Patient Experience - Do interventions to improve patient experience increase quality of care, hospital efficiency and patient loyalty?

The Economist Intelligence Unit Healthcare Patient experience Do interventions to improve patient experience increase quality of care, hospital efficiency and patient loyalty? Evidence review A report for Siemens Healthineers Contents 1. Introduction .................................................................... 3 2. Review methodology ....................................................... 5 3. Overview of the literature ................................................ 6 4. Findings – where does the value accrue? ........................ 8 5. Findings within each domain ......................................... 12 6. Association between patient experience and outcomes .. 21 7. Discussion .................................................................... 23 9. References ................................................................... 31 10. Appendix .................................................................... 35 Terms of Use This evidence review has been produced by EIU Healthcare Ltd for Siemens Healthineers. It must not be distributed to, or accessed or used by, anyone else without prior written permission from EIU Healthcare Ltd. Commercial use is not permitted without prior written agreement from EIU Healthcare. EIU Healthcare Ltd has taken care in the preparation of this evidence review, but makes no warranty as to its accuracy and will not be liable to any person relying on or using it for any purpose. EIU Healthcare Ltd 20 Cabot Square, London E14 4QW Phone: 020 7576 8366 Contact email: [email protected] 1. Introduction Measuring patient experience as an indicator of performance has become the norm. Hospital benchmarking traditionally used a range of standardised indicators—for example length of stay or death rates—to rank hospitals, with those performing well held up as exemplars for poorly performing organisations to follow. The shift away from pointing the finger at poorly performing organisations towards the use of patient experience is deemed more inclusive and ensures that the best performing healthcare providers are not left to their own devices.1 Positive benchmarking results can also risk masking individual reports of a disappointing patient experience, or poor standards.2 It has been argued that by measuring patient experience effectively, the resultant data can help shape the healthcare environment. In this way the involvement of patients and the public, nationally and locally in quality improvement projects are both a marker of improvements that need to be made, and a precursor to high quality care.3 Patient feedback on the experience of using healthcare services is therefore recognised as both a vital source of information for quality improvement, and a key marker of quality.2 Our rapid review asks whether there is evidence that interventions to improve patient experience also improve hospital efficiency, clinical outcomes and patient loyalty. We have focussed on identifying the most reliable, high- quality literature from the past five-years, with an emphasis on randomised controlled trials where they existed. We expect that interventions focussing on patient experience will lead to more satisfied patients—but do they also impact on fundamental metrics such as costs, readmissions, mortality and morbidity? Below we present three key findings that emerged from the review. What is patient experience? There is substantial literature on the definition of patient experience; definitions fluctuate dependent on both the aims of the researcher and the healthcare context. The Beryl Institute, a community of practice dedicated to improving the patient experience, defines patient experience as “the sum of all interactions, shaped by an organisation’s culture that influences patient perceptions across the continuum of care.”4 This definition focuses on the extent to which patient experience efforts are believed to have a positive impact, or to make improvements to the healthcare system. These areas might include customer service, reducing patient and family anxiety, patient loyalty, new patient attraction, employee engagement and retention, improvements to financial outcomes and physician engagement and retention.5 Organisations placing optimal patient experience at the forefront of their mission statement are likely to create a more sustainable workplace. Sustainability does not only benefit the organisation, but allows patients to feel engaged and responsible for the quality of care they receive. The process is therefore cyclical.5 Patient experience is often conflated with patient satisfaction, but they are different. Satisfaction is seen as a judgement about whether expectations were met. Satisfaction ratings are influenced by varying standards, different expectations between patients and how often the patient uses care services. 6 A positive patient satisfaction score means care is adequate, and a low score means there are problems that need action. Patient experience, on the other hand, captures and untangles the views and experiences of people who may have had a poor health outcome but a positive patient experience, or those who emerged with a clean bill of health but experienced poor care. Patient experience goes beyond satisfaction; it is a composite measure also closely linked to employee engagement, given a patient’s experience of care is dependent on the composite actions of healthcare professionals and the healthcare environment. Measuring patient experience is more helpful than just looking at patient satisfaction. For example, knowing that 10% of patients evaluate their care as “poor”, or waiting times as “fair”, is not particularly helpful. Satisfaction- ratings can’t tell you what to do if patients are dissatisfied. Alternatively, knowing precise details about what went wrong during a care episode, such as communication or understanding treatment options, makes a difference as there is a call to action. Service improvement activity requires specific data about what actually happened—and that can be found through the evaluation of patient experience.6 Patient satisfaction asks “how did we do?”, while patient experience asks “what happened?” In this review, we collated patient experience interventions into the following four domains, based around the “target” of the intervention: 1. Interventions directed at patients: such as making staff photographs available to all patients (the “FACES: Faces of all clinically engaged staff” tool), empowering patients via summaries and care plans, and patient education and coaching initiatives 2. Interventions directed at staff: most commonly these involve improving staff communication skills, for example via workshops, or taking action to increase staff satisfaction and thereby reduce staff turnover 3. Interventions directed at the system: often these involve the application of complex real-time patient experience measurements, applied through complex IT systems. The addition of patient experience measures into electronic health records can, for example, facilitate shared-decision making 4. Interventions directed at the interface of care: smoothing the transition between different parts of the healthcare system, and coordination of care across the interface of different contact points. This might include primary and secondary care, or different specialists involved in one patient 2. Review methodology This is a review of the most reliable, recent literature, not exhaustive in scope but with an aim to provide an indicative representation of the literature. A range of databases were searched by an experienced information specialist, and resulting articles were prioritised based on an appraisal of the quality of the study. Selected articles were summarised and key data—on the methods and outcomes measured—were extracted for analysis. Through this structured approach we aim to provide a reliable and unbiased cross-section of the literature. The search protocols were designed to focus on how interventions to improve patient experience can lead to downstream improvements in patient outcomes, healthcare system efficiency and patient loyalty. The review was pragmatic in nature, and therefore not constructed to be a systematic review, although the methods were systematic in manner. The following databases were searched: ● MEDLINE and Embase (via Embase.com) ● Scopus (via Scopus.com) ● Google Scholar The search was in English only, and focused on evidence published in the last five years (since 2012). Search techniques were used to focus the search and ensure retrieval of a manageable number of articles; for example, searching only in certain fields, such as the title, or using indexing terms as “major topics” only. The full search strategy for Embase.com is provided in the Appendix. In addition to database searching we reviewed grey literature (literature published outside of the academic publishing process). In order to prioritise the most reliable evidence, we focused on identifying high quality reviews of the literature and comparative studies—i.e., where patient experience interventions were compared either to a time before the intervention, or to control settings where the intervention has not been introduced or implemented. Identified high quality and highly relevant documents were used as “pearl citations” around which supplemental search techniques—such as citation mapping, reference harvesting and similar/related article searching—were used to identify further studies. The searches identified over 1,800 publications. The search results were imported into a database and duplicates were removed. The first sift was conducted using title and abstract only, after which the full text of articles were acquired in order to identify studies for final inclusion in the review (n=28). Full text articles were appraised and relevant data extracted in evidence tables, and from there into summary tables, as seen in the text. We first analysed the data on outcomes from all of the included studies to provide an overview, before clustering the data in each of the domains of interest into separate tables. In addition to the analysis presented in the findings section, four short case studies were authored which explore in more detail some of the key issues and challenges around implementing standardisation processes and protocols. The case studies have been created as short narratives to complement the main flow of the literature review. Full evidence tables are provided in the appendices for all 28 extracted studies. 