As low-cost, high-quality healthcare providers, ASCs must continue to demonstrate excellence to avoid or minimize reimbursement cuts as aggregate healthcare dollars are reduced. In addition, publicly reported data will provide the impetus for other healthcare verticals to narrow the gap in patient safety as they will be forced to confront deficiencies. As competition increases, timely insight from patients, employees and physicians becomes increasingly more critical to ASC market superiority.
Presently this insight is either lacking or underutilized in the ASC industry. This is partially due to facilities being slow to adopt new and more effective sources of patient data collection, assimilation and response. Numerous advances in technology and data collection within this decade provide facilities the opportunity to gather at least 2-3 times the data points collected in legacy approaches in a fraction of the time.
The opportunity to improve operational performance and financial health requires small investments in properly collecting patient data and transforming it to actionable decision-making information. The upside for the ASC community is huge. Global improvements across the ASC sector will allow ASCs to continue to be positioned as a market leader in healthcare. Future programs (e.g. value-based purchasing) will be tied to both process adherence and absence of negative outcomes. While some reimbursement will be tied to scoring, the greater reward for ASCs will be through publicly reported statistics.
Facilities must shift time from reviewing scores to adopting better capture processes and focus more energy in patient issue resolution. The latter provides a wealth of operational effectiveness feedback. An inefficient survey method is counter-productive in terms of effective use of staff time, internal cost and patient loyalty opportunity cost.
If executed properly, your patient, employee and physician feedback serves as input to quality- and process-improvement monitoring. The opportunity to maintain a fluid feedback model is at the industry's fingertips. This insight will no longer be a luxury but a necessity as the rules within healthcare reimbursement and competition continue to evolve.
Benefits realization begins with leadership
To reach the highest level of benefits realization, leadership must not only buy in but be engaged in the surveying process. Leadership must be active in taking an introspective look at various feedback and help define areas of opportunity along with measurable and attainable goals. Leadership must embrace the newer processes and share the importance of improved feedback mechanisms within the organization. A patient-centric model must become hard-wired into the organization’s culture.
Impact of industry public reporting
The competitive landscape has already been changing. Public reporting of healthcare process adherence and negative occurrences allow consumers to be more informed than ever before. Hospital Consumer Assessment of Healthcare Policies and Services (HCAHPS) easily brings patient satisfaction and process adherence data to the prospective patient’s computer. Other programs such as SCIP (Surgical Care Improvement Program) highlight adherence to patient safety measures that to the layperson are imperatives and should be as close to 100-percent adherence as possible. Anything less makes little sense to the healthcare consumer. National scores found on Web sites such as Hospital Compare illustrate that not all healthcare providers meet preventive measure standards. ASCs must excel in these measures to exude confidence in the consumer consistent with historical levels of excellence. ASCs will continue to compete against not only one another, but hospitals as well. Publicly reported scores provide a common denominator scorecard that may trump reputation when scores vary significantly.
Psychological impact of the patient experience
There are two distinct measures in patient care — the patient's perception of their experience and their clinical outcome. Chronologically, the first measure is the patient experience. The clinical outcome is a longer-term measure based on recovery and improvement. Specific outcome and experience attributes make or break the reputation and demand for a physician or facility. In the long run, the orthopedic surgeon who demonstrates outstanding success with meniscus repair will continue to gain business through referral.
However, as outcomes require time to pass, it is imperative that the facility focuses on the various satisfaction components of the patient experience. Until the clinical outcome reaches fruition, the experience translates to the perception of care. This is what gets shared with family, friends and co-workers. Until their recuperation or recovery is complete there is an inherent transference of the patient experience to their prospective improvement.
Patient expectations of excellence
Patients and their families expect excellence throughout the entire healthcare experience. This includes clinical and non-clinical inputs. In short, nothing from the experience is forgotten or dismissed.
Each patient experience has several touch points. Scheduling and instructions provided prior to surgery occur before the patient enters the door. Registration, wait time and pre-surgical interaction with clinical staff set the tone for the experience.
The intra-operative component has the most impact on outcomes. However the patient is likely under anesthesia or sedation during this time. The post-operative activities such as pain management, recovery and discharge instructions might be the most memorable, assuming the patient’s sedation has worn off to allow them to recollect this interaction.
The patient expects each of these components to be executed with respect, courtesy and precision. In the patient’s mind anything short of excellence may translate to a care issue. It is the responsibility of the provider to strive for perfection in all facets of interaction, both clinical and non-clinical.
