ProvenCare

by Glenn D Steele

  GEISINGER CARESITE SPECIALTY PHARMACY

  ProvenCare Biologics reengineering includes a more formalized use of indications and treatment protocols, redesign of accountabilities in the treatment transaction, and the reporting of treatment adherence, as well as a change in location of the actual treatment itself. This is more convenient for our patients, as opposed to treatment being provided in individual specialty or subspecialty doctors’ offices. We are able to utilize Geisinger’s CareSite specialty pharmacies, in various locations throughout our geography, which has worked very well. A summary of the effects of reengineering and relocating the biologic treatments is detailed in Figure 11.7.

  FIGURE 11.7 CareSite Specialty Pharmacy (dollars in 1,000s)

  LESSONS LEARNED

  • Overuse of biological medications causes unjustified financial and clinical ill consequences.

  • Reengineering of biologics usage can be done to the benefit of patients.

  • You must redefine indications, application, accountability, and patient and family input to optimize the use of biologicals.

  • The process is dynamic and iterative and takes advantage of a changing knowledge base.

  • Changes must be made regarding who is accountable for the treatment, how it is managed, and where it is given.

  • As is the case with all of our reengineering and innovation, patient and physician satisfaction is key to success.

  12

  ProvenExperience

  Six-year-old Maddy is a fan of Elsa, the queen in Disney’s animated film Frozen. When Maddy was admitted to Geisinger’s Janet Weis Children’s Hospital, it was Elsa who helped make her feel better. Maddy’s concerned father, James, a member of the armed services and unable to be at her side, wanted to do something special. “Could the character Elsa from Frozen visit Maddy?” he asked his friend Tiffany Noll, nurse team leader for Geisinger’s Mountain Top outpatient clinic. She immediately knew who could help: her friend Kim Duffy, operations manager of the children’s hospital.

  Kim just happened to have an Elsa costume from the previous Halloween. Donning it the next morning and braiding her long blond hair to be fully in character, she was at Maddy’s bedside when she awoke. Mother Nature contributed to the surprise: it snowed overnight. Maddy’s favorite Disney character brought a message of cheer from her Daddy: “He wanted you to know what a special little girl you are and how much he loves and misses you. Look! There’s snow outside, just for you.”

  This is the essence of Geisinger ProvenExperience: treating patients like family, empathizing that they are in a tough situation, and doing our best to make it easier for them. We endeavor to do this for all patients, 100 percent of the time, and offer a money-back guarantee when we fall short.

  Before Dr. David Feinberg officially started as CEO in May 2015, he spent a month visiting every Geisinger clinic and hospital, meeting with patients such as Maddy and staff and team members such as Tiffany Noll and Kim Duffy. He also visited patients in their homes and continues to do so regularly.

  As he sat on patients’ beds and asked about their care, he learned that people had mixed feelings about Geisinger. Patients were thrilled beyond belief that they had such great medical care in their part of the country, but they said there was still much we could do to help them to get better.

  They told us that it was loud in the hospital at night, which disturbed their rest and recuperation. In addition, patients were confused about their care when transitioning from the hospital to skilled nursing facilities or their homes.

  Patients endured a lot of waiting. It could take weeks to get an appointment, and the scheduling process itself was daunting. They observed that our physician office hours were not especially convenient for people working or going to school. Parking structures and buildings were difficult to navigate. Patients didn’t understand their bills.

  Although well-intentioned, employees were not uniformly friendly, nice, or caring. Patients wanted our healers to listen better, understand their situations, and partner with them to come up with a plan for their care. They often were bothered more about the process of care than their diagnosis.

  Geisinger patients are very trusting of their healthcare provider. Much of our service area is rural and small-town U.S.A., with hardworking and family-oriented citizens who know and care about one another and have a true sense of community. In his regular rounding on patients in their homes, Dr. Feinberg has checked on an elderly woman injured chasing away a bear who stole a freezer off her porch. He’s visited a man receiving in-home infusion for cancer treatment who likes to watch TV, but limits how much because of the cost of electricity. When we recently built a four-story parking garage, which is free of charge, patients avoided it because they didn’t know how to use it, so we positioned staff in the garage to help them understand how to navigate it.

  Patients were accustomed to restricted access to care because of geography. Remarkably, they were content to wait until we could see them. And they would wait weeks for an appointment with us rather than drive two hours to Philadelphia to be seen more quickly. We were providing incredibly high-quality care for this trusting community, but we were not always easily accessible and not consistently compassionate.

  For nearly 15 years, Geisinger reengineered our processes to achieve world-class care, quality, safety, and value. Every aspect of this effort began by asking how patients’ outcomes were to be improved, and we often included input from patients and their families in the care redesign. Our strategy was to take as much care as possible out to where our patients lived and worked, and even out of the doctors’ offices and into our patients’ homes, so we could provide the right care at the right time in the right place.