3. Overview of the literature The results from 28 studies were extracted from the literature and the interventions described and discussed. The majority of studies were from the United States and Canada (20 studies); the remaining were distributed between European countries, including Denmark, France, Germany, Czech Republic, Norway and the United Kingdom. Apart from one multi-country study which included a sample of data from Turkey, all of the studies were from high income countries. Eleven of the studies described randomised controlled trials, and a further seven studies had a before-and-after design. Apart from one systematic review, the remaining studies were either observational in nature (two studies), meaning the results were obtained retrospectively, were without a control group, or were cross sectional (seven studies). These weaker study designs, without meaningful controls, are by nature less informative than controlled trials and are often unable to prove causality. While the randomised controlled trials are considered the Blue Riband of research designs, a number of those retrieved had questionable methods. Often participants were not “blinded”, meaning they knew if there were in the intervention or control group, and so may be influenced to respond to the investigators accordingly. Also most interventions were very local in context and so possibly limited in how informative they could be to other institutions or organisations. Potential methods to improve the applicability of interventions to improve patient experience are discussed in later chapters. The interventions described in the included studies were categorised and discussed under four domains: interventions directed at 1) patients, 2) staff, 3) system and 4) the interface of care. The majority of studies we describe studied interventions at the interfaces of care (11 studies) and staff (nine studies). Interventions directed at patients Technological change, reforms to professional education and the commitment of governments in healthcare, are enabling the patient voice to become less passive.7 For example in the UK the national patient survey uses a systematic approach to measuring the experience of patients using NHS services. It collects feedback on service delivery from patients’ reported experience—including on what is important to patients, which is sometimes otherwise left unmeasured.8 Patient empowerment has been a UK government focus for many years, yet results have been less than ground breaking, and recent policies continue to emphasise the need for fundamental change. Other countries, particularly some low and middle income countries, are still working on moving away from traditional notions of the patient as a passive participant. In giving patients the opportunity to expand their role, and equipping them to do so, providers of healthcare allow the creation of new models of care. This potentially generates not only efficient healthcare services, but also encourages a return to the basic constructs of care such as dignity, safety and respect.7 Furthermore, research suggests that the extent to which patients are involved in their care has a significant impact on the quality of their treatment and can make significant differences to costs.9 Interventions directed at staff Interventions directed at staff include the development of staff communication skills to improve the patient- professional relationship, for example coaching staff through the use of motivational interviewing, or running workshops on “etiquette-based” physician communication. Ensuring that the vision of improving patient experience is meaningful to frontline staff needs specific focus, as healthcare leaders typically direct from an organisational perspective. A lack of focus can lead to differences in the understanding of patient experience,10 which may lead to disparities in what different staff in different healthcare organisations measure, making it more difficult to compare outcomes across organisations. Investing in staff doesn’t always mean primarily investing in improved communication techniques—for example, research suggests that investing in staff happiness can have a direct impact on patient satisfaction. API Healthcare in the US found that for every 10% of nurses reporting job dissatisfaction, the likelihood of a positive patient recommendation decreased by 2%.11 Interventions directed at the system As well as staff and patients, patient experience interventions can focus on improving the healthcare system as a whole. There are health systems that show pockets of good practice across the globe, embedding patient experience into their foundations. In the US, some patients have access to a ‘patient decision aid’ through their electronic medical record, to facilitate shared decision making about their care. In Nepal and Nigeria, a national standard was developed using the real life experience of mothers to challenge professional mind-sets and provide a stimulus for improving frontline healthcare teams. The ‘Just Ask’ campaign in Denmark is a population- wide distribution of tools to support and prompt patients to overcome the intimidation some patients feel from doctors. In Denmark and Malawi, part or full ownership of the medical record is being given to the patient. These are all promising steps, but they are often isolated initiatives.7 Interventions directed at the interface of care Interventions aiming to improve the interface of care focus on the organisation and coordination of care across the interface of different contact points within the healthcare system. This might include primary and secondary care, different specialists involved in one patients care,8 or patient treatment pathways. Patients value healthcare professionals who have an understanding of their individuality, the unique way each healthcare professional manages their condition, and how it impacts their everyday lives. As patients’ needs go beyond physical health conditions, healthcare systems should be equipped to recognise and accommodate the need for physical, psychological and emotional support, which might require the combined support of multiple providers. Consequently, consistency of care, establishing trust, providing relevant information and reassuring patients their care will be coordinated efficiently12 are key components for improvements at the interface of care, care- coordination, and a step towards sustainability under growing pressures.7 These kinds of improvements have the potential to make a difference to the patient and the provider. For example a UK project aiming to improve the patient experience of trauma pathways by improving coordination and efficiency of treatment regimens found improvements to the time taken for patients with a fracture to get to theatre, which reduced from 2.3 to 1.7 days, reduced length of hospital stay by 33%, and the mortality ratio by 36%.1 4. Findings – where does the value accrue? The research questions our literature review aimed to explore were: ● What are the most commonly used “patient experience” interventions? ● What outcomes—patient or process outcomes, provider outcomes and patient loyalty—have been used to measure the impact of interventions? ● Which are the most effective interventions at improving patient outcomes, provider outcomes and/or patient loyalty? We shall look at each in turn. Research question 1: What are the most commonly used “patient experience” interventions? As noted in the methods, we grouped patient experience interventions into four domains: interventions directed at the patient, staff, system and interface of care. Interventions at the interface of care were reported in 11 studies, staff interventions in nine studies and patient interventions in five studies. The fewest number of studies included systems improvements (three studies). While this is not a full scoping review, our review did focus on the highest quality of evidence, and so this suggests that the most recent high quality research for improving patient experience has been focussed on improving the patient journey at interfaces of care, and how staff can be trained to provide a better patient experience. In addition to looking at the intervention targets, we also sorted patient experience initiatives according to intervention components. This was a necessary step as many of the studies use complex interventions, built up of many complementary components, including individual coaching, patient pathways, institutional or facility (re)design, group training, IT system and (sometimes real-time) patient experience measurement tools and feedback. These components may act both independently and interdependently. The most commonly found intervention component was individual coaching—witnessed in 18 interventions. This is partly because of the diverse range of activities within this group, including patient education, communication training, e-learning, communication aids, self-management tools, information booklets and mindfulness training. Care-coordinators were the second most common component, found in 12 interventions—this includes patient navigators, case management and wider care-coordination activities. Institutional or facility design was found in nine interventions; group (including external) training in eight, and patient pathways and IT systems in seven interventions each. The use of patient experience measurements tools as an explicit part of the intervention (as opposed to an outcome) was found in three interventions. Institutional or facility design was found in some degree in patient experience initiatives across all intervention targets (table 1). What form this took varied by intervention, but the fact that it was ubiquitous shows how interventions to improve patient experience go to the heart of how healthcare is organised and managed. Table 1: the number and percentage of intervention target initiatives which incorporated certain intervention components. For example, of the 11 “interface of care” interventions we included in the review, 6 of them (56%) incorporated elements of individual coaching, 10 of them (91%) incorporated a care coordinator, 3 of them (27%) incorporated institutional design, and so on. Intervention components Intervention targets Individual Care- Institutional Group Patient IT Measurement coaching coordinators design training pathways systems tools Interface of care (n=11) 6 (56%) 10 (91%) 3 (27%) 0 (0%) 5 (45%) 3 (27%) 0 (0%) Staff (n=9) 9 (100%) 1 (11%) 1 (11%) 8 (89%) 0 (0%) 1 (11%) 0 (0%) System (n=3) 0 (0%) 1 (33%) 3 (100%) 0 (0%) 0 (0%) 3 (11%) 3 (100%) Patient (n=5) 3 (60%) 0 (0%) 2 (40%) 0 (0%) 2 (40%) 0 (0%) 0 (0%) Research question 2: What outcomes - patient or process outcomes, provider outcomes and patient loyalty - have been used to measure the impact of interventions? In order to understand what outcomes have been investigated in research on improving patient experience, we clustered outcomes measured from the included 28 studies into those that would primarily be of interest to the patient, and those of primary interest to the provider. Naturally these will overlap to some extent, particularly in the case of patient outcomes, which are important to all stakeholders. However, we assume that in addition to patient outcomes, providers will be interested in ensuring their institutions run efficiently. Table 2 lists the most commonly measured outcomes in this review. Table 2: List of the patient and systems outcomes measured in this review Patient outcomes Healthcare provider outcomes ● Quality of care ● Costs ● Access to care ● Readmissions ● Other patient reported outcomes (eg stress/anxiety) ● ED visits ● Patient satisfaction ● Length of hospital stay (LOS) ● Improved disease management ● Health care use ● Care coordination ● Outpatient use ● Patient-provider relationship A majority of studies reported on patient outcomes rather than healthcare provider outcomes (table 3). The paucity of provider-outcomes measured means the link between improvements to patient experience and their impact on efficacy improvements to the health service—such as reductions in hospital stay, reductions in re- admissions or better hospital ratings—will be more challenging to prove. Table 3: The number of studies looking at improved patient outcomes versus improved provider outcomes Domain – Total no. of studies Patient outcomes Provider outcomes interventions direct at… Patient 5 6 2 Staff 9 9 1 System 3 4 0 Interfaces of care 11 7 3 Total 28 26 6 Research question 3: Which are the most effective interventions at improving patient outcomes, provider outcomes and/or patient loyalty? Looking at the outcomes measured in more detail, we can see that patient satisfaction and the patient-provider relationship were measured in 10 and 9 studies respectively (table 4). These were the most commonly reported outcomes—both of which are patient outcomes. The most commonly measured provider outcomes were readmissions and healthcare use. Costs were measured in two studies (table 4). Table 4: the most commonly measured outcomes in each category as well as out of all 28 included studies Interfaces Outcomes Patient Staff System All studies of care Patient satisfaction 3 2 3 3 10 Patient-provider relationship 1 4 1 3 9 Other patient reported outcomes 1 2 0 2 6 Improved disease management 