Customer satisfaction rises with new teams
Here’s how functional improvement approach works
Huron Valley Visiting Nurses of Ann Arbor, MI, took no short cuts when it came to improving its quality and processes, but the agency’s year-long functional improvement team approach is beginning to pay off.One sign of Huron Valley’s success is the consistent improvement in customer satisfaction scores over the past year. In the first quarter of 1996, various elements on the patient satisfaction survey ranked from 67% to 100%. The four following areas were below the agency’s performance goal of 90%:
• how clearly patients were told how payment was made;
• how well nurses explained patients’ medication regime and drug interactions;
• how clearly staff explained when they’d be discharged;
• how easy it was for patients to reach staff between visits.
Once those areas were identified, the functional improvement teams began addressing them in the first quarter of 1996. Patient satisfaction scores in all four areas