At the University of Missouri neurophysiology lab, we introduced an effective training technique to improve provider communication skills and assessed its impact on patient experience. The Mentoring, Education, and Engagement (MEE) technique generated significant success by improving survey scores for patient experience as well as employee satisfaction.
Patient satisfaction is directly related to employee workplace satisfaction.
Breaking down the barrier between physicians and other health care providers, and among different health care providers, is essential.
Employees need to be trained in patient communication.
One-to-one mentoring and feedback is better than “blame” culture.
MEE is an effective way to foster an open learning environment and break down these barriers.
The University of Missouri (MU) Health System is a comprehensive academic health center where patients from each of Missouri’s 114 counties are served by approximately 6,000 physicians, nurses, and health care professionals at MU Health Care. Providing an outstanding patient experience is of paramount importance as the organization strives to deliver a high standard of care. Patient experience is a component of patient centeredness, one of six health care quality aims proposed by the National Academy of Medicine. Further, patients value and expect interpersonal aspects of health care. Many hospitals and health care centers face challenges in meeting this expectation, and our neurophysiology lab was no different, facing multiple resource demands, and employees lacking the education and skills needed to meet the demands of ever-evolving health care and its consumers. There also was room for improvement for employee satisfaction scores in the lab.
Our goal was to develop and implement an effective technique that could help foster the interpersonal relationship between the patients and the neurophysiologist and neurophysiology staff so as to improve the quality of patient experience as well as employee satisfaction. The Mentoring, Education, and Engagement (MEE, see Figure 1) technique focuses on engaging employees — such as electrodiagnostic technicians, neurophysiologists, and neurologists — in an open conversation on improving patient experience; developing educational resources, including hands-on training, role-play, and pocket flash cards to help with interpersonal patient communication; and providing one-to-one mentoring to employees who need help, all aimed to generate a team spirit and a learning environment among peers.
The MEE Technique
The technique is based on three fundamental principles of Mentoring, Education, and Engagement. This was executed in three phases of preparation, training, and implementation. Leading these efforts were the study authors with input from the human resources department at the hospital.
The preparation phase was from approximately 12 weeks, spanning July 2015 to September 2015. The first 8 weeks involved meeting with staff in the departments with high patient experience scores to learn best practices. An observation visit with feedback from a patient- and family-centered care trainer from the hospital’s human resources department helped analyze potential areas of improvement.
After these visits, we spent about 4 weeks designing new brochures and cards for patients providing department information, name of technician, type of test, and doctor’s name and phone number; we also designed wall magnets (with a brain design) with department information for patients. In addition, we ordered water bottles, juice, and crackers for patients.
The training phase, about 12 weeks from October 2015 to December 2015, involved simulation training with staff engaging as patient and technician, conducting spot surveys of both the simulated patient and technician after completing tests, and discussing areas of weakness in the simulated patient encounter. The training was done for an hour every day, and all the technicians got to play both the patient and technician role at least thrice during this period. The technicians were instructed to follow ICARE principles (Integrity, Commitment, Advocacy, Respect, Excellence) in all simulated patient encounters. Patient- and family-centered care training and employee engagement training was conducted by the study co-authors in addition to a patient- and family-centered care trainer from the hospital’s human resources department to improve teamwork and morale in the department.
The implementation phase (January 2016 to August 2016) involved a monthly meeting (one hour at the end of each month) to discuss patient experience scores and feedback and ways to improve the scores and feedback. In addition, daily observations with immediate feedback by supervisors/managers and peers were done. After implementation, the technique became ingrained among staff; training is provided when needed for new employees.
The Execution and the Team
The team comprised the study authors and the electrodiagnostic technicians who undertook the initiative to improve patient experience. After training, the team implemented the MEE technique and behavior with every patient who presented to the neurophysiology lab. The patients were asked to voluntarily participate and complete the National Research Corporation (NRC) Picker Catalyst survey. The survey was sent to 836 patients, of whom 218 patients completed it (response rate 26.1%), from January 1, 2016, to September 30, 2016. Patients were divided into three quarterly groups: those who presented from January 2016 to March 2016, from April 2016 to June 2016, and July 2016 to September 2016. Scores were collected from each quarter and were compared to the scores obtained from patients who presented to the neurophysiology lab in the fourth quarter of 2015, from October 1, 2015, to December 30, 2015, when the MEE technique had not yet been implemented. That survey was sent to 350 patients, of whom 70 completed the survey (response rate 20%). The survey instrument was the same for each quarter.