  As we built our ProvenCare portfolio, the capacity for our service lines to do everything to which they aspired often pushed them against the boundaries of their capability. We always were concerned that too much innovation might diminish the all-important provider/patient interaction, and we viewed decreased patient satisfaction as the first warning signal. Rapid expansion through merger and acquisition made this challenge even more formidable, as we blended people and organizational cultures. While we kept our focus on our patients and their families, we were only partially successful in mitigating our over-aspiration and continuing to achieve the highest levels of patient satisfaction.

  Now with many ProvenCare services in place, we are building on our innovation energies and our intention by elevating the patient experience to historic levels. We are applying Geisinger’s renowned ProvenCare model and methodology, perfected over years of development and experience, to the patient satisfaction issues of responsiveness and compassion. The goal is to offer the high-quality, high-value, safe care for which Geisinger is famous in a more culturally sensitive, compassionate, private, connected human way patients don’t expect. We will not settle to be simply the best in the healthcare industry. Geisinger won’t rest until all patients are satisfied 100 percent of the time, and we have the best customer service in any industry.

  PROVENEXPERIENCE BEST PRACTICES

  There’s a long history of patient-experience initiatives at Geisinger that foreshadowed the launch of ProvenExperience in late 2015. For example, for 20 years, we’ve been surveying patient satisfaction, learning from that feedback, and teaching professionalism to all new staff members, programs spearheaded by Victor J. Marks when he was director of dermatology. Since around 2000, all Geisinger physicians and advanced practitioners have participated in a four-hour course covering one-on-one patient communication skills. Medical residents work with actors posing as patients to practice skills and learn how to handle communication challenges.

  In 2014, Dr. Steele named internal medicine associate Greg F. Burke and chief nursing officer Susan M. Robel chief patient experience officers. Geisinger needed to get the entire organization on board to recapture the more patient-centric feeling present when the system had just two hospitals. The goal: to do things right for patient
s and treat them like family all the time.

  A systemwide Patient Experience Steering Committee, broadly reflective of key caregivers and geographies, was formed to develop Geisinger’s standards for the patient experience. We used the acronym ABIGAIL, a touchstone to founder Abigail Geisinger, to reintroduce the patient experience mission and establish behavioral standards or expectations: Accountable, Befriend, Inform, Genuine, Acknowledge, Involve, and Listen. (See Figure 12.1.) Because employees and their families are also patients, they strongly connect with Mrs. Geisinger’s “Make my hospital right, make it the best” admonition to her founding medical director. Some 99.7 percent of all physicians and most staff completed the initial ABIGAIL training, and all new employees complete online training and are required to agree to adhere to the standards.

  FIGURE 12.1 ABIGAIL Standards

  From involvement in developing the ProvenCare lumbar spine surgery procedure, Dr. Burke had nurtured the idea to “Geisinger-ize” the patient experience, to establish a level of service guaranteed to meet a rigorous set of patient-experience best practices. We would eliminate variation and make it happen every time. We would certify patient satisfaction, just as certain medical procedures and services are under the ProvenCare model, and call it ProvenExperience. The idea gained momentum with Dr. Feinberg’s arrival in mid-2015, when he further challenged the organization to a money-back commitment: patients unhappy with a service or procedure could request reimbursement of all or part of their copay.

  We identified best practices for broad implementation, starting in late 2015:

  • Consistent patient communication, using the C.I.CARE (pronounced see-I-care) communication framework

  • Transparency in reporting quality metrics

  • Leadership rounding

  • A consistent professional appearance

  • Bedside shift report, hourly rounding, and whiteboards in hospital rooms to improve communication and service

  • Calls the night before surgery and patient rounding on demand

  • Transition to home care

  • Same-day appointments with phones answered by human beings

  • Notes pushed to the patient

  • A redesigned, easy-to-understand bill

  • Standardized continuous service recovery

  Many healthcare systems select one or two patient-experience best practices to implement, but Geisinger is endeavoring to make them all happen every time with every patient. Implementation is under way on each campus across the system.

  The C.I.CARE Patient Communication Framework

  Geisinger is implementing the C.I.CARE communication framework, developed at UCLA Health and now used at Stanford Medicine and other healthcare systems. The framework is designed to ensure consistent employee communication with patients and colleagues. The C.I.CARE acronym stands for:

  • Connect with the patient or family member using Mr./Ms. or the preferred name.

  • Introduce yourself and your role.

  • Communicate what you are going to do, how it will affect the patient, and other needed information.

  • Ask and Anticipate patient and/or family needs, questions, or concerns.

  • Respond to patient and/or family questions and requests with immediacy.

  • End with Excellence, courteously explaining what will come next or when you will return.

