribute to the underperformance.
3. Decided to optimize the existing private patient experience feedback tool and available coaching. This resulted in an enhanced, more focused feedback tool with questions addressing the patient’s satisfaction with key points of contact during the visit. We structured the questions to reflect the VHA survey question intent and, unlike the VHA national tool, we encouraged comments regarding compliments and suggestions for improvement.
4. Shared the plan with all clinical sites and staff to more fully engage the patient’s voice, share successes and areas for improvement regularly and to “set a high expectation for success”.
5. Expanded the patient’s opportunity to participate in feedback from a tablet-based or paper-based questionnaire via an “invite” offered at the front desk during check out by email or text message.
6. Reviewed the number of feedback invites by clinical site daily and provided positive feedback to high performing sites. We tracked response rates monthly as well to ensure the “invite” process remained robust.

What resources, if any, did you engage – either internally or externally – to address the problem?

The Martinsburg VAMC worked with pCare, a leading patient engagement improvement organization that provided point of care feedback software, actionable push reporting and performance improvement support, best practices and evidence-based improvement tools, to gather point of care feedback from Veterans leaving the primary care clinic. As Veterans check out of their primary care appointments, clerical staff asked the Veterans if they would be willing to answer a few anonymous questions about their recent primary care visit.

If the Veteran agreed, they were able to provide feedback using a hand-held tablet at the clinic, or they could answer the questions after their visit via a text or email-based questionnaire sent to their desired location. The patient feedback software allows for both the secure capturing of real-time patient feedback, but also the dissemination of patient feedback to clinic leadership and practitioners in the time, format, and frequency of their choosing.

pCare also provides performance improvement coaching from experts with extensive experience in health care and backgrounds in performance improvement and patient experience improvement methodologies. The Martinsburg VAMC primary care team met with their pCare coach monthly to advance improvement efforts and to refine the customizable solution to meet their targeted needs.

Purpose:

• To obtain valid and reliable evaluations of veterans’ healthcare experiences with VHA ambulatory care.
• To obtain these evaluations using a standardized questionnaire and consistent methodology nationwide, thereby permitting the reporting of valid results, trending over time, and the comparison of local results with VHA internal benchmarks.
• To support assessment of VA’s initiative to provide Veteran centered primary care through implementation of Patient Aligned Care Team (PACT), based on a patient centered medical home (PCMH) mode

Survey Administration Protocol

SHEP administers mail-based surveys. Veterans selected for the survey are sent a pre-survey notification letter explaining the nature and goals of the upcoming survey and encouraging the veteran to participate. One week later the questionnaire is mailed to everyone in the sample. Thank you/reminder postcards are sent to the entire sample one week later. Data collection remains open for three weeks after the postcard is mailed.

SHEP measures that feed into S.A.I.L.:

• In the last six months, did anyone in this provider’s office ask you if there was a period of time when you felt sad, empty or depressed?
• In the last six months, did you and anyone in this provider’s office talk about things in your life that worry you or cause you stress?
• In the last six months, did you and anyone in this provider’s office talk about a personal problem, family problem, alcohol use, drug use, or a mental or emotional illness?
• Provider Rating: Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

What lessons did you learn that you would share with others as they consider addressing a similar issue?

Improving the patient/family experience is challenging due to the multiple points of potential failure including the clinic environment, point of first contact (lobby, help desk, clinic front desk), nurse visit, provider visit, check out and contact with the clinic via phone or secure email. Given the multiple sites of care and the highly variable results across these sites, we needed to review, accept and imagine what the results truly represented.

Did a poor impression of the care result from a grumpy conversation at check in? Or with the nurse? Or with the provider? It is important to allow patients to share their www.theberylinstitute.org stories and they must be shared with the staff to allow for self reflection. Of key importance was envisioning the patient’s visit and the attempt to identify points of contact with the staff/clinic and determining how to gauge the patient’s satisfaction with that point of care though the question-design process.

Our staff wish to be perceived as caring and helpful. Encouragement, liberal sharing of clearly understood data with reinforcement of good practices through positive communication, frank sharing of underperformance and holding clinic leaders and providers accountable for the results have been keys to success.