Evolution of surveying purpose
Patient surveying is an industry accreditation requirement. Technically there are three requirements: (1) survey the patient; (2) benchmark results against peer facilities; and (3) take action on the feedback provided. Beside the accreditation requirement, survey scores are often used for some form of compensation. However, the industry has been conditioned to accept mediocrity in survey execution because the focus of the surveys has been more on the score than learning from the feedback.
Generally speaking, the entire healthcare industry has underachieved when deploying and monitoring patient satisfaction in both execution and evaluation. The survey has inherited more flaws over time as the focus has been on attaining a high score. This has led to common survey inadequacies including: (1) not enough evaluation statements; (2) limited feedback questions; (3) lack of categories; (4) lack of continuity or fluidity; and/or (5) wording that is inconsistent or too difficult for all respondents to understand. If the right questions are not asked the value of the evaluation becomes limited. The ASC deprives itself the opportunity to make improvements and spend time remedying inferior experiences. Industry conditioning has reduced surveying from a learning tool to a handful of numbers that are often void of meaning.
Survey effectiveness
There are four components that must all be effective for the entire survey process to be deemed successful: (1) survey content and rationale; (2) the mode of survey administration; (3) leadership access; and (4) patient issue resolution and management.
• Content and rationale. Many legacy surveys that exist for multi- and single-specialty ASCs have not evolved with organization and industry change. A critical success factor is to ensure the final survey deployed reflects facility uniqueness. Each evaluation statement must provide some magnitude of value when responded to. Over time the questionnaire needs to evolve to remove statements providing little or no value. To maintain optimal effectiveness, statements are added to reflect new processes, facility specialty or quality assurance oversight. The survey must contain enough statements to evaluate the entire experience. The facility needs to be able to discern whether individual components of the care continuum are effective and reflect excellence.
Even-scale survey models create a forced response. The patient either agrees, disagrees or has no opinion (not applicable). A middle response of neutral provides no evaluation value and skews both individual and overall scoring. Verbs and adjectives must be consistent. A statement should not attempt to evaluate two different measures. The category responses need to be limited to four options, plus the not applicable choice. Finally, the language needs to be easy to understand and statement with unmistakable clarity.
Two indicators encompass all measures, but do not supersede them. The two patient loyalty indicators measure: (1) if the patient will recommend the facility to others; and (2) if the patient is confident in the care provided. From a clinical standpoint the encounter may have been successful, yet patient loyalty is based on how immediate patient needs were attended to. One negative experience may negate 10 or more positive experiences.
• Mode of survey administration. The mode of administration may negate feedback value. The chance to capitalize on feedback is highly predicated on (1) timing; (2) percent of response; (3) comments provided; and (4) leadership access. The two critical success factors having the greatest impact on effectiveness are timing and percent of response.
Patient feedback is as good as its opportunity to be actionable. A critical success factor for effective surveying is the ASC’s ability to follow up with patients in a timely manner. This obviously requires the survey to be returned as promptly as possible.
Mailing surveys poses timing and response challenges. It requires time to provide patient addresses to a third-party, and the survey has an outbound and inbound mail delay. It might take 4-8 weeks from the date of service for a return. Typical response rates for mailed surveys range from 15-30 percent.
Handing out surveys at time of discharge removes the outbound mail delay and timing can be reasonable (1-3 weeks). The response rate, however, ranges from 20-35 percent.
Electronic surveying yields the greatest response (45-65 percent) and from a timing perspective, greatly exceeds all other modes (2-5 days for completed return and view). Electronic surveying is the most cost effective as postage is not required, nor is data-entry upon return.
For most organizations, a combination of electronic surveying and handed-out paper surveying works best. A facility should target collecting e-mail addresses from at least 60 percent of their patients and dispel the myth that older people will not respond electronically. In fact, patients 65-and-older comprise the highest percentage responding age group for electronic surveys.
If current survey administration occurs at the end of the visit while the patient is onsite, discontinue this practice immediately. The patient is likely uncomfortable, still medicated and anxious to get home. The feedback includes survey bias and may exclude helpful information the patient may be reluctant to share given their lack of privacy.
• Leadership access. The survey's ease of use upon receipt varies from mode to mode. A paper survey is cumbersome when self-administered by a facility. Envelopes are opened and entries might not be tallied until the end of the month. More important, the survey with negative feedback might not reach the right person who should follow up with the patient for days, if at all. Organization leadership has challenged the veracity of results, citing that some negative surveys may be discarded upon return and never be addressed.
Electronic surveys and paper surveys administered by a third party provide leadership immediate feedback. Sophisticated survey providers alert facility leadership to a separate and distinct collection of surveys containing dissatisfaction as these may warrant immediate follow-up. A best practice affords the facility's gatekeeper to assign the follow-up to the appropriate stakeholder.