The NRC Picker Catalyst survey consists of 23 questions, of which three key drivers of patient experience were selected for analysis in this study. These were:
- Did you have confidence and trust in the staff/technicians performing your tests or procedure?
- Did staff/technicians who performed your tests or procedure listen carefully to you?
- Did staff/technicians who performed your tests or procedure treat you with courtesy and respect?
Patients were asked to respond to the above questions in terms of yes or no responses. Three versions of a yes response were offered — Yes, somewhat; Yes, mostly; and Yes, definitely — but we only counted the “Yes, definitely” responses; the others were not considered successful. Regarding their overall level of satisfaction with the testing facility, a scale of 0 to 10 was used, with 0 being the worst possible testing facility and 10 being the best possible testing facility. We counted only scores of 9 or 10; the others were not considered successful. Scores from all four quarters were obtained and were compared to assess the difference in level of patient experience, before and after the implementation of the MEE technique. The corresponding P values were also obtained. The results were as follows (see Figure 2):
For the main question, “Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best possible facility, what number would you choose to rate this outpatient testing facility?” the percentage of patients who gave scores of 9 or 10 improved nearly 9 points, from 74.90% in the fourth quarter of 2015, before implementation of MEE, to a combined average of 83.67% for the first three quarters of 2016, after implementation of MEE (p<0.003). For the question, “Did you have confidence and trust in the staff/technicians performing your tests or procedure?” the percentage of patients scoring definitely yes increased nearly 10 points, from 79.03% in the fourth quarter of 2015, pre-MEE, to a combined average of 88.77% for the first three quarters of 2016, post-MEE (p<0.001). For the question “Did staff/technicians who performed your tests or procedure treat you with courtesy and respect?” the percentage of patients scoring definitely yes increased more than 7 points, from 86.33% in the fourth quarter of 2015, pre-MEE, to a combined average of 93.71% for the first three quarters of 2016, post-MEE (p<004). For the question “Did staff/technicians who performed your tests or procedure listen carefully to you?” increased nearly 6 points, from 85.00% in the fourth quarter of 2015, pre-MEE, to a combined average of 90.91% for the first three quarters of 2016, post-MEE (p<0.006).
In addition to patient satisfaction improvement, employee satisfaction scores increased. Data from a Gallup online survey tool from January 2015 (pre-MEE) was compared to data from January 2016 (post-MEE). A change of 0.2 points in the mean score was considered statistically significant; response choices ranged from 0 to 5, with 5 being the best. The overall mean employee satisfaction score of the neurophysiology department increased from 4.01 to 4.42 (Figure 3). For the question “In the last 7 days, have you received recognition or praise for doing good work?” the mean score increased from 3.00 to 3.9 (Figure 3). Also, the score of employees reporting that “In the last year I have had an opportunity to learn and grow” increased from 4.25 to 4.60.
Where to Start
Feedback is the reflection of patient’s satisfaction. Regular review of feedback from patients should be undertaken in real time and after the clinical interaction, so as to address their concerns regarding the facility. Communication is the key to providing a positive patient experience. Lack of demonstrating open communication — such as listening to the patient and showing empathy and respect for his or her concerns, and explaining the procedure — is reported as a significant concern in almost a quarter of unsatisfied patients. Special training for improving communication skills including role-play, patient simulation, and pocket checklists on key behaviors (see Figure 4) should be implemented. It is essential to break down the barriers between physicians and other health care providers and, more important, the hierarchy based on seniority/experience among different health care providers. Engaging all employees (physicians and all health care providers) in an open conversation on ways to improve their communication skills and patient experience breaks down this hierarchy and creates a learning and respectful workplace environment. Finally, it is critical we move away from a blame culture and instead focus on providing one-to-one mentoring for those staff who might be struggling to acquire these new skills.
Patient experience and, more so, patients feeling respected, are directly related to employee satisfaction in the workplace. Making physicians and all health care professionals partners in this process and providing them with the necessary tools through education and one-to-one mentoring is an important step toward improving patient experience. Monitoring of performance is beneficial in improving the overall quality of patient care, and we are constantly implementing new techniques to provide an outstanding experience to our patients.
Acknowledgements: Raja Bodepalli, MD, Research Scholar in the Department of Neurology at the University of Missouri; and Dave Geiger, BS, RRT, Director of Respiratory Care and Diagnostic Center in the Department of Professional Services Administration at the University of Missouri.