Patient surveys taken before the pandemic can provide guidance as we reopen our practices. Herewith, some advice on managing the transition from the office to the mixed realm of online visits and "distanced" physical encounters.
Covid-19 has irrevocably disrupted the way we practice office-based medicine. Clinicians and health systems have had to adapt to new care models, workflows and reimbursement structure while we seek greater understanding of this new contagious illness in our midst. Pandemic adjustment has also, in many cases, sidelined processes aimed at improving patients' experience of care, such as surveys, patient-family advisory councils (PFACs), communication skills improvement initiatives, and other initiatives that support patient-centered care. As many practices prepare for a gradual re-introduction of in-person care with its inherent charge to keep patients, providers, and staff safe, it's best to reexamine processes to ensure that transition also preserves an optimal patient experience.
The influx of new patient satisfaction survey data has diminished during the pandemic, as patients, offices and health systems tackle urgent adjustments, and now, many standard survey questions are less immediately relevant. We know from historical data, however, that key drivers of positive patient experience and loyalty include confidence in the care provider, coordination of care, responsiveness to patient concerns, listening, and courtesy.1 To meet these ends, our patient-experience leaders have developed strategies for successful adaptation in four key areas: communication, care access and coordination, responsiveness, and teaming.
To meet these ends, our patient-experience leaders have developed strategies for successful adaptation in four key areas: communication, care access and coordination, responsiveness, and teaming.
Beyond clinical competency, trust in the care provider relies heavily on clinicians’ active listening, empathic communication, and not seeming rushed. There are established techniques to practice, and we know that communication skills training improves the patient's experience.2 With video and audio still making up a sizable portion of visits, and in-person care now complicated by the physical barrier of personal protective equipment, it is important to incorporate the emerging best practices for creating presence; these include greater attention to vocal tone and tempo, facial expressions and body language, reflection, mindful practice, and extra effort to check for understanding. Securing a well-lit space free of distraction in which to conduct virtual visits is also critical. Rather than imposing more expectations on our administration, clinician-leaders have initiated a series of weekly webinars presented by clinicians for our fellow clinicians, focused on best practices for telehealth. These webinars offer updates on documentation requirements and use of technology, as well as guidance on adapting relational communication skills to virtual care and the new in-office constraints.
Support for patients new to virtual technology should be part of the communication process. To ensure a smoother transition, we have created a three-stage approach: patient portal electronic messaging with instructions for downloading and using our telehealth platform, a second review by the staff who schedule telehealth visits, and finally a dry run by the medical assistant preparing the patient for a visit in the virtual exam room.
Clinician and staff communication must provide warmth, attentiveness, and reassurance in the face of the anxiety we may share with our patients, especially as we welcome them back into our office space.3 Local clinical managers need to reinforce this point through frequent check-ins and demonstration by example. A "pocket note" is also being developed as a quick reference for providers and staff. (Table 1, Table 2)
| • Be aware that PPE can be scary to patients. Verbalize welcome and reassurance.
• Articulate slowly and clearly, as PPE muffles voices.
• Communicate why you’re following Covid-19 safety measures.
• While masked, use body language, hand gestures, and eye contact to enhance communication. For example, elevate your eyebrows as a sign of welcome, tilt your head and nod as a sign of attentiveness. Don’t squint or rub the neck or chest, as this indicates stress or worry.
• Demonstrate compassion for patients’ circumstances and awareness of unspoken anxiety.
• Create follow-up visit workflow which incorporates telehealth.
• Have a clear plan for concerns which cannot be seen in the office or adequately addressed virtually.
• Express empathy in response to anxiety and urgency expressed by the patient.
When meeting patients in person:
| • Prepare and practice with technology beforehand.
• Verbalize clearly when referring to the EMR, as the patient cannot see it.
• Focus on the patient. If looking away from the patient, explain why.
• Practice active listening techniques, paraphrase, reflect, and use empathetic statements.
• Recognize that Covid-19 related stress and anxiety may affect our patients’ attentiveness.
• Present information in smaller portions with frequent use of Teach-Back.
• Remind ourselves and our patients to situate in a quiet, private environment for consultation.
• Ensure that technology connections are clear, and that the light, position, and backdrop are optimized for video viewing on both the clinician and patient end.
When meeting patients virtually:
Care Access and Coordination
Continuity of care also presents some new challenges. When we resume in-office care, many patients may be reluctant to risk leaving their homes. We have addressed their fears by clearly communicating office hygiene and distancing precautions, while continuing to offer non-office based options for care. Office capacity is constrained by social distancing guidelines, underscoring the ongoing need for virtual visits. By evaluating risk and engaging in shared decision making, patients and clinicians can select the option that best meets individual needs.