2 3 0 1 6 Quality of care 1 2 0 0 3 Care-coordination 0 0 1 1 2 Access to care 0 0 0 1 1 TOTAL: patient outcomes 8 13 5 11 37 Readmissions 1 1 0 2 4 Health care use 0 0 0 3 3 Costs 0 0 0 2 2 Outpatient use 0 0 0 2 2 ED visits 1 0 0 0 1 Length of hospital stay 1 0 0 0 1 TOTAL: Systems outcomes 3 1 0 9 13 TOTAL: All 11 14 5 20 50 The evidence suggests that, on average, interventions for improving patient experience do overall improve patient outcomes and, to a less extent, provider outcomes. Table 5 shows the ratio of the number of improvements witnessed to the number of studies in each domain—with an average of 1.4 improvements (positive outcomes) in studies aimed at the patient, 1.1 improvements in studies aimed at staff, 1.3 improvements in studies looking at interventions directed at the wider system and 0.9 improvements in studies looking at the interface of care. Table 5: The total number of improvements in each domain Domain – Total no. of Total number of Improvements/no. interventions direct at… improvements studies of studies Patient 8 5 1.4 Staff 10 9 1.1 System 4 3 1.3 Interfaces of care 10 11 0.9 In order to understand which outcomes benefit the most from interventions aimed at improving patient experience, we constructed an aggregate score for each outcome, using a score of +1 for each improvement 0 for no change, and -1 if the outcome worsened (table 6). A score to study ratio was calculated to show the number of improvements witnessed for each outcome against the number of times it had been reported in studies. Table 6: The success of each outcome over all 28 studies, against the total number of studies which studied each outcome Total number of studies looking at Score to study Outcomes Total score ratio this outcome Access to care 1 1 1 Patient-provider relationship 7 9 0.8 Improved disease management 5 6 0.8 Patient satisfaction 8 10 0.8 Quality of care 2 3 0.7 Other patient reported outcomes 3 6 0.5 Care-coordination 0 2 0 Health care use 2 3 0.7 Costs 1 2 0.5 Readmissions 1 4 0.25 ED visits 0 1 0 Length of hospital stay 0 1 0 Outpatient use 0 2 0 Table 6 shows that patient satisfaction, the patient-provider relationship, and patient disease management, all frequently reported outcomes, are often found to improve when using patient experience interventions. Access to care was measured in one study, and found to improve in that study. Other outcomes that consistently improved include health care use and quality of care. At the other end of the scale, it is not surprising that evidence reporting re-admissions is fairly poor given how many other factors aside from patient experience are likely to play a role in the reasons for hospital admissions. However the low number of improvements to care-coordination is a little surprising given that the patient-provider relationship and improved disease management, both of which scored highly in terms of improvements, are both key elements of efficient coordination. Before over analysing this finding, it is possible studies may not have been able to show a relationship between these constructs because they simply didn’t aim to, or perhaps they had not transformed the findings of their studies into care-coordination improvements, which would require the involvement of healthcare managers and elements of system re-design, perhaps beyond the scope of their study. We will explore this in later chapters. The following sections discuss each intervention target domain in turn and provide details on exactly which studies in each domain showed improvements or no change, with respect to each specific outcome. We discuss within each domain how different intervention components were utilised. 5. Findings within each domain Interventions directed at patient improvements Five studies addressed patient experience interventions that were directed at empowering the patient (table 7). 13- 17 Three investigated patient education interventions using individual coaching,14-16 and two addressed patient welfare.13, 17 All studies were performed in the hospital setting; two were from the USA, and one each in Canada, Germany and the UK. Of the total 10 outcomes reported, seven showed a significant improvement, and three showed no difference. Most of the improvements were to patient outcomes, including two improvements to patient disease management using interventions aiming to encourage patients to self-manage their condition. The first of these studies provided patients with treatment summaries and care plans,15 and the second an information booklet detailing their condition, and instructions to write in a personal diary.16 Patient satisfaction was improved using sensory stimulation applied to MRI scanners,17 a visual communication aid detailing the different role of each healthcare professional involved in individual patient care, improved the patient-provider relationship14 and music played in healthcare waiting rooms reduced patient anxiety (reported as “other” patient outcomes in table 8).13 When rating their satisfaction with the hospital experience, 50% of patients provided with a visual aid (FACES instrument) to help them recognise their healthcare providers gave a high satisfaction rating compared to 36% of those receiving normal care.14 A recent demand for improving hospital ratings, viewing patients as customers looking to shop around for exceptional healthcare and having the right to choose,11 may be a contributing factor to the focus on patient improvements. There were also improvements to provider outcomes. The study using educative treatment summaries and care plans also found emergency departments were used less and patients needed fewer re-admissions to hospital when equipped with additional information and support.15 Not all of the studies that measured patient or provider outcomes found improvements. There were three interventions which found no significant difference to patient or healthcare provider outcomes. The sensory stimulation study not only aimed to calm patients but also reduce patient movement during scans which would improve the quality of the image. Sensory stimulation was not able to make a difference to the quality of the image (patients continued to move around while being scanned), but did improve patient satisfaction.17 The study which found playing music in healthcare waiting rooms reduced patient anxiety, also aimed to improve patient satisfaction but did not find any improvements.13 Providing patients with information booklets regarding their health condition, and encouraging them to complete a personal diary, aimed to, but did not see reductions to patient length of hospital stay.16 However more than one study in this review attempted to address the link between investing in patient experience and improvements to hospital length of stay, which is very difficult to associate with patient experience alone when so many other factors affect this outcome.16 Table 7: Overview of the five studies addressing interventions aimed at patients Provider Patient outcomes outcomes mes outco orted vider relationship disease management of care ved Interventio missions visits S pro Author, date Country n Setting D O L Patient satisfaction Patient-pro Read E Im Quality Other patient rep Biddiss, Treatment Hospital 201413 Canada approach setting ↑ ↔ Brener, Patient Hospital 201614 USA education setting ↑ ↑ Kenzik, Patient Hospital 201615 USA education setting ↑ ↑ ↑ Schmidt, Patient 201516 Germany Hospital education setting ↑ ↔ Stanley, Treatment Hospital 201617 UK ↔ approach setting ↑ Outcome not reported ↑ Significant improvements ↔ No change reported ↓ Significant decline Interventions directed at staff Staff engagement and staff training are considered important facilitators for enabling healthcare organisations to make the best use of patient survey data.2 The evidence is growing to support the direct impact that staff engagement has on patient experience. For example, hospitals scoring in the top 10% for employee engagement have been found to score higher on overall hospital rating metrics than hospitals in the bottom 10% for employee engagement.18 Also, staff engagement scores in the UK National Health Service show that patient experience improves, inspection scores are higher, and infection and mortality rates are lower when there is strong staff engagement.19 We found nine patient experience studies addressing interventions directed at staff (table 8). All but one of these studies focussed on interventions to improve staff training or staff education either to individual clinicians or teams as a whole.20-26 One study addressed both training and care-coordination interventions.27 Some examples of training provided in the studies include enhancing clinician well-being to improve the patient approach,28 teaching motivational interviewing techniques to clinicians,20 professional communication training,23 and a disease management pathway taught to whole primary care practices. Of these nine studies, five took place in hospital settings,20, 21, 24, 27, 28 three in primary care22, 23, 25 and one in an academic setting with pre- graduate physicians.26 There were 10 reported improvements overall. Only one study addressed the impact of staff interventions on provider outcomes, using motivational interview training and a communication/treatment approach as the intervention, aiming to help patients remember their medication and consequently reduce re- admissions to hospital.20 Although this study did indeed reduce the number of re-admissions its case and control allocation was not randomized, a convenience sample was used (i.e. patients who were “easy to reach” only) and participants were not blinded to intervention or control groups which means the results need to be treated with caution Additionally, as mentioned previously hospital admissions/re-admissions are likely affected by many other factors. All of the studies investigating the impact of communication skills training on the patient-professional relationship20-28 improved the patient experience. Although, in addition to the 10 improved outcomes,20-23, 25-28 there was one worsening outcome, (which resulted from an underpowered study so should be interpreted with caution)20 and three finding no significant difference to outcomes.20, 24 Of those studies finding improvements, three were related to improvements to the patient provider relationship.21-23 The first of which used real-time, daily patient feedback to physicians, alongside coaching and revisits of patients reporting suboptimal satisfaction with their care.21 This study also found an improvement to patient satisfaction.21 The second used motivational interviewing techniques for cancer survivors,22 and the third provided communication training and listening techniques to physicians.23 Two studies found improvements to quality of care.26, 28 The first used an e-learning intervention to improve physician communication26 and the second used mindfulness training for clinicians.28 Motivational interviewing techniques also found improvements to disease management,22 as did a targeted disease management program delivered to whole primary care practices.25 The final improvement, categorised as “other patient reported outcomes” arose from mindfulness training which also made patients feel they were better understood by their clinicians.28 On the contrary to studies finding improvements, one study which aimed to improve patient satisfaction and disease management using motivational interview techniques found no significant difference to improvements, but again is a result which should be treated with caution due to a weaker study design (participants were allocated to groups in a non-random manor, which can cause systematic bias).20 It is important to address the limitations of the studies as it provides some explanation for contrasting or non-significant results which run the risk of diluting the message of truly effective patient experience interventions. For example a study delivering 