Patient satisfaction: there is more work to be done
Nahid Azad, MD
Our health care system is under continuous pressure to improve patient satisfaction. Quality methodology is a proven way to focus on patient satisfaction, but it requires cultural change to lead process change. A direct focus on patient experience and satisfaction will drive systemic change throughout the hospital. Multi-level leadership, from front-line clinician to senior executive, is key to successful cultural change for improving my patient satisfaction metrics. Front-line quality initiatives need more support to maximize their impact.
As a front-line clinician in an academic medical hospital, I am expected to improve my clinical performance. Part of my performance assessment is based on patient surveys. However, as a specialist, my domain of influence in meeting patient expectations is limited and is a small part of the overall patient experience. Several physicians treat the same patients as they move from admission to discharge, following different protocols and directives. I have limited ability to directly change the end-to-end care processes. However, quality methodology provides both the tools to identify care gaps and the potential to drive change into hospital processes, increasing my patient satisfaction metrics.
Quality methodology focuses directly on patient satisfaction rather than on health care providers. Different front-line units may be at different levels of quality maturity,1 often driven solely by regulatory requirements. We need to move beyond these minimum requirements and make patient satisfaction the primary focus of quality assurance, with regulatory requirements just one of many constraints.
This paper discusses patient satisfaction from the position of a front-line clinician who has led small quality-improvement projects in an academic hospital and has had difficulties obtaining support for operationalizing the findings. It examines the key performance factors for leading the introduction of quality methodology into our front-line units. This challenge is not the application of the technical quality toolkit; these tools are easily learned and applied. The real challenge is to take the tool findings and improve patient experience and satisfaction throughout the hospital. The challenge is to enable people to make the required changes in a rigid system with organizational and process barriers that resist change. The challenge is, therefore, to change the culture within our health care organizations. Top
Quality methodology2 is not new; it has been used for decades by many organizations, large and small, and has a proven track record.3 There are many quality frameworks, methods, principles, and toolkits — including Total Quality Management,4 IOM 6-diminsions,5,6 IHI Triple Aim,7 Six Sigma,8 Malcolm Baldridge,9 and LEAN10,11 — targeted at specific aspects of quality management. The private sector went through a major ISO 900012 quality transformation in the early 1990s as a way to improve both “customer satisfaction” and “employee satisfaction.” There is no reason to believe that quality management methods would not achieve similar results in our public health care system. In fact, we require that most medical equipment suppliers have appropriate quality certification.
First, we have to recognize that we have a “burning platform” and that we will have to change how we provide care. Given the rapidly changing patient demographics (e.g., aging), improving medical technology, and financial realities, the current system, designed decades ago, must change to meet evolving patient needs and expectations.13-20
This type of transformation is not for the faint hearted and may lead to process change that, in turn, will often lead to difficult organizational change.
It is said, “Every system is perfectly designed for the result it gets.”21 To change the outcome, we need to change the system. Our system is a network of processes, each consisting of a network of smaller processes. Each process should have an owner. For any given process, the “process activities” need to change to affect the outputs/results. This change requires negotiations with and adjustments by the owners of the input and output processes. Figure 1 summarizes the standard process structure.
For leaders promoting disruptive change, the good news is that quality methodology, by redirecting the focus to patient satisfaction, gives everyone a new perspective. This new perspective provides both the permission and the encouragement to think differently and more creatively. Proven quality tools may reinforce this thinking, help translate thinking into proposed action, and consequently lead to recommendations for process change.
Realistically, within the current environment, organizational momentum and existing barriers may prevent many of the recommended changes from being implemented. To paraphrase Einstein: our thinking creates problems that the same type of thinking will not solve. We need each unit to commit to quality improvement and to be accountable for introducing the innovative changes required to increase patient satisfaction. Moreover, systemic change may be disruptive, impacting many management levels and organizational structures. Senior management can use quality methodology as a tool to lead the type of multi-year cultural transformation they deem necessary.
Therefore, we need to focus on the leadership challenge from the perspective of front-line clinicians and not on the mechanics of applying the prescriptive quality tools. Exactly what support do front-line clinicians need to lead sustainable, innovative change? Top
Six key performance factors
Table 1 summarizes the six key performance factors needed for a successful patient satisfaction program in support of front-line clinicians and the seven associated ISO 9000:2015 and ISO 9001:2015 quality management principles.23
Visible executive support, funding, and goals
Executives must continually and visibly support the strategic direction of the quality improvement plan. If it is not clear to everyone that the senior executives are committed to the program, busy staff will recognize this and disengage.