If and when they do return to the office, patients should know what to expect -- from parking their car to exiting the facility. Simple, clear language must convey that the entire team is focused on the safe delivery of care. Clear messages in multiple formats have been deployed (direct voice calls, email, website, posters, floor markers for distancing guidelines, directional signage, safety scripting for front desk staff and greeters) and will likely reassure returning patients.
Caring for acute febrile respiratory illness in the office setting presents an exceptional safety challenge, perhaps requiring a separate zone of the office designated exclusively for these patients. Practice leaders are asked to speak honestly and supportively in order to determine which staff and clinicians are willing to take on the increased personal risk of caring for the acutely ill. If this is beyond the scope of what a practice can offer, clear contingency plans must be in place to address acute care needs, perhaps through virtual care, urgent care or other designated sites.
Workflows have required adjustment to virtual care and remote staffing. As we resume some office based care, we will need to innovate ways to shift between virtual and in-person workflows in order to ensure that proper after-visit follow up care is arranged.
Prompt response to patients' telephone and online-portal messages is a key experience driver, which the pandemic has complicated. Along with expediency, renewed empathy will be vital to address messages that may be more laced with fear and anxiety than usual. As the assault of Covid-19 continues, more of our patients will succumb to this disease -- or try to mourn a loved one who has. Providing support to grieving people is a task that care teams are often called to perform, but not on the scale we have recently seen. Practices are creating plans, such as public memorial boards, to honor those who have died or are in mourning.
As the assault of Covid-19 continues, more of our patients will succumb to this disease -- or try to mourn a loved one who has. Providing support to grieving people is a task that care teams are often called to perform, but not on the scale we have recently seen.
A great patient experience comes from a team that is caring and well cared-for. To this end, demonstration of co-worker compassion and support is vital. Huddles have proven to be a valuable teaming concept, and are transferrable to the virtual space. Meeting pandemic challenges requires an “all hands on deck” approach, with leaders providing guidance, empowerment and walking the talk.
The pandemic will continue to take an emotional toll on clinicians and support staff. We must expand on the pre-pandemic progress made in addressing burnout. Wellness resources, ranging from peer support to individual or group psychotherapy must be readily available to support all health care workers, especially as we begin to emerge from what, for many, has been a truly life altering epoch.4 Penn Medicine has created a robust web platform, PennMedicineTogether (https://www.med.upenn.edu/PennMedicineTogether/), an easily accessible, comprehensive depot of information, counseling, and other resources available to all employees -- clinical and non-clinical -- during the pandemic and beyond. The Penn Medicine Listening Lab (https://pennlisteninglab.org/) is another important resource we have created for our patient and care provider community. “Created by patients, caregivers, staff, and providers, the Penn Medicine Listening Lab is a storytelling initiative that embraces the power of listening as a form of care.” This an opportunity for members of our health system to care for each other through the medium of hearing and telling stories housed in a web-based library. It was developed well before the Covid-19 pandemic, yet current circumstances have highlighted its value.
The Covid-19 pandemic is far from over, but we have reached a turning point as we resume some elements of in-person patient care. While we await new tools for evaluating patient satisfaction in the pandemic era, we can rely on well-established data that underscore what we know of what truly matters to our patients. This is an opportune time to revisit core components of a great patient experience, as we creatively adapt and reinvigorate our best practices for safe and compassionate practice.
Jeffrey Millstein and Stephanie Kindt have nothing to disclose
Press Ganey. (2013) Protecting Market Share in the Era of Reform: Understanding Patient Loyalty in the Medical Practice Segment. Press Ganey Associates, Inc. https://www.pressganey.com/resources/white-papers/understanding-patient-loyalty-in-the-medical-practice-segment
Boissy A, Windover AK, Bokar D, et al. Communication Skills Training for Physicians Improves Patient Satisfaction. J Gen Intern Med 2016;31:755-761 .
Chou C. How COVID-19 Disrupts—and Enhances—My Clinical Work. J Patient Exp 2020;7:144-145 .
Dzau VJ, Kirch D, and Nasca T. Preventing a Parallel Pandemic - A National Strategy to Protect Clinicians’ Well-Being. N Engl J Med 2020; .
NEJM Catalyst Innovations in Care Delivery
June 24, 2020
Copyright ©2020 Massachusetts Medical Society.
Published in issue: January 5, 2020
Published online: June 24, 2020
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