• Patient issue resolution and management. The value of the entire survey process lies in the facility's effectiveness at following up with dissatisfied patients, as well as creating a knowledge repository of comments, feedback and follow-up.
First, leadership absolutely needs to be immediately alerted to surveys containing issues. Attending to, dealing with and learning from patient issues provides true actionable data. Disgruntled patients should be contacted by the facility associate that can relate to and address the issue, leaving the patient with the confidence that they were listened to and, if action is required, things will be addressed. Patients appreciate time and energy they believe is sincere. The initial goal is to remedy dissatisfaction as early as possible to protect patient loyalty.
Second, the facility must make patient issue data actionable and learn from issues shared. Salient details from the discussion with the patient, as well as staff accountable for explaining the issue must be documented. The patient's insight gives the facility the chance to review processes to determine if any corrective action is warranted.
Patient issue tracking helps determine if issues are isolated or patterned. An isolated issue may be explainable, yet not be excusable. Patterned issue identification offers an early foray to a process- or quality-improvement initiative. The ability to learn of under-performance at the earliest stage arms the facility with an immediate risk mitigation tool to prevent failure points from perpetuating.
The aforementioned use of patient issue resolution data is transforming insight to "quality intelligence." Leadership must have access to this data through simple and intuitive reporting that is easily shared at risk management and quality assurance meetings. Internal benchmarks are developed with measurable tracking to ensure the issues are corrected and do not resurface.
Risk mitigation
Insight from patients will not guarantee a positive outcome. However, as facilities learn that inadequate time is spent in the pre-operative assessment or recovery time was shortened due to increased caseload, a potential "failure point" has been identified that could compromise patient safety. This discovery may require improved documentation, policies, education and intervention from leadership. Failure point identification and corrective action can mitigate unnecessary risk or an adverse event for the next patient.
Evaluating performance properly
The evolution of surveying has conditioned the industry to focus on the wrong things, often misinterpreting feedback. Most ASCs tie a compensation component to their overall patient satisfaction score, placing great importance on a single number. The number is insufficient as a standalone metric.
Not all evaluation measures are created equally. Accordingly, some scores must be scrutinized more closely than others. More than half of the survey must measure care attributes such as clinical interaction, recovery, pain management and discharge activities. Too many surveys are unbalanced with respect to clinical and non-clinical measures. If poor clinical performance is concealed by several outstanding responses to facility appearance, comfort and parking, there is a problem and the survey content should be revisited for revision.
The provider needs to look more granularly at the responses and this requires the survey performance analysis to provide several different views of the data. The analysis needs to be provided monthly in order to identify issues promptly. Changes in ratings, peer benchmarking and evaluating 100-percent patient satisfaction are some of the methods providers can use to analyze data.
• Change. The best indication of which issues need to be addressed are those issues whose ratings have experienced the most change. Leadership needs a dashboard of the top score deltas from the prior month. If negative deltas are large, a trend analysis is viewed prior to jumping to conclusions. If viewing scores over a time-significant period of six months or greater illustrates score spikes, these might be investigated for improvement or celebrated for excellence.
• Peer Benchmarking. It is helpful to know how each performance indicator fares against your peers. Having an industry average provides a barometer that is necessary to indicate if your performance is in line with a statistically significant average. Each evaluation measure bears a different peer average. Facilities that are part of a management group should take advantage of a second average, which is their corporate average. Corporate averages are extremely helpful and guiding to management group executive leadership.
• Evaluating 100-percent satisfaction properly. The overall score must be kept in perspective. The presence of dissatisfaction can easily be lost or ignored by high overall and individual scores. There is a second score known as a "clean survey" score that helps balance the overall score and has taken off in industry adoption as a more powerful barometer.
A clean survey score provides the facility with the percentage of patients that were 100-percent satisfied with their experience. A "clean score" of 95 indicates that 95 out of 100 patients responded without any negative responses present. Conversely, if there is a single measure responded to negatively for the majority of the surveys, the clean survey score could plummet —even in the presence of a strong overall score. A mature, clean survey analysis does not penalize the provider for negative responses to statements that pose some ambiguity or have minimal lasting value. This score may be harsh and humbling, but the pursuit of excellence with this measure bears tremendous reward.
Abandoning the overall score as the capstone measure requires the organization to shed years of conditioning. The facility must accept that multiple benchmarks are healthy and help prevent complacency as excellence is pursued. As leadership balances their overall scores, critical key performance indicators and their complementary clean survey score, they have the power of evaluating performance at a glance. This allows key stakeholders to spend more time on patient follow up and quality improvement.
