Engaging behavior

Teresa Pasquini, one of the most influential people involved in the management of Contra Costa County Regional Medical Center, has no training in healthcare, doesn't collect a paycheck from the publicly owned safety net hospital and has a history of animosity toward the local healthcare system.

Yet Pasquini and about 50 other patients or family members of patients have teamed up with the leaders of 166-bed Contra Costa County Regional to give the hospital executives what they previously didn't have or seek out in an extensive way: the voice and point of view of the patient, especially as it concerns how care is delivered by the hospital.

As a result of her efforts as a patient advocate for mental-health patients, including her son, Pasquini was one of the community members asked to participate in an unusual program working alongside executives to improve the hospital's operations. She participates in one of the four formal patient-hospital partnership groups that tackle specific issues in the hospital, in Martinez, Calif., about a 25-mile drive north from Oakland.

The goal of having patients so actively involved at Contra Costa County Regional is to give the hospital's leadership insights it could not get elsewhere. “We can't see what they can see,” says Anna Roth, CEO of Contra Costa County Regional and the executive who pushed for the move to give patients and their families a stronger voice in the healthcare system.

Focus groups and surveys offer an attempt to get the patients' views, but that is not the same as having a patient at your side telling you what it's like, Roth says. “There is no single more powerful way to change than bringing in patients,” Roth says. “We did it because we had to.”

Despite some special challenges they face as government safety net institutions, a growing number of public hospitals like Contra Costa are, in varying degrees, trying to get patients and their families more involved in the care process. In doing so, they are joining a movement found throughout the healthcare system as a whole. “The push is huge,” says Barbara Balik, a senior faculty member for the Institute for Healthcare Improvement and a principal for Common Fire Consulting, which advises provider organizations on clinical quality and safety.

Some of the broader shift is driven by federal healthcare reform, but the patient-engagement effort got a big boost in August when the Gordon and Betty Moore Foundation committed up to $500 million toward a program that seeks to boost meaningful patient and family engagement and assist with the re-engineering of hospital systems and processes, all working toward reducing preventable patient harm to zero.

Officials for the foundation say that while it is generally agreed upon that increased patient and family engagement is a good thing, more needs to be learned about how to increase and measure the success of patient engagement, says Dr. George Bo-Linn, chief program officer for the effort unveiled this year, called the Patient Care Program. Bo-Linn stresses that patient engagement is different from patient satisfaction, and says increased patient engagement might increase satisfaction, but increased satisfaction doesn't mean engagement has increased.

The program intends to place a lot of emphasis on reducing the loss of patient dignity that can accompany a visit to a hospital. “We believe that not meaningfully engaging patients and their families in their own healthcare more often than not results in a loss of dignity and respect,” Bo-Linn says. “We think the loss of dignity and respect is just as an important a harm, just as measurable a harm, as a surgical complication.”

Pasquini wasn't always a friend to Contra Costa County's public hospital for just that reason. She and some other members of the community were fighting for mental-health patients to get the right to go directly to the psychiatric emergency department instead of going to the general ER, as had been the policy years past. “The intent was honorable—they thought they would be able to provide medical assessments better” through the general ER, Pasquini says. Nevertheless, some psychiatric patients did not want to go to the general ER and publicly experience a mental-health episode, and the administration at that time would not budge, she says.

But after Roth took over as hospital CEO in 2009 and established the explicit goal of giving patients a real voice in their care, the change took place and the doors to the psych ER were opened to admitting patients. “The opening of the door was huge; that was a huge accomplishment,” says Pasquini, who now sits on a mental-health partnership group with the hospital and also participates in executive management meetings. “We truly are respected partners.”

Contra Costa's work, which cuts across a number of clinical and administrative lines, has encouraged other public hospitals in the San Francisco Bay area to explore how to boost patient engagement, says Melissa Stafford Jones, president and CEO of the California Association of Public Hospitals and Health Systems. The association has even become involved in the patient-engagement efforts, and recently invited a patient to participate at a board meeting. “I found it to be a very powerful experience,” Stafford Jones says.

In part because of what Contra Costa has accomplished, officials at vertically integrated San Mateo (Calif.) Medical Center concluded that its efforts to make its care more patient-centered should include patients in the design of how it provides care, says Dr. Susan Ehrlich, the 73-bed hospital's CEO. The industry's increasing focus on putting the patient at the center of healthcare is one of the most fundamental changes taking place in the industry, Ehrlich says. “This is one of the most exciting and interesting things we're doing right now,” she says.

As a result, San Mateo has made relatively big changes such as inviting patients to participate in Lean quality-improvement events, and less dramatic ones such as adding family greeters in its psychiatric emergency department, Ehrlich says.

San Mateo has found that sometimes the patients or patient family members complaining the most can offer the greatest insight into areas of operation needing attention. A regular letter-writer often complained about long lines and less-than-friendly staff members at the hospital's pharmacy. After being invited to a quality-improvement meeting, the letter-writer's ideas were incorporated into changes at the pharmacy. “His views and perspectives on the way that we work … have been invaluable,” Ehrlich says.

