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Bridging the Diversity Canyon: Your next level of patient experience depends on it
There is an opportunity in healthcare to deliver equitable care to demographically different populations by gaining an understanding of their specific needs.
When cultural and social challenges exist in healthcare, bridging the diversity gap can be realized through effective communication and advocacy.
Engaging patients, families and caregivers in the opportunity for improvement can result in outcomes that significantly impact an organization’s performance.
Experience Framework Alignment
Culture and Leadership
Patient, Family & Community Engagement
Staff & Provider Engagement
Quality & Clinical Excellence
About this Case
Inova is Northern Virginia’s leading nonprofit healthcare provider, recognized in 2019 by U.S. News & World Report which named Inova Fairfax Medical Campus the #1 hospital in the Washington, DC region for the fifth time. Inova’s region and community is a cultural and linguistic melting pot of residents, workers, and visitors. Demographically, 51.2% of residents are white, leaving 48.8% of residents non-white or bi-racial, with the top minority populations being Asian, Hispanic, Middle Eastern, African, and Black.
For 16 years, the Agency for Healthcare Research and Quality (AHRQ) has reported on healthcare quality and disparities. The annual National Healthcare Quality and Disparities Report is mandated by Congress to provide a comprehensive overview of the quality of healthcare received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. This case study proves that when the proper approach to highly effective communication and advocacy is implemented, there are positive outcomes that can significantly impact an organization’s performance around safe care, quality care, and patient centered care. And, although metrics are improving year after year, miscommunication or misunderstanding of medical information continues to result in thousands of lives lost and millions of dollars expended in lawsuits annually.
This case study is a culmination of observations at several hospitals with various demographic profiles. The opportunity for this initiative presented itself at a healthcare facility not associated with Inova, yet it shared very similar demographic challenges, as the two entities are located within the same Northern Virginia region. The one constant is that a multitude of cultures and varying degrees of socio-economic conditions are prevalent across the country and around the world.
What was the opportunity, issue or challenge being addressed?
Unlike a scheduled surgical or procedural patient, or a pregnant woman expecting a baby, it is the population classified as “Medicine patients” at Inova Health who often find themselves in a different realm of care. The vast majority of these patients are unplanned admissions who enter the inpatient world via Emergency Departments; many are very complicated patients with a history of complex medical issues. It is this complicated, unplanned, “don’t want to be here in the first place” patient that proves to be the most challenging. Yet, we take on this challenge as healthcare professionals to provide the best care and outcomes possible.
In direct alignment with safe, high quality, and patient-centric care, highly effective communication is the foundation for superior care delivery outcomes. However, when taking language, culture, and socio-economic variances into account, there can be a huge disconnect, which can lead to medical errors, confusion, implicit biases, and sometimes intentional disparities in care. It is the organization’s responsibility to provide diverse cultural, linguistic, and essential social initiatives that will enhance effective communication and understanding, thereby reducing or eliminating confusion, and ultimately improving the safe delivery of care, which leads to successful patient outcomes and experiences.
What specific steps did you take to address the problem?
We followed the below steps to create personal connections with patients through welcoming, attentive, person-centric encounters.
Step 1 - Provided and presented data trends to the hospital Administrative Leadership team so as to clearly illustrate the need for a change in our approach toward improving overall Quality, Safety, and Patient Experience. Through our presentations, we displayed the confidence and willingness to turn around the poorest performing unit within the entire multi-hospital system. The baseline metrics were a combination of HCAHPS (Patient Experience) results, Nurse satisfaction, and Hospitalist feedback.
Step 2 – Established understanding among C-suite Leaders that one singular approach does not fit all when providing care and services in a regional melting pot. There are too many mitigating factors among varied patient populations that prohibit the ability to implement a homogenous program. In order to realize improvements among this most challenging population, WE HAD TO GET OUT OF OUR BOX!!
Step 3 - Suggested a small test of change involving the introduction and implementation of a totally new and unique combined approach to enhancing the patient/physician/nurse experience for the purpose of improved outcomes. This approach involved a newly created role combining two distinctively different existing positions.
NOTE: The position purposely did not involve clinicians but did require baseline knowledge of medical terminology and understanding of healthcare processes both inside and outside of a facility.