45 minute communication training to physicians, an intervention similar in scope to those finding positive outcomes in other studies in this review, found no improvements to patient or provider outcomes; however this may have been due to the control group having significantly different characteristics to the intervention group, another source of systematic bias.24 Table 8: An overview of the eight studies addressing interventions directed at staff mes vider outco Patient outcomes Pro orted mes of care ordination missions vider relationship outco disease management Read Quality Care-co Patient satisfaction ved Other patient rep pro Patient-pro Author, date Country Intervention Setting Im Dobkin, 201628 France Staff training Hospital setting ↑ ↑ Hyrkas, 201420 United States Staff training Hospital setting ↓ ↔ ↔ ↑ Indovina, United 201621 States Staff training Hospital setting ↑ ↑ Khan, 201427 United Staff States training/care- Hospital coordination setting ↑ Kvale, 201622 United States Staff training Primary care ↑ Maatouk, 201623 Germany Staff training Primary care ↑ Seiler, 201724 United States Staff training Hospital setting ↔ Smidth, 201625 Denmark Staff training Primary care ↑ Snow, 201626 United Kingdom Staff training Academic ↑ Interventions directed at systems improvements More than half (54%) of healthcare executives state patient experience and satisfaction is one of their top priorities (HealthLeaders Media’s 2013 industry survey data).29 This review however found only three studies which intended to improve the patient experience by targeting the healthcare system,30-32 an approach which requires the involvement of health leaders. Two studies were conducted in the primary care setting30, 32 and one in the hospital setting;31 all studies were conducted in the US30-32 and addressed the application of US national measures of patient experience in healthcare settings. All three studies took advantage of existing healthcare IT systems, which enabled the linkage of routine electronic medical records collecting individual information about people’s health, with the scores accrued from national measures.30-32 They also all focussed their interventions on making improvements to the design of the healthcare institution, IT systems, improving the efficiency of patient experience measurement tools and the coordination of care (table 1). Patient experience interventions aimed at improvements to the healthcare provider can be described as complex interventions, as they aim to improve patient outcomes, patient health, patient satisfaction as well as reducing costs for the healthcare system.23 This may require, but is not limited to, monitoring and measuring healthcare journeys over time, whilst simultaneously empowering patients to monitor their own healthcare pathways through appropriate education.32 We found four improvements overall, all of which improved outcomes for the patient (table 9). Two studies measured patient experience as a composite outcome using the national, US-based Patient Centred Medical Home (PCMH). The PCMH is a standards setting, healthcare delivery model, and coordinating patient treatment through the primary care physician, to ensure patients receive necessary care. The PCMH has been described as a “reform model” as its purpose is to change the way care is delivered using infrastructure support and technical assistance, creating a “triple aim of healthcare.”32 This triple aim involves simultaneously improving the patient’s experience of care and their health while reducing healthcare costs. To become a certified PCMH however, primary care practices have to show they have already performed certain services for patients, including improved access to care and improved quality. The PCMH is regulated by the National Committee for Quality Assurance, an organisation dedicated to improving health care quality by developing standards and measurement tools that organisations can use to assess performance and identify improvement opportunities.33 Of these two PCMH studies, both found improvements. One found improvements to patient satisfaction by interviewing patients registered with a PCMH before and after implementation of an intervention to improve “high value elements,” which were considered responsible for positive patient outcomes and cost reductions.32 The second study investigated primary care practices that were either fully, partially or not at all registered as a PCMH and compared patient experience between the three. Improvements to patient experience and the patient- physician relationship were found for fully registered PCMH above others.30 Short follow up periods may be one explanation for interventions aimed at the healthcare provider failing to find improvements in terms of length of hospital stay or health care use. Each study aiming to show systems improvements only used a follow up period of a year. Despite decision makers being eager to obtain results, a short follow up period might provide an overly pessimistic view of the PCMH, by capturing the negative effects of a systems change.34 Another US “reform model”, the Hospital Consumer Assessment of Healthcare Providers and Systems score (HCAHPS), is the first standardised and publically reported source of patient experience information in the US. HCAHPS scores are fairly influential to the allocation of funding for workflow and systems design the US, for example they can result in hospitals losing or gaining 1.5% of their Medicare. 11 HCAHPS information is publically reported which means its ratings can be compared to hospital efficacy. This creates an almost real-time platform for cost efficiency and patient experience evaluation. The final systems study included in this review compared HCAHPS scores from 4500 hospitals to the number of patients with hospital-acquired conditions. It found that hospitals that had patients with relatively fewer hospital- acquired conditions reported more improvements to patient experience. This study reports a “correlation” between patient experience and quality of care, but cannot prove causation.31 Finally, it is worth noting that a recent UK systematic review identified 11 hospital quality measures with the potential to develop systems improvements when applied to healthcare settings. This study provides a framework for choosing instruments fit for measuring patient experience, and is a useful go-to for organisations embarking on quality improvements. For example it prioritises instruments that can be used to assess impact on quality, validity, reliability, cost efficiency, and educational impact.35 Table 9: Overview of the three studies addressing interventions aimed at systems improvements Patient outcomes vider relationship ordination Author, date Country Intervention Setting Patient satisfaction Patient-pro Care-co Dorr, 201632 Care-coordination USA (PCMH) Primary care ↑ ↔ Patient experience Stein, 201431 USA measurement tool Hospital setting ↑ (HCAPS) Patient experience Xin, 201730 USA measurement tool Primary care ↑ ↑ (PCMH) Outcome not reported ↑ Significant improvements ↔ No change reported ↓ Significant decline Interventions directed at interfaces of care Across our four intervention targets, studies that looked at improving patient experience at the interface of care were most numerous (table 10). This makes sense when you consider that patient experience relies on the smooth co-operation of the many layers of healthcare found both within, and between healthcare organisations. Of the 11 studies addressing interfaces of care, two studies used patient navigators,36, 37 and nine used care- coordination interventions.38-46 Patient navigators are individual coaching interventions that aim to improve medical follow up, improve adherence to medical regimes, and provide meaningful social support. In doing so it is thought post-discharge transitional care will be enhanced and hospitalisations will be reduced.37 Care- coordination is more of an umbrella term to describe deliberate interventions similar to patient navigators, but with the overall aim of improving the patient-professional relationship and efficiency of care. For example some of the care-coordination interventions included: implementing referral templates to improve care pathways;46 introducing a specialist model of care for patients with complex conditions;47 evaluating the use of electronic medical records to improve coordination of care,2 and implementing a systematic care management intervention aiming to increase primary care use and reduce hospital admissions and reduce costs.40 This last study found cost savings of approximately 8% per person per month for spending on all medical services over a four year period for people enrolled in the systemic care management intervention.40 There were a total 20 reported outcomes, 10 of which were improvements. Of the ten improved outcomes, seven improved outcomes for the patient and three improved outcomes for the provider; one study improved outcomes for both the patient and the provider. One study using patient navigators found worse outcomes to hospital admissions (i.e. an increase in admissions).36 Despite the positive value of patient navigators in other patient focussed outcomes, this particular study focussed on a variety of age groups, and while successfully improving outcomes for older patients, found worse outcomes for younger patients. This may in part be attributable to younger people having different needs (see case study 3) which may be uncovered by intense interventions or coaching. Should the study period have been longer, it may be able to show improvements for both, or give a more reliable answer than a re-admission rate based on 30 days post-discharge. One study reported improvements to patient and provider outcomes simultaneously using an intervention aimed at whole primary care practices. The intervention encouraged physicians to focus their treatments for older people on a patient centred model of care, aiming to improve disease management and improve the access to care for older people; the study reduced primary care use, as well as improving patient disease management outcomes.38 Our review suggests that only research at the interface of care was able to consistently report outcomes of primary importance to the provider, as well as improving patient outcomes, with one study finding an improvement in costs and two finding reductions in healthcare use. The interface of care may be the most effective target point for patient experience interventions which aim to address both patient and provider outcomes simultaneously. Table 10: Overview of the 11 studies addressing interventions aimed at the interface of care. Patient outcomes Provider outcomes mes outco orted ordination osts missions C vider relationship disease management Read Outpatient use Access to care Health care use Care-co Patient satisfaction ved pro Patient-pro Im Other patient rep Author, date Country Intervention Setting Balaban, 201536 United States Patient navigators Hospital setting ↓ ↑ ↔ Balaban, 201737 United States Patient navigators Hospital setting ↔ ↔ Burkhart, 201638 United States Care-coordination Primary care ↑ ↑ ↑ Chan, 201539 United States Care-coordination Hospital setting ↔ ↔ Filmore, 201440 Unites States Care-coordination Various ↑ Goncalves, 201641 United States Care-coordination Hospital setting ↑ Groene, 201542 Multi Care-coordination Hospital setting ↔ McHugh, 201643 United States Care-coordination Primary care ↑ Migdal, 201444 United States Care-coordination Hospital setting ↑ Wahlberg, 201746 Norway Care-coordination Primary care ↑ ↔ Zulman, 201745 United States Care-coordination Primary care ↑ ↔ ↔ Outcome not reported ↑ Significant improvements ↔ No change reported ↓ Significant decline The Intelligence Economist Unit 6. Association between patient experience and outcomes Most of the patient experience interventions described here report patient outcomes more frequently than outcomes that are of primary