  C.I.CARE reflects a broad set of communication actions that everyone throughout the organization can practice, from dietary and housekeeping workers to administration and volunteers, as well as clinical healers. We expect each employee to use C.I.CARE in every interaction throughout Geisinger, in person and on the phone.

  This communications framework was operationalized with a broad, systematic rollout as a major training process in every level of the organization. All 30,000 employees received training from their leaders and completed an online course. C.I.CARE was established as a competency, just as cleaning an IV or inserting a catheter are for nurses. Crucial for follow-up and reinforcing this approach, we created a tool for leaders or peers to observe others and document whether and how the behaviors are being performed.

  Transparency in Reporting Quality Metrics

  Geisinger is among the first dozen U.S. health systems to be transparent about caregiver ratings. Geisinger patients searching for caregivers on our website will find that their profiles show patient satisfaction scores and patient comments. The patient satisfaction rating is an average of all responses on the nationally recognized 10-question Press Ganey Patient Satisfaction Survey.1 Responses are measured on a scale of 1 to 5, with 5 being best.

  Press Ganey randomly selects patients seen at Geisinger outpatient clinics to receive a survey, sent via U.S. mail or e-mail within a few weeks of appointments. We receive more than 165,000 survey responses annually, a response rate of around 18 percent. We share the ratings on our website to help patients and families make informed decisions about healers, and we use the data for continuous improvement in patient care and for constructive feedback to healers and staff.

  Ratings are updated monthly, and comments are posted weekly, with a one-year archive. We post both positive and negative comments, but remove offensive, abusive, or malicious language; names or detailed information that jeopardize patient confidentiality or privacy; and comments exclusively about other clinicians. Only about 2 percent of comments are not displayed. Patients may also request to remove a comment.

  In addition, we do not display ratings or comments for clinicians with fewer than 40 survey responses, due to lack of statistical validity. Transparency currently is available only for outpatient clinic healers. In addition, we don’t survey the experiences of patients seeing nonemployed Geisinger clinicians, residents, and fellows.

  Future improvements may include enabling our healers to respond to a comment and innovative psychoanalytic tools to more closely match healer and patient compatibility.

  Leadership Rounding

  Geisinger instituted consistent, coordinated leadership rounding in 2015. Between 20 and 150 leaders representing administrative and clinical departments and the Geisinger board of directors meet monthly on each campus for several hours. They fan out to visit inpatients on units other than their own, knocking on doors, washing their hands, and asking about the care. They address anything that needs immediate attention, and treat the patients as they would their own family member, correcting food delivered in error, getting a pillow, or helping a patient to the bathroom.

  During one early leadership round, for example, Joi Siebecker, medical-surgical operations manager, and Angelo Venditti, chief nursing officer, discovered that one floor of Geisinger Community Medical Center in Scranton lacked sufficient thermometers, so they went to a local CVS Pharmacy, purchased seven, and had them in clinical staff hands within 30 minutes.

  The leaders also find out what is going well and convey the appropriate compliment, plus go upstream with a thank you, for example, to the person who hired the nurse and the unit IT and facility managers who support the nurse’s work.

  Regrouping to debrief, the leaders share both the positive and the negative. We assign ownership for addressing systemic issues and report on follow-up items from prior rounds.

  An unprecedented simultaneous rounding episode at all 11 hospitals in late 2015 connected leaders by live videoconference. Deemed “the largest leadership rounding taking place in America,” more than 500 executives from across Geisinger gathered at their respective hospitals, simultaneously embarking on a walking tour to engage patients and caregivers and listen to their praise and concerns. The assignment was to fix anything they could and to take care of issues right then.

  A Consistent Professional Appearance

  To ensure that patients can identify various team members and their roles readily, Geisinger has enacted a new professional appearance policy. Starting January 1, 2016, all 3,000-plus registered nurses wear pewter-colored uniforms displaying an embroidered Geisinger logo, along wit
h a newly designed name tag spelling out “registered nurse,” as patients don’t always know what R.N. means.

  The neutral pewter, or dark gray, uniform color existed at a hospital joining the Geisinger system in 2015 and is appropriate for both male and female nurses. The pewter scrubs may be worn with an alternative color, such as white pants. A more pediatric-friendly secondary color, ceil blue, is worn instead of white by healers working with children.

  Geisinger works with one supplier to size and provide the uniforms to nurses in various styles of their choice. Financial support of $150 was granted to each nurse, sufficient to purchase a week’s supply of uniforms, and supplier discounts help with subsequent purchases.

  Studies show that patients associate clean, well-pressed white lab coats with professionalism in physicians. Geisinger supplies and encourages all doctors, physician assistants, and nurse practitioners to wear white coats when interacting with patients. Underneath, we ask our healers to dress as if presenting for a job interview. We view that medicine is not a casual business, so dress should not be casual.