Step 4 – Identified SMART Goals, i.e., Specific/Agreed upon – Measurable –Attainable – Relevant – Time Based
A. Improve patient understanding of care being rendered, physician communication, nurse communication, and understanding of medication/medication side effects (Multiple survey results)
B. Improve physician satisfaction through enhanced communication (Survey Monkey)
C. Improve nurse satisfaction through enhanced communication and support to support additional understanding by the patient (Survey Monkey)
What outcomes were you looking to achieve?
The plan involved implementing a cost-neutral initiative to improve several aspects of the Patient Experience, along with improved nurse and physician satisfaction by bridging communication and understanding the gaps of our complicated, linguistic and socio-economically-challenged patient population. Of equal importance was to maintain positive outcomes for our perceived less-challenged patient population, who typically possess even higher expectations.
What process was used to develop a solution?
The foundation of this study was based upon community demographics, organizational complaints and grievances, and Patient Experience results. Through the compilation of data and feedback, we identified the missing link needed to improve Patient Experience (HCAHPS) outcomes among the most challenging of patient populations. We collated patient feedback as well as interviewed nurses, techs, care coordinators, and physicians. Each vantage point provided insight through different lenses into the multi-disciplinary challenges encountered.
What resources, if any, did you engage to address the problem?
This study involved the use of two individuals who possessed the capacity and ability to expand their existing roles and become that of a Patient Navigator, one who helps guide one’s hospital journey across the continuum of care, and a Patient Advocate, one who supports, promotes, defends, or maintains the all-important interests of patients. Cross-training of these individuals in each other’s responsibilities created the new position of the Patient Advi-gator and the Patient Advo-gator resulting in “the bridge” to support, promote, defend, or maintain the interests of patients while helping to guide one’s hospital journey. For the test period, the Advi-gator and the Advo-gator each worked ten-hour shifts for a combined seven days per week coverage (1.75 FTEs).
The person in the Advi-gator and Advo-gator roles is a service excellence expert who possesses strong analytical and conflict resolution skills to ensure open communication between patients, families and the caregiving team. Each position:
- Provided direct communication and support upon arrival through discharge as part of a coordinated, consistent and empathetic setting for the patient.
- Sought to represent the patient's voice, work with multiple units and teams, and was available to patients as a resource to assure patient understanding and comfort.
- Anticipated patient needs; provided support & advocacy; facilitated communications between patients & staff; provided on-the-spot "service recovery" and served to trouble-shoot when challenges arose.
- Offered input into patient experience and organizational processes as well as advocates for patient and family needs by sharing the health care experience with care providers.
- Became a partner in patient-related projects aimed at improving hospital services; reviewed and provided feedback on patient education materials and communication.
- Required being a Qualified Medical Interpreter (Spanish), to provide real-time interpretation for Providers.
What was the ultimate outcome of your effort?
The baseline measurement period was eight months, January thru August 2017, compared to our intervention period of 4 months, September thru December 2017. The overall Patient Experience HCAHPS survey results revealed improvements in 18 of 22 questions asked of patients (82%).
Individual question results ranged from .5% to 15.9% with an overall average of >5.0% Top Box scores above baseline data.
Notable dimensions of improvement included: Understanding of medications and their side-effects, overall responsiveness, physician courtesy and respect, and both nurse and physician explanations of care.
Survey Monkey results showed that 88% of nurses were either satisfied or very satisfied, and 4% were dissatisfied with the intervention and subsequent outcomes.
Of physicians polled through Survey Monkey, 82% indicated that the program helped provide much better service to their patients, thereby resulting in their own personal satisfaction with the outcomes.
What lessons would you share with others addressing a similar issue?
- Understand your community demographics and collect accurate data accordingly. Quality, safe, and patient- centric care are relatively prescriptive, not individualized. You cannot place demographically diverse patient populations in the same box and expect experiential improvements across the board. As you chase excellence in the world of Patient Experience, it will be your ability and willingness to adapt to the variations of your patient populations that will take you from good to great!
- Listen to every level of your organization, as critical insight can be acquired through those who are a true reflection of your community (your primary service area).
- Remember, seek first to understand; our patients are as different as they are alike. It is incumbent upon us as healthcare providers to improve population health within the communities we serve by building bridges.
For more information contact:
Leon Ransome, Patient Experience Leader
Inova Fairfax Medical Center