interest to providers—such as costs, readmissions, healthcare utilisation and patient loyalty. This may be because of limitations around data collection methods, short follow up periods, the number of confounding elements obscuring a clear association, or because researchers and implementers of patient experience interventions have mostly chosen to focus on patient outcomes. Nevertheless, the wider literature does discuss associations between patient experience scores and other outcomes, including costs. Because these are correlations we don’t know in what direction the arrow of causality flows. Also, association data cannot provide information on what types of interventions are most effective. However, it is informative to look at some recent articles in the area, and ask whether they offer insight into broader trends. Efficiency and financial measures The relationship between cost and patient experience is tricky. A recent systematic review found the relationship between healthcare costs and quality is inconsistent, with most studies finding a “small to moderate” association—the authors suggested that this was partly because there were considerable differences between the methodologies in each study included in this systematic review, making associations difficult to identify.48 Additionally, of those studies intending to find improvements to costs but didn’t, often measured outcomes in populations of high risk and very unwell patients. This makes detecting a cost saving effect more difficult, as very unwell patients need more healthcare which is associated with higher costs. Cost savings are therefore more likely to be detected among a population with a variety of healthcare needs.34 A key financial element for providers is their relationship with payer organisations. In the US, Medicare’s Hospital Value-Based Purchasing Program financially rewards hospitals with better patient reported experience scores. This means patient experience scores for factors such as hospital staff communication skills have become key hospital performance measures, although Value-Based Purchasing incentives only account for about seven per cent of the association between patient experience and hospital financial performance, as measured by net margins.49 Nevertheless, a recent analysis did find that for every 10% increase in the number of patients giving a hospital a “top box” HCAHPS score, there is an increase in net margin of 1.4% compared to hospitals receiving a “bottom box score.”49 Clinical measures A rather stronger relationship is found between patient experience and clinical outcomes. A systematic review from the UK recently investigated the links between patient experience and clinical safety and effectiveness outcomes such as mortality, physical symptoms, length of stay and adherence to treatment. A consistent positive association was found between patient experience, patient safety and clinical effectiveness for a wide range of disease areas, settings, outcome measures and study designs. It showed improvements in both self-rated and objectively measured health outcomes, such as adherence to medications, hospitalisations, length of stay, and primary-care visits.50 Another study exploring the links between better patient experience and favourable clinical outcomes in US hospitals found better patient experience was associated with favourable clinical outcomes, specifically in hospital complications.51 Although patient experience doesn’t always correlate directly with high-quality care, Page 21 of 45 The Intelligence Economist Unit patient experience measures can address attributes of care that promote and increase quality in the long run.52 The US Agency for Healthcare Research and Quality suggests that improvements to patient experience have been associated with other important systems indicators, such as delays to test results, and gaps in communication posing broad implications for clinical quality, safety and efficiency. 52 One study found a focussed endeavour to improve patient experience in one hospital resulted in a 4.7% reduction in employee turnover.53 Patient loyalty Patient experience means different things to different organisations. The concept of patient loyalty becomes a major focus area for healthcare systems in countries that do not have state provided healthcare, and are increasingly shopping around for the right provider. For example, In the USA patients change providers based on experience, with relationship quality being a major predictor of patient loyalty. In these scenarios, enhancing patient experience is regarded as a potential driver of hospital performance. A 2015 survey of health care consumers found that brand and reputation were an important patient consideration when choosing a hospital.54 Another study found that patients reporting the poorest-quality relationships with their physicians were three times more likely to voluntarily leave the physicians’ practice than patients who had the highest quality relationships.55 Avoidable adverse effects also play a role; for example, patients treated at hospitals with higher rates of serious pressure ulcers were less likely to recommend the hospital to others.31 Because these are association studies they cannot show causality. However, the associations bring us full circle—the use of patient experience as a measure of quality of care. The evidence suggests that you don’t choose to improve patient experience or quality of care; the two are inseparable. Page 22 of 45 The Intelligence Economist Unit 7. Discussion The aim of this review of the recent literature on interventions to improve patient experience was to ask whether there is evidence that investing in patient experience measures improves patient outcomes, provider outcomes and patient loyalty. In effect, is measuring and focussing on patient experience a fuel for innovative, efficient and patient centred healthcare systems? Why is patient experience important? Certainly there has been an increasing focus on the measurement and improvement of patient experience from many healthcare organisations. There’s no one reason why this is the case—rather, it depends on the structure of the healthcare system, and your place in it. A positive patient experience is of course a goal in itself, but allied to this there is the hope that improvements in patient experience through a focus on patient care, staff education and system improvements will in turn benefit the wider healthcare system, such as by reducing the average length of hospital stay, or lowering costs. In addition to benefits to the wider system, the concept of the “lifetime value of a patient” is also important, particularly to hospitals and other practices that are paid via fee-for-service. Lifetime value of the patient is the amount of revenue a healthcare provider can expect to “earn” from services delivered to a patient throughout their entire lifetime. There are various ways this can be calculated, but most calculations take into account 1) how much profit the provider makes from a typical visit, exam or session, 2) how many times a year the average patient books a service, 3) how many years the average patient remain with the provider, and 4) how many other patients they are likely to refer to the provider. The greater the average lifetime value of a patient, the greater the long-term sustainability of the hospital or provider. This view of patients as consumers means the practice of displaying hospital quality ratings for patients to access is becoming the norm, and patients have the ability to pick and choose the healthcare services they feel meets their needs.11 Hospitals therefore have an incentive to keep patients interested, for if a hospital loses a patient, they lose that patient’s potential lifetime value. Similarly, hospitals become interested in patient acquisition—and associated lifetime patient values. Governments and other national payers with a responsibility for population health however warn that patients should be viewed as ‘community assets’ rather than sources of need or revenue generators.7 In doing so, it is argued that patient empowerment—measured though patient experience—potentially offers a route towards a solution to many problems of healthcare today. These include issues such as the rising burden of disease, aging, end of life care, and the challenge of coordinating care for people with multiple complex conditions.7 Improving patient experience may also improve life for healthcare staff. A US study investigating eight healthcare organisations with a reputation for successfully promoting patient-centred care found staff satisfaction was positively linked with improving patient-centred care.56 On the flip side, emphasis towards investing in staff satisfaction, ensuring staff are trained appropriately and improving retention, is receiving increasing attention in terms of influencing patient experience. Data driven staffing decisions are becoming popular, as they allow health systems to make numerous gains including streamlined workflows, better patient care, engaged staff and a robust IT system for collecting and storing patient data,11 useful for further workflow analyses. Whichever way you look at it, the measurement and enhancement of patient experience is important for all actors in healthcare systems, from patients and staff through to providers, payers and national Page 23 of 45 The Intelligence Economist Unit governments. This remains the case whether the healthcare system is purely market driven, or supported by some kind of social risk-sharing, including Beveridge and Bismarck styled health insurance. While interventions can be targeted at different parts of the system—we’ve described four targets: patients, staff, system level and at interfaces of care—and be delivered with varying components and modes of delivery, certain barriers and facilitators to successful implementation did emerge from the literature. Barriers and facilitators to implementation Why were some of the studies in this review unable to achieve what they set out to do, reporting no difference or in some cases negative outcomes? One UK study helps shed some light on this matter. 43 This study aimed to explore the effectiveness of a complex patient safety intervention in hospital wards, and found it made no impact on outcomes. Rather than shrugging their shoulders and walking away, the authors decided to investigate why their intervention had failed. They discovered there was a “dilution” of the intervention during the trial. In certain wards, the intervention had not been implemented at the required “dosage”. This was dependent on factors such as the ward setting and the level of participant engagement fluctuating between wards. It turned out that the intensity of support for certain interventions at organisational level did not automatically predict strength of engagement at the level of the individual wards. The researchers found that for full implementation to occur it was necessary to have full alignment between senior management and ward teams.57 Organisational challenges, including the gap between senior management and staff involved in the delivery of care, are commonly cited as barriers to implementation. Certainly the strength of relationships between key stakeholders and effective communication go hand in hand. These relationships have been described as essential in ensuring the effectiveness of “reform” models, such as the PCMH and the HCAHPS. Despite these models addressing different sectors of healthcare, across both primary and secondary care, there have been attempts to align the goals of both hospital executives (HCAHPS) and primary care providers (PCMH) to enable these two systems to become partners. An article from the US on the role of hospitals in medical home initiatives included some thoughts on strategies to secure hospitals’ support and participation.58 The overall aim of patient-centred medical homes is to improve coordination between