Imagine you are trying desperately to reduce your fall rate and you have instituted a program with bed alarms for patients who meet certain criteria. You may find yourself really pleased to note a reduction in falls, but at the same time you are noticing your patient satisfaction scores are taking a hit. Patients are talking about the noise of alarms, of feeling infantilized, of their sense of control being taken away. Is there a link? Maybe, according to an editorial in the American Journal of Medical Quality.1
Author Sue Moffatt-Bruce, MD, PhD, chief quality and patient safety officer at Wexner Medical Center of Ohio State University in Columbus, and a thoracic surgeon in practice there, writes with her colleagues that there has been a shift over time of the competing pressures.
In 2013, it was just process measures (70%) and patient experience (30%) as described through HCAHPS results that informed the rewards of value-based purchasing from the Centers for Medicare & Medicaid Services (CMS) to hospitals. Last year, a new piece was added to the pie: outcomes measures, taking up a quarter of the circle and reducing process measures to 45%. This year, the wedges change again: HCAHPS and outcomes are each 30%, process measures are 20%, as is the newest slice, efficiency. Next year, process shrinks to 10%, HCAHPS and efficiency are each a quarter, and outcomes are 40%.
What does this mean? It means that the balancing act just gets trickier, Moffatt-Bruce says. “People do not want to recognize this tension, even though they know in their hearts it is there,” she says. “We have to be sure that we are putting the emphasis in the right place this year and next.”
The issue of falls is a good one to take as an example. Explaining your efforts can change the way a patient sees them, she says. Saying that you are most concerned about the safety of the patient and ensuring that he or she doesn’t fall could make a bed alarm or other fall reduction effort more palatable.
“Right now, we aren’t even empathetic about the situation,” she says. “They do not know what we are thinking when we alarm their beds or restrain them. Then when we ask them to rank their experience, we are surprised that they view it as negative. We have to do a much better job explaining our thinking to patients and their families.”
In the editorial, Moffatt-Bruce and her peers note that patient-centered care — a term of a decade’s provenance — may be the savior for all. Making sure you make the patient the focus of everything you do — and thinking about how what you do might be perceived by the patient — is key.
Quality professionals have two jobs, Moffatt-Bruce says. First is to help administrators understand the link between quality and the bottom line. This will help them understand that they have to “fund the mission,” she says. “The patient must be the true north metric for us. They must be the center of everything we do.”
Even more important, you must explain to the physicians the competing tensions in the value-based purchasing pie, Moffatt-Bruce says. “They do not understand the concept, and that they have to now balance patient experience with outcomes is a completely foreign concept to them. They need to be educated about it, be accountable for it, and recognize that they must develop a level of empathy to the tension between care processes and outcomes.”
Doctors — and nurses — should also be aware of how they are doing, both as individuals, and as units and hospitals, in terms of these value-based purchasing data points. “They could go look at Hospital Compare, but what tired doctor or nurse does that?” she asks. Make it easy for them to see where they stand, and where your facility stands.
Sometimes, Moffatt-Bruce says, “physicians and administrators think that we can define value. But the patient is the one who defines it for us, and we keep forgetting that.”
Which brings her to the final point: Engage your patients. If they are at the center of all you do, you probably already do this. But make sure they are in the loop with every single process happening to them. Information is power, and one of the biggest reasons people hate being in the hospital is that they are no longer in control of their life, she says. By keeping patients in the loop about what you are doing and, importantly, that you are doing it to keep them safe and get them well, you are more likely to help the patient feel good about the experience in the hospital. That 25% of your value-based purchasing pie will be secured. “Make what you do at the bedside clear, transparent, and practical,” Moffatt-Bruce says. “If you ever have need to have more explanation, it’s when you are sick. It gives patients something to focus on.”
Moffatt-Bruce is publishing a paper in Management Science this year that is a study of different hospitals and this tension. She hopes to put it in the medical literature, too.
For more information on this story, contact: Sue Moffatt-Bruce, MD, PhD, Chief Quality and Patient Safety Officer, Wexner Medical Center, Ohio State University, Columbus, OH. Email: firstname.lastname@example.org.
- Moffatt-Bruce S, Hefner JL, McAlearney AS. Facing the tension between quality measures and patient satisfaction. Am J Med Qual. 2014 Nov 3. pii: 1062860614557352.