Embrace several feedback inputs
Stopping with patient insight would be naïve. Patients don't have the capability of informing leadership if inappropriate flash sterilization is a common practice or if operational constructs are under-performing. Clinical, departmental and leadership insight can be gained from surveying employees, physicians and referring physicians.
The value of these exercises is two-fold. First, the insight gained from staff directly involved with pre-, intra- and post-operative care (the eyes and ears of the facility) are paramount to improvement identification. They confirm or dispel under-performance concerns noted in patient surveys. Their input is the impetus for improving current-state processes, as well as providing insight to cultural- and interpersonal-dynamic management.
Second, the facility’s ability to review perception shared from these three groups is essential to the facility’s long-term success. Nurse retention is one example. The facility’s ability to listen carefully to nursing staff is a vital talent management activity. Protecting these valuable employees requires no elaboration.
Satisfied physicians and referring-physicians influence top-line revenue. They are the key drivers and influencers for the organization’s caseload. Scheduling and the availability/readiness of OR suites are typical satisfaction drivers. Yet recognizing their satisfaction with the competency of staff, readiness and quality of supplies and instruments, ease of transcription use and a host of other key performance indicators will measure physicians' ability to practice efficiently and effectively. Recognizing their satisfaction across all these measures must be continuously monitored. Surprises are not acceptable.
'Closed-loop quality management'
The ability to tie measurable benefits to revised processes gives facility leadership a roadmap and rationale to approaching improvement. The facility’s action taken on workflow issues increases staff satisfaction, loyalty and therefore retention. This occurs while making investments in patient safety through improved workflow and adherence to policies.
Closed-loop quality management assumes there is an open means of providing constant feedback. Insight must be available from all customers — patients, employees and physicians. All information and data is interrelated and should be respected accordingly. The ability to constantly monitor, synergize and introspectively assess this information keeps a facility’s effectiveness at peak performance.
Relationship of patient satisfaction with employee and physician satisfaction
Extensive analysis across hundreds of facilities reveals a strong correlation between employee and patient satisfaction. The ‘influence attributes’ most important to employees are personal satisfaction and patient care. Underperformance in patient care will impact staff satisfaction. A common cause of issues stems from increased caseload without an adequate staff increase. This affects both the patient and employee and at times is the underlying cause of staff turnover.
There is also congruence apparent when comparing staff satisfaction with measures from physicians and referring physicians. Do not assume their issues are always brought to leadership’s attention. Staff must be reached out to constantly and their issues must be listened to with follow up provided. There may be issues closely tied with physician influence attributes that if not attended to could cause them to bring business elsewhere.
Do not underestimate the importance of referring-physician satisfaction. Referring physicians are often not surveyed. In fact, their reputation is at stake with the delivery of care provided by whom they refer you to. Several issues or complaints will move their referrals to other providers.
Financial performance
Sustained financial performance only occurs when operational excellence, education and customer service (to patients, families, staff and physicians) are optimized. Anything short ultimately leads to parabolic fluctuations in revenue and cost avoidance/cost reduction performance.
Continuous quality improvement will equate to more satisfied patients. Addressing satisfaction of employees, physicians and referring physicians will provide improved staff retention, case load and revenue.
Changing industry
Suffice to say, ASCs always have a lot at stake. There are many lobbying and reimbursement pressures that will persist. The ASC's best course of action is to continue to provide the highest levels of service and care excellence in healthcare.
Too many facilities are reluctant to expand their feedback mechanisms for various reasons discussed. This level of contentment is unacceptable in today’s competitive landscape. The facility must invest in the best models of patient, employee and physician insight if they wish to remain the best. The truth is most of these models actually cost significantly less than internal self-administered processes so there is no excuse not to pursue them.
The future bears uncertainty, however the direction of newer programs points to rewards for excellence in delivery. The consumer is already being made more informed of process adherence and other metrics they may interpret at face-value. It is imperative that the organization takes all steps necessary to continuously monitor and improve process. This cannot be done without the insight from patients, employees and physicians.
The ASC delivery model is more malleable than other healthcare providers in addressing issues, responding to process improvement needs, mitigating risk and ultimately delivering better outcomes. Consumer-driven healthcare models will apparently emphasize process adherence and measurable outcome data. It is imperative for each provider to effectively transform internal feedback into actionable decision-making data for sustenance in the industry. The way in which each facility tactically addresses this transformation will greatly determine its destiny.
Mr. Faraclas is president and CEO of CTQ Solutions. Learn more about CTQ solutions by visiting www.ctqsolutions.com.