primary and secondary care to reduce over utilization of care and avoid costly and unnecessary emergency and inpatient services. The strategies to bring hospital’s on board and ensure successful implementation included: 1) make the business case for hospital participation within medical home initiatives; 2) help the conveners and other stakeholders leading medical home initiatives to improve or clarify the roles for hospitals in PCMH initiatives; and 3) offer conveners and other stakeholders strategies to successfully engage hospitals and secure their support and participation. Overall therefore, the strategy is to align the goals of hospital executives and primary care providers so the two can become better partners. Not only would this approach help bring hospitals on board, but it would make collaborations more sustainable. In the UK, “multi-specialty providers” is a term given to healthcare staff with the role of improving care- coordination between primary and secondary care—a similar objective to the reform models of the USA. They are care navigators, preventing overuse of GP services.59 Instead of individual teams of professionals serving individual practices, multispecialty providers intend to join services together, providing services to populations that most require it. This streamlining of services and alignment of teams and objectives means that efforts to improve patient experience are more likely to be Page 24 of 45 The Intelligence Economist Unit implemented successfully. Key to successful implementation of these multi-specialty providers is: 1) learning and adapting quickly, via timely monitoring and evaluation loops broken down change-by- change and team-by-team, with a view to quickly scrapping interventions that don’t work; and 2) making sure that new models of care are suitably contracted, so that organisational forms and financial flows are supporting the overall goals rather than getting in the way. So what this suggests is, problems with communication and differing relationships, sometimes between senior and less senior staff, sometimes between hospitals and organisations, may affect both the implementation and effectiveness of patient experience interventions.57 Organisational and structural matters and ensuring alignment of stakeholders is also critical. Those looking to employ patient experience interventions to improve the healthcare system therefore need to make sure they have a strong implementation platform, within which the strength and consistency of coordination between different contact points are addressed. Strengths and limitations of the review This review set out to provide an indicative representation of the best in recent research literature in the implementation of interventions to improve patient experience. We do not claim to have covered all the literature on patient experience. Our approach was to use a structured search across academic databases and pre-agreed inclusion and exclusion criteria to select only articles that satisfied certain methodological criteria. We therefore believe that while our review is not comprehensive in nature, it is a fair reflection of the research literature. While we focused on the highest quality evidence we could find, it is fair to say that the quality was at times weak. A number of the articles were randomised controlled trials, but often these were limited by poor methodological factors. Sometimes interventions were applied to single practices, and while this can present an opportunity to pilot a new intervention and break ground towards a larger evaluation, it can’t tell the difference between the effects of one intervention from other characteristics of the practice implementing the intervention. We also described some association studies; these can report on correlations that may be worthy of investigation, but they say little about causality. Most studies overlapped in the outcomes they measured, and our decision to cluster outcomes into “patient” outcomes and “provider” outcomes was pragmatic rather than ideological. As was our choice to group studies into four domains dictated by the target of the intervention: patient, staff, system or care interface. Other classifications could have been used, but we felt it helpful to think of patient interventions this way. Finally, patient experience interventions are often context specific, and so the exact method of implementation may not necessarily be reproducible. As a result of this, it can be difficult to identify take home messages that can be extrapolated to others trying to reproduce the results in a different setting. Conclusions This review of recent evidence aimed to shed some light on the benefits of investing in patient experience in healthcare. There is a diversity of approaches that institutions such as hospitals can take in order to improve patient experience. We organised our discussion of the research literature based on thinking about patient experience in terms of the “target” of the intervention: patients, staff, system and interfaces of care; we also considered the “components” of interventions: individual coaching, group training, care-coordinators, patient pathways, institutional design, IT systems and measurement tools. Page 25 of 45 The Intelligence Economist Unit The majority of studies we looked at targeted interventions to improve patient experience at the interface of care—by this we mean efforts to tighten coordination between service providers and facilitate efficient patient pathways across institutions and departments. These “interface” interventions result in improvements to both patient and healthcare provider outcomes. Although there were fewer studies looking at patient empowerment through education and other initiatives, these were also found to be successful and led to improvement in indicators of importance to both patients and providers. Interventions directed at staff, and systems improvements such as reform models like the PCMH, were not unsuccessful as such, but did result in fewer improvements overall. They also tended to only result in improvements in patient outcomes, rather than provider outcomes. In terms of the components of interventions, the most common approach was individual coaching followed by the use of care coordinators (such as patient navigators). The only component present in at least one intervention across all four different target groups was the use of institutional or facility design—this shouldn’t be a surprising finding, as patient experience is at the heart of how healthcare is structured, managed and delivered. Looking across wider association studies, we report evidence that suggests investing in patient experience may be associated with better hospital outcomes, improved profitability and greater patient loyalty. However there are so many other factors effecting systems outcomes, making direct associations to patient experience interventions is challenging. Nevertheless patient experience is an important outcome in its own right, and as patients wield progressively more clout in terms of recommendations, referrals and measures of patient loyalty, all providers need to ensure they are delivering an excellent patient experience across the continuum of care. Recommendations It is possible to draw some pointers from this evidence review for future patient experience initiatives. 1. Hospitals must be aware of and invest in their patient experience 2. Patient experience is important not only for patients, but there is evidence that better patient experience can also improve staff morale and reduce turn-over 3. There is no single best approach to improving patient experience; instead, efforts should be made across a range of implementation targets. These include patients, staff, system and interfaces of care. 4. Thinking about institutional or facility design will help ensure that patient experience interventions are embedded in the workplace, and improvements are sustainable 5. Alongside the implementation of patient experience interventions themselves, it is critical to put in place mechanisms to measure impact, and regularly review progress 6. When implementing patient experience interventions ensure alignment of values and objectives between management and staff delivering care 7. Many trials were methodologically weak and prone to bias, with short follow-up periods and little attempt at blinding or randomisation. Future trials would benefit from using more rigorous research methods. Page 26 of 45 The Intelligence Economist Unit 8. Case studies #1. A national patient experience survey60 How do we go about measuring patient experience nationally, creating a pubic facing data source for the benefit of people and individual organisations wishing to draw on and develop patient experience interventions? The National Cancer Patient Experience Survey was designed to monitor national progress of cancer care, to provide information to drive local quality improvements, assist commissioners and providers of cancer care, and to inform the work of various charities and stakeholder groups supporting cancer patients. Where clinical outcomes have registries, patient experience has iterative national surveys. The survey included all adult NHS patients with a confirmed primary care diagnosis of cancer discharged in April, May or June 2016. Questionnaires were sent by post, with two reminders where necessary, but also included an option to complete online or over the phone. The total sample size was 109,663 patients, of whom 72,788 responded. The overall response rate of 66.4% compared favourably to other NHS surveys, and a very high proportion of respondents said that they would be willing to participate in further surveys to ask about their health and healthcare. Main results included: Results relating to information about their care: Seventy nine per cent said they had the results of their tests explained to them in a way they could completely understand. Eighty-three per cent with more than one treatment option said that before their cancer treatment started, the options were explained to them completely; 78% said they were involved as much as they wanted to be in decisions about their care and treatment. Results relating to the staff-patient relationship: Ninety per cent of respondents said that they were given the name of a clinical Nurse Specialist who would support them through their treatment. When asked how easy or difficult it had been to contact their Clinical Nurse Specialist, 86 % said this was ‘quite easy’ or ‘very easy’. Ninety four per cent of respondents said that hospital staff told them who to contact if they were worried about their condition or treatment after they left hospital. Despite these positive results, the national picture of experience of care remains inconsistent. Patients get more information about some areas than others, and information about chemotherapy and radiotherapy appears to be better before treatment than during it. Care and support from health and social services at home appears to be less positively experienced than care received in hospitals. This on-going national survey continues to create a useful insight into the experience of cancer patients, including identifying those areas which health care services and hospitals needs to work on to achieve better outcomes. The key to its success, and patient involvement, has been the oversight provided by a national Cancer Patient Experience Advisory Group. The Group set the objectives of the survey programme and guided questionnaire development. Page 27 of 45 The Intelligence Economist Unit #2. A healthy workforce for improved patient experience61 NorthCrest Medical Centre is a not for profit community hospital serving Northern Middle Tennessee and Southern Kentucky. It employs 840 staff members. The Centre found that following budget cuts their patient satisfaction scores were showing a decline, and decided to take action to improve them. NorthCrest started with the assumption