One key element of the process is the executive quality management system (QMS). The QMS is a set of policies, processes, and procedures needed to plan and implement core health care services to meet patient satisfaction goals. Promotion of the organization’s quality strategic plan and QMS is essential at every opportunity. Executives must continually send a clear message that organizational barriers and entrenched management resistance will be overcome and that change will happen. Staff must be convinced that investing their time and effort in support of change will not be a waste of time or, at worst, a career-limiting decision.
In addition, every leader must be a change agent.24 Patient satisfaction goals must be among every manager’s performance objectives. Quality must be on the agenda of every operational meeting: Are milestones being met? What projects need help? What successes can be celebrated? What best practices can be shared?
Change agents should be recognized, encouraged, and supported. Continual reinforcement of the quality plan will help drive behavioural change throughout the organization. Behavioural change will gradually lead to cultural change; staff will communicate more effectively, transparency will improve, and teamwork will increase. The quality focus will give staff both permission and encouragement to change their behaviour. Top
One key role of executives is to provide quality program funding. Staff must see words translated into action. Quality programs need dedicated funding for training, specialized staff, and project management.
To help promote cultural change, quality training is required for all team members, particularly those on the front line. What does a quality-centric organization look like? How does it behave? How do I behave? What is our QMS? How do I fit in? What is in it for me? Are we doing a good job? How do we know?
By investing in front-line training, executives demonstrate that the change is real and that they are committed to achieving the quality goals. Change will not be effective unless endorsed and supported by front-line personnel.
It is critical that leadership support these first two key performance factors, as they demonstrate the intimate relation between management and front-line staff. Front-line staff will identify many specific opportunities to improve patient satisfaction. On the other hand, executives have the power to change the system, but are too distant from patients; they need front-line input to determine which system changes are required. Top
Strong quality leadership at all levels of management
The quality officer in each unit is responsible for developing the unit’s QMS, including patient satisfaction metrics. These officers provide focused leadership to influence the operational managers to develop key metrics, benchmarks, and both quality assurance (QA) and continual quality improvement (CQI) projects. The quality officer owns the unit QMS and the operational managers own the key operational metrics. The unit quality metrics must align with higher-level metrics.
Naturally, there will be resistance; the quality officer must recognize and help overcome that resistance (seizing the opportunity to educate staff further on the quality agenda) to help both management and staff embrace change. Resistance provides valuable information for change agents. Furthermore, the quality officer must be a senior team member with both credibility and authority, in addition to appropriate communication and influencing skills. Top
Process ownership, documentation, and approval
Quality programs focus on processes of care rather than individuals. Part of the quality officer’s role is to ensure that policies, processes, job aids, and associated records all have owners and that these owners periodically update, review, and approve the processes according to the unit QMS. Approved process documentation is stored in the QMS library. Members must be trained to ensure that approved processes are adopted. Process documentation, compliance, and ongoing improvement are key to achieving quality goals.
Naturally, each process receives input from other processes and delivers outputs to other processes, many of which will be outside the unit’s organizational boundary. The quality officer must work closely with other quality officers to facilitate this process evolution and adoption, ensuring no gaps or overlaps.
Effective defect management process
There are two classes of defects: issues identified internally and issues highlighted by patients, caregivers, or patient advocates.
An essential part of quality methodology is the recognition of problems and opportunities (quality defects). The reporting of defects in meeting patient expectations is a positive action, an action that is necessary to meet quality goals. Associating defects with a process rather than an individual and encouraging the reporting of both problems and opportunities are critical parts of the quality culture. Our current processes often do not include soliciting feedback from other internal units. Quality initiatives, focused on patient satisfaction, will require more comprehensive feedback from patients. Top
Quality training for everyone includes training in the defect management system. A process may be incomplete (defective process), a process may not be followed (non-conformance indicating a training issue), or a new patient satisfaction opportunity may be identified (process improvement). A database is required to track all reports, with clear ownership assigned for the resolution of each defect. In many cases, defect analysis leads to QA corrections and small projects. Less frequently, defect analysis highlights major care gaps that require larger CQI projects or programs to introduce new processes and potential organizational changes. The triage step will determine which defects need resolution and in what timeframe.