Officials at 387-bed Alameda County Medical Center, Oakland, Calif., have found that working with patients in healthcare design has opened their eyes to problems that occur when patients must deal with more than one hospital unit, which generally have been managed separately but need to work together.

For example, if physicians go on rounds around 2 p.m., and nurses note an order for a medication around 2:30 p.m., while the discharge pharmacy closes at 3 p.m., by the time the order gets to the pharmacy, there may be difficulty filling the prescription, says Kimberly Horton, chief nurse executive at Alameda. This slows the patient's discharge and may delay another patient from getting an inpatient bed.

“We realize that frequently the experience the patient has is dictated by how well the departments work collaboratively,” which is not always good, Horton says. “We're getting rid of those silos.” Alameda also has created a special team with patients and family members who advise the hospital and participate in Lean quality-improvement projects.

There also are direct financial reasons for hospitals to make it easier for patients and their families to be engaged in their care. The federal standards being used to recognize the meaningful use of electronic health records are ramping up the amount of information that needs to be made available to the patients to qualify for the financial incentives in the second stage of the program.

“Stage 2 really had much more emphasis on patient engagement,” says Dr. Jeff Hummel, medical director for clinical informatics at Qualis Health, a Seattle-based not-for-profit healthcare quality-improvement and consulting group. The final rule for Stage 2 mandates that EHR technology must provide patients with an online means to view, download and transmit selected data.

Alameda County Medical Center and others are including more low-tech approaches to boosting patient engagement. Alameda's heart clinic, where much of its patient-engagement work originated, has patient navigators to assist patients in coordinating their care through a self-funded pilot, and the hospital has partnered with community groups to try to perform follow-up care with homeless patients, Horton says.

She says that the fact that their often uninsured patients delay care and may not get a lot of primary-care services means patients tend to be sicker, which complicates patient-engagement efforts that take place early on in the care process. As a result, the medical center promotes its engagement efforts at times when patients are better able to absorb information, after they've been treated.

Public hospitals also face a different set of challenges than do private hospitals in boosting engagement among patients and their families. “A public hospital may face more difficulties,” given they often are struggling financially, their patients may not have the level of social and economic resources as patients at private hospitals have, Bo-Linn says. And the generally greater level of diversity can create social and language barriers to engagement, he adds.

“Nonetheless, even with those challenges there is nothing to suggest … that public hospitals should be less dedicated to patient and family engagement,” and one can argue that they should be more engaged, he says.

San Mateo's Ehrlich echoes that, saying that “public hospitals need to be held to the highest standard” for taking care of their safety net patient population. “We have to be judicious stewards of their care.”

At 469-bed Hennepin County Medical Center in Minneapolis, executives are working to transform the care processes. Caregivers attend hospital-sponsored events in which physicians and staff sit down for a day to hear stories told by patients and family members about the care they've received. The events include three patient panels, one of which is composed of hospital employees who have been patients.

“They tell us the good, the bad and the ugly,” says Kathy Wilde, chief nursing officer. All physicians and staff are required to attend one of the meetings, which in total are estimated to eventually cost $1.7 million to conduct, Hennepin officials say.

Yet Hennepin's progress as measured by improvement in patient-satisfaction scores has not been as good as hoped, Wilde says. Hennepin's status as an academic medical center has made it tougher, she says. The teaching environment makes it more difficult to always put the patient first, but Hennepin is moving in the right direction, she says. For example, the hospital is shifting multidisciplinary rounding so that patients can learn more about their care.

Wilde's colleague, Sheila Moroney, director of patient experience services and patient and family-centered care, says that Hennepin officials expect the move toward more patient-engaged care will pay off to the degree they want, but notes that improving the patient experience can be more difficult at a safety net hospital, given its role and patient population.

“It's not the same as delivering (care) through a suburban … hospital with a waterfall in the lobby,” she says.

Moreover, often overburdened staffers and physicians at public hospitals might not be receptive to changes that at least in the short term will make their job harder. “It's a tougher work environment,” says Dr. M. Bridget Duffy, CEO of ExperiaHealth, a patient-experience consultancy based in San Francisco. “My heart goes out to the people in the trenches at public hospitals,” Duffy says.

UC Davis Medical Center, Sacramento, has turned what was once considered a portent of doom for nurses—the arrival of a patient-relations official on a floor—into an event that now might be welcomed by patients and staffers, says Cheryl Clyburn, manager of patient relations at the 563-bed hospital.

The patient-relations official meets with the patients not to survey them, but to make sure their needs are being met and they have the information they need. At first, nurses did not appreciate the visits but now are more inviting, Clyburn says. Some floor nurses will even encourage a visit for certain patients if they see a need, she says. Key to the success of that effort is finding a person who can relate to patients and the staff members, she says.

Contra Costa's Roth says that getting hospital staff and physicians to go along with its somewhat drastic patient-engagement changes has been a relatively smooth process. “It wasn't as tough a sell as people might think,” she says. “It does help that the CEO is strongly on board.”

And Roth expects the process to continue even if she were to leave the medical center. “This is a key strategy,” she says. “It's not my strategy, it's our strategy.”

TAKEAWAY: Safety net hospitals are getting patients and their families more engaged in the care process and in healthcare design.