that patient satisfaction is tightly correlated to employee satisfaction. With fewer staff to care for more patients, NorthCrest decided to make adjustments to their overall workforce strategy so they could focus both on quality care goals while supporting their employees. They completely re-structured their care-coordination team, beginning with appointing a non-clinical leader to manage the team. Secondly they cut down on using external staffing to support gaps in the staff schedule, which was managed by the internal staff themselves, meaning front line staff were engaged with the needs of the organisation. Staff were also provided with cross-organisational training, so they could work in any department. In addition to this, NorthCrest discovered lengthy discharge times were reducing patient satisfaction scores. So to improve the length of time taken to arrange discharge, NorthCrest implemented transition coaches, a similar concept to that of patient navigators, which supported patients and their families to understand how to care for themselves after leaving the hospital. Using transition coaches, NorthCrest reduced discharge time by 60 minutes. Behind this strategic approach, NorthCrest invested in an IT system to collect and utilise real-time data to improve outcomes, make more strategic staffing decisions and lower their operating costs. The system facilitated the sharing of workforce data across the continuum of care. This was considered an important investment because evidence suggests that when patient interventions have failed it is often because there is insufficient workforce structure or senior management to ensure consistency of approach. Real-time information helped to improve workforce integration and align objectives. Providing this holistic approach to staffing and scheduling that focused on creating a positive working environment for employees, NorthCrest were able to improve the overall patient experience. The workforce were more engaged, making them more aligned with the improvements required to ensure quality of care and patient satisfaction. In the past, there was an emphasis on health systems to create a workforce that was cost efficient. Now healthcare systems are looking at combining staff management with patient satisfaction, quality of care and employee engagement metrics. Page 28 of 45 The Intelligence Economist Unit #3. Supporting patients through care transitions. The patient navigator37 With a 30-day readmission rate becoming the benchmark quality measure to evaluate hospital-to-home transitional care in the US, this has placed emphasis on the quality of transitional care. There is evidence to suggest that readmissions can be prevented with improved inpatient and post-discharge care. Here we look at the example of patient navigators. Patient navigators facilitate hospital discharges with a view to preventing readmissions. Depending on the particular model of care, they can: direct patients towards appropriate services, provide treatment planning, offer referrals, support patients and families, and generally help patients to break out of the never ending discharge-admission cycle that some find themselves in. To test the effectiveness of patient navigators, Balaban37 and colleagues set up a randomised controlled trial that employed community health workers as patient navigators who provided assistance for 30 days to high-risk patients following their transition from hospital to home. The study evaluated how patient navigators impacted on hospital-based care and outpatient appointments. The navigators helped with coaching, provided assistance with medication, outpatient appointments and transportation, communication with primary care, and helped patients to maintain self-care. This study revealed that for older patients, patient navigators reduced the use of hospital services; for every five patients assigned to a patient navigator program, one hospital-based encounter was prevented over 180 days. Patient navigators were also successful at directing older patients back to outpatient providers during the critical 30-day-post discharge period, which could have averted the possibility for further hospital-based care. These results help to justify the use of low cost community health workers as patient navigators to reduce available high-cost medical care in older-high risk patients. However, quite the opposite was found for younger patients. Here, patient navigators did not reduce hospital use. The researchers suggested that this might be because these younger patients—eligible for the patient navigator trial—actually have more complex problems than most older patients. As the patient navigator program is designed to increase access to care, unmet health needs were revealed which required further treatment. This research provides good evidence for the use of patient navigators for older people, but also indicates the need for understanding the population being served, and analysing longer term trends. With the proliferation of capitation or global payment programs there will be increasing interest in how best to identify high-quality, cost effective transitional care strategies such as—in some instances— patient navigators. Page 29 of 45 The Intelligence Economist Unit #4. Using data and research to improve patient expereince.62 Cleveland Clinic serves a dispersed population; for example about half of their heart clinic patients come from outside Ohio. Most of their patients therefore have a choice of hospitals they can go to for their care. Consequently, when the Clinic’s patient experience scores were found to be poor compared to many of their competitor hospitals, there was general agreement that something had to be done. The Clinic knew that they had poor waiting times compared to their peers, and it was assumed that this was a key driver behind their poor patient experience scores. However, they decided to commission some external research anyway, to understand what it was that their patients prioritised. The results were surprising. The three elements of care that their patients prioritised were all what could be tackled by improving “soft” skills. They were 1) to be treated with respect, 2) to receive improved communication from staff, 3) to be treated by, and interact with, happy staff. Respect was important to patients because they wanted providers to treat them like individuals and engage with them personally—rather than be cold and objective clinicians. Improved communication was a factor because it turned out that many patients used proxy measures like communication between physicians and nurses to assess the quality of care they’re getting. Finally, happy staff were perceived as being more approachable; for example, if a patient saw a doctor who appeared to be in a hurry, they asked fewer questions of them because they didn’t want to get in the way of whatever it was the doctor was meant to be doing. These findings were the opposite of what the clinic expected to find. Before the research, when emergency department clinicians were asked what they thought was the major contributor to patient dissatisfaction, they answered “It’s the waiting times.” But actually, the research showed that waiting times were the least important thing to patients. Rather, it was whether they received displays of concern and caring (including while they were waiting) that was driving their (dis)satisfaction. As a result of the research, training and coaching was implemented to improve communication skills (both between professionals and between professional and patient), and patient experience improved as a result. The take home message was that while improving soft skills led to improvements in patient experience, it was only through quantitative and qualitative research and rigorous data collection that the clinic knew what to tackle and how. Page 30 of 45 The Intelligence Economist Unit 9. References 1. Robinson P, Tyndale-Biscoe J. What makes a top hospital? Patient and staff experience. London: Comparitive Health Knowledge System, 2013. 2. Raleigh V, Thompson J, Jabbal J. Patients' expereince of using hospital services: An analysis of trends in inpatient surveys in NHS acute trusts in England, 2005-13. London: The Kings Fund, 2015. 3. 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Parent and Provider Experience and Shared Understanding After a Family-Centered Nighttime Communication Intervention. Academic Pediatrics. 2017;17(4):389-402. 28. Dobkin PL, Bernardi NF, Bagnis CI. Enhancing Clinicians' Well-Being and Patient-Centered Care Through Mindfulness. The Journal of continuing education in the health professions. 2016;36(1):11-6. 29. Rice C. 5 ways to raise HCAHPS scores via staff engagement. HealthLeaders Media Insider: HealthLeaders, 2014. 30. Xin H, Kilgore ML, Sen BP. Is access to and use of primary care practices that patients perceive as having essential qualities of a patient-centered medical home associated with positive patient experience? Empirical evidence from a U.S. Nationally representative sample. Journal for Healthcare Quality. 2017;39(1):4-14. 31. Stein SM, Day M, Karia R, et al. Patients' perceptions of care are associated with quality of hospital care: a survey of 4605 hospitals. 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National Cancer Patient Expereince Survey. Derbyshire: Quality Health, 2016. Available from: http://www.ncpes.co.uk/reports/2016-reports/national-reports-1/3572-cpes- 2016-national-report/file. 61. Healthcare A. Achieving Quality Care and Patient Satisfaction. Driven by LEAN Initiatives. Wisconsin, United States: API Healthcare, 2015. Available from: http://apihealthcare.com/sites/default/files/pdf/NorthCrest_Medical_Center_Case_Study.pdf. 62. Merlino J. Automating and Integrating Patient Satisfaction Data to Achieve IHI Triple Aim Goals. Salt Lake City, Utar: Health Catalyst, 2017. Available from: http://www.healthcatalyst.com/wp-content/uploads/2014/12/SuccessStory-Patient-Satisfaction- Data.pdf. Page 34 of 45 The Intelligence Economist Unit 10. Appendix Embase.com search strategy #22 #19 NOT #20 AND [english]/lim #21 #19 NOT #20 #20 #14 AND #17 AND [2012-2017]/py AND ([conference abstract]/lim OR [conference paper]/lim OR [letter]/lim OR [note]/lim) #19 #14 AND #17 AND [2012-2017]/py #18 #14 AND #17 #17 #15 OR #16 #16 intervention*:ab,ti OR 'post intervention':ab,ti OR 'pre intervention':ab,ti #15 improv*:ab,ti OR impact*:ab,ti OR influen*:ab,ti #14 #1 OR #2 OR #3 OR #4 OR #6 OR #7 OR #13 #13 #11 AND #12 #12 experience:ti,ab #11 #8 OR #9 OR #10 #10 'patient centred':ab,ti OR 'patient centered':ab,ti #9 'nurse patient relationship'/mj #8 'doctor patient relation'/mj #7 'patient* experience*':ti #6 'patient centeredness'/de #5 'patient preference'/mj AND experience:ti,ab #4 'patient empowerment'/de #3 'patient engagement'/de #2 'patient satisfaction'/mj AND experience:ti #1 'patient experience'/de Page 35 of 45 The Intelligence Economist Unit Overview of all included studies Outcomes reported Author, Nature and scope of Intervention date Country Intervention theme Setting Outcome measured Patient education using Improved: Health care use patient navigators Face to face/coaching Hospital setting Primary = Worsened: Readmissions High risk safety In-network 30-day No change: Outpatient use Balaban, United Care transition program 201536 from hospital to home Interfaces of net patients hospital readmissions States Hospital visits and 30 day care (patients without Secondary = post discharge telephone medical Rates of outpatient outreach. insurance) follow-up. Patient education using patient navigators 1 - Hospital based No change: Readmissions and outpatient use Face to face/coaching Hospital setting utilisation, a composite of Balaban, United 201737 Care transition program Interfaces of General ED visits and hospital States from hospital to home care medicine admissions Hospital visits and 30 day inpatients 2 - Hospital re- post discharge telephone admissions