Periodic compliance audits
There are two key metrics in a quality program. The first is whether patient satisfaction is improving and on track to achieve our goal. We can influence but not control this metric — our patients will tell us. The second is under our control: do we pass our internal quality audits? Audits assess compliance with our QMS and our operational processes. It is doubtful that we can achieve our external goal if we do not achieve our internal goal.
Translating theory into action
At the Ottawa Hospital (TOH), many examples demonstrate the successful application of the key performance factors listed above. Quality is the first of five directions in the TOH strategic plan.25 TOH has taken a number of significant steps to actively support culture change and to encourage front-line quality initiatives in support of improved patient satisfaction. It has established a Quality & Patient Safety Department, including the Centre for Patient Safety, to offer technical expertise/tools, and to provide forums to share ideas and promote best practices.26 One key accomplishment of this group was to facilitate/expedite the approval of QI projects by the Research Ethics Board. This step removed a major roadblock that prevented many quality projects from starting. The TOH-wide electronic health record system (Epic, Verona, Wisc., USA) will provide a framework for more front-line input into processes, directly impacting patient satisfaction.
However, in my experience, the success of executive-led projects is not necessarily matched by that of front-line initiatives. Recommendations from patient satisfaction surveys, feedbacks, and related pilot projects at the unit level have not been fully operationalized, regardless of findings. Management may be reluctant to discuss either organizational or process change. It is difficult to tell whether funding or resistance to change is the real problem; as a result, patient satisfaction opportunities could be missed.27,28 On the other hand, larger executive-led projects, with end-to-end funding, have better success.
An example of a larger comprehensive CQI activity at TOH is the Lung Cancer Care Project.29 This 2.5-year project was initiated to improve patient satisfaction by reducing wait times. The result was an impressive reduction from 92 to 47 days from referral to initial treatment. Sustained management and executive support resulted in the redesign of 12 major patient flow processes, 57 workflow changes, and the removal of 270 constraints. Resources were provided for consultation, system design, and software development.
This project developed the Ottawa Health Transformation Model within the TOH strategic plan framework to help align the key domains of people (culture), processes, and technology. Process documentation and integration were built into the automated workflow management system. Defect management was provided by a project management steering committee that met weekly. Regular audits track performance via a dashboard that reports performance indicators for each process step. Most important, this project has introduced a sustained cultural change that has resulted in improved satisfaction for both patients and staff/providers.
Quality goals cannot be achieved without strong, visible executive commitment reinforced by active leadership at each organization level. The six key performance factors will help leaders introduce the cultural change that is required to enable front-line clinicians to drive change in the system and raise our patient satisfaction metrics.
Although executive-level projects often succeed, front-line initiatives often “die on the vine.” Lower-level management needs concrete patient satisfaction improvement objectives to force them out of their comfort zone, take on risk, and support meaningful quality projects, leading to continual operational improvement. Management appointments should likely be shorter to encourage innovation; long-duration appointments tend to encourage complacency.Top
It is true that health care is a complex system; however, large, complex private-sector companies have successfully navigated the quality challenge. We can do this.
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27.Azad N, Lemay G, Li J, Benzaquen M, Khoury L. Perspectives from geriatric in-patients with heart failure, and their caregivers, on gaps in care quality. Can Geriatr J 2016;19(4):1-7. https://tinyurl.com/y69ym766
29.Fung-Kee-Fung M, Maziak DE, Pantarotto JR, Smylie J, Taylor L, Timlin T, et al. Regional process redesign of lung cancer care: a learning health system pilot project. Curr Oncol 2018;25(1):59-66. DOI: 10.3747/co.25.3719
30.Azad N. Leading the medical division: a small business in academia. Can J Physician Leadersh 2015;2(2):48-54. https://tinyurl.com/y5b6w4la
Nahid Azad MD, FRCPC, CCPE, is a professor of medicine at the University of Ottawa. She is a full-time geriatrician at the Ottawa Hospital and has held many leadership positions. Her research and leadership focus on cardiovascular disease, heart failure, gender health, and quality improvement.