calls 3 - ED visits 4 - Outpatient visits Care-coordination Improved: Access to care, other patient Facility design reported outcomes, health care use Model of care (institutional), fostering healing environment and Access to primary care Burkhart, United building dynamic providers 201638 States partnerships between Interfaces of Primary care Primary, speciality and patient, family, health care emergency care use provider and other health Clinical indicators for team members. chronic disease. Patient centred care innovations to improve Page 36 of 45 patient and provider The Intelligence Economist Unit experience and the environment in primary care Hospital setting No difference: Other patient reported Safety net Improvements to outcomes, patient-provider relationship Care-coordination hospital HCAHPS scores in three Face to face/coaching (patients without domains: Chan, United Nurse led care transition Interfaces of medical Communications domain 201539 States insurance) of HCAHPS program care Hospital visits and post Ethnically Medication domain of discharge phone calls diverse low HCAHPS income Nursing domain of population HCAHPS Older people Care-coordination Improved outcomes: Costs Facility design Model of care Primary care Filmore, Unites (institutional), systemic Interfaces of Non elderly 201440 States care management people with Reductions in costs intervention integrating care Medicaid professional care insurance managers with technology Care-coordination Improved outcomes: Patient provider Goncalv United Face to face/coaching Interfaces of Hospital setting Nursing care behaviour relationship es, 201641 States Communication aid to improve nurse/patient care Older adults scores relationship Page 37 of 45 The Intelligence Economist Unit Patient-reported No change: patient satisfaction experience measures Multi: Czech Generic 6-item measure Republic, Care-coordination Hospital setting of patient experience France, Technology/electronic Four condition (NORPEQ) Groene, 3-item measure of Impact of models of care Interfaces of pathways, 201542 Germany, health data Poland, Stroke, Acute patient-perceived care Portugal, for different condition myocardial preparation Spain, pathways on patient infraction, hip Two single item Turkey experience. fracture. measures of perceived involvement in care and hospital recommendations Improvements in four Improved outcomes: Improved disease domains of the AF4Q: management Care-coordination Care-coordination - Facility design binary scale Model of care Patient satisfaction - 0-10 McHugh, United (Institutional), offering financial support and Interfaces of Primary care scale 201643 States Chronically ill Provider interaction and technical assistance to care adults support - binary scale communities of patients Receipt of recommended participating in the care for diabetes - binary model. scale Pre and post intervention scores compared. Care-coordination Improved outcomes: Patient provider Technology/electronic Improvement in patient relationship Migdal, United health records experience as measured 201444 States Audit evaluating the Interfaces of Hospital setting by physician-patient impact of electronic care interactions using the health records on patient ARC program. experience Care-coordination Primary outcome= Improved outcomes: Patient satisfaction Model of care (health Quality indicator score No difference: Care-coordination Wahlber g, 201746 Norway care staff) Interfaces of Primary care Secondary outcome= Referral templates for care Patient experience as different diagnostic measured by self-report groups questionnaires. Page 38 of 45 The Intelligence Economist Unit Primary outcomes= Improved outcomes: Patient satisfaction Changes to healthcare No difference: Costs, health care use costs Care-coordination Acute and extended care Model of care (healthcare utilization staff) Secondary outcomes= Zulman, United Comprehensive patient Interfaces of Primary care Interventions effect on 201745 States assessments, intensive care MRI centres Impact participants case management, care- satisfaction and coordination, social and activation levels recreational activities assessed with an improvement survey administered at baseline and 6 months. Patient welfare Improved outcomes: Other patient reported Healthcare environment outcomes Biddiss, Systematic review Hospital setting No change: Patient satisfaction 201413 Canada addressing adaptations Patient Health care Patient stress and to the healthcare waiting rooms anxiety environment that may reduce anxiety Patients able to Improved outcomes: Patient provider recognise their care relationship, patient satisfaction Patient education Hospital setting providers by photograph, Care approach Patients with name and role. Brener, United Communication aid to cognitive or Patient ratings of 201614 States enable patients to Patient visual communication among recognise their impairment and healthcare team healthcare professionals non-fluency in members. Satisfaction English with the hospital experience as assessed by a survey. Page 39 of 45 The Intelligence Economist Unit 1- If the patient had Improved outcomes: Improved disease received a written management, readmissions, emergency Patient education Hospital setting summary of all cancer department visits Kenzik, Unites Care approach/self- People over age treatment received 201615 States management tool Patient 65 2- If a written summary of Treatment summaries Cancer the follow up plan had and care plans diagnosis been received 3-If the follow up for care had been explained Primary= Improved outcomes: Improved disease Patient education Post-operative LOS management Care approach/self- Hospital setting Long-term global health- No difference: Length of stay Schmidt, Germany management Patient Patients over 201516 related quality of life on Information booklet and age 65 year post-operative patient diary Elective surgery Secondary= Postoperative stress and patient complications Patient subjective Improved outcomes: Patient satisfaction Patient welfare experience of the MRI Healthcare environment scans No difference: Quality of care Scanning physician’s Stanley, United Technology 201617 Sensory stimulation and Patient Hospital setting evaluation of movement Kingdom its effect on patient MRI centres during the scan experience during MRI Two numeric rating scales of patient scans experience. Page 40 of 45 The Intelligence Economist Unit Measures of stress and Improved outcomes: Quality of care, other burnout in clinicians patient reported outcomes using: Perceived Stress Scale Staff training Beck Depression Delivered face to face Inventory External training Sense of Coherence test Dobkin, France Mindfulness stress Staff The Maslach Burnout 201628 Hospital setting reduction for clinicians Inventory treating patients with Five Facet Mindfulness chronic illness Questionnaire Rochester Communication rating scale Roter Interaction Analysis System Staff training Primary = Improved outcomes: Readmission Delivered face to face Medication adherence No change: improved disease management, Hyrkas, United 201420 External training States Nurses taught patient Staff Hospital setting Therapeutic alliance patient satisfaction Patient experience Worsening outcomes: Other patient reported centred and motivational Readmissions between outcomes interviewing techniques groups Primary outcomes= Improved outcomes: Patient satisfaction, Proportion of patients patient provider relationship reporting top box scores on daily surveys Secondary outcomes= Staff training Hospital setting Percentage change for Delivered face to face English or scores recorded for 3 Indovina, United In practice Spanish provider-specific 201621 States Real time patient Staff speaking questions from the daily feedback to clinicians to patients survey, the median top improve patient General medical box HCAHPS scores for experience patients the 3 providers related questions and overall hospital rating, and HCAHPS percentiles of top box scores for these questions. Page 41 of 45 The Intelligence Economist Unit Staff training/care- Improved outcomes: Patient provider coordination relationship Delivered face to face Khan, United 201427 In practice Hospital setting States Nurse briefings, case Staff Night shifts Top box patient experience scores conference and nurse Children’s wards changeover communication model Improved QOL using 2 Improved outcomes: Improved disease summary scores management (physical health and mental health) The following indicators measured: Staff training Social roles/activity Kvale, United Delivered face to face Primary care limitations 201622 States In practice Staff Cancer Self-efficacy for Motivational interviewing survivors managing Chronic Disease scale Patient activation measure-short form patient health questionnaire depression scale Care-coordination Changes to workplace Improved outcomes: Patient provider Staff training based assessment of relationship Maatouk, Delivered face to face physician’s 201623 Germany External training Staff Primary care communication Communication training behaviour obtained using provided to physicians the Roter Interaction Analysis System. Staff training Patient experience No difference: Patient provider relationship Delivered face to face scores Seiler, United (lecture and video) Before, during and after 201724 States External training Staff Hospital setting study time Communication training HCAHPS survey data on provided to physicians both medical and surgical patients Page 42 of 45 The Intelligence Economist Unit Staff training Improved outcomes: Improved disease Face to face, whole management practice level training four, two and a half hour sessions Patient’s assessment of In practice training their care after the Disease management Smidth, 201625 Denmark model focussing on: Primary care implementation of the Policies and resources Staff Patients with disease management Self-management COPD program measured using the Patient-Assessment- support of-Chronic-Illness-Care Delivery system design (PACIC) instrument. Organisation of healthcare Clinical information systems Patient actors rating of Improved outcomes: Quality of care doctors communications Staff training skills using the Doctors 20 minute E-leaning Interpersonal skills communication training questionnaire (DISQ) Snow, United External training Students rating of the 201626 Kingdom Delivered to medical Staff Academic modules effect on their students skills and confidence using a multiple choice questionnaire (MCQ) and an Objective Structure Clinical Examination (OSCE). Care-coordination Improved outcomes: Patient satisfaction, care- Facility design coordination System level model of care Dorr, United 201632 High value elements Pre-study and post-study States delivered to primary care System Primary care patient satisfaction using practices consisting of: CAHPS survey Practice facilitation, IT- based reporting and financial incentives Page 43 of 45 The Intelligence Economist Unit Primary outcomes= Improved outcomes: Patient satisfaction Four domains of the HCAHPS were examined. Patient experience Hospital overall rating of measurement tool 9 or 10 Facility design Patients would definitely Stein, United recommend the hospital 201431 Electronic hospital States database System Hospital setting Doctors always Compares HCAHPS communicated well scores to hospital Patients always received complication rates help as soon as they wanted. Secondary outcomes= Physician communication Responsiveness of hospital staff Patient experience Improved outcomes: Patient satisfaction, measurement tool patient provider relationship Facility design Assessing patients Electronic survey of experiences of Patient Xin, United 201730 patient experience States Determine effectiveness System Primary care Cantered Medical Homes using the Medical of PCMH model for Expenditure Panel improving healthcare Survey quality and patient experience Page 44 of 45 The Intelligence Economist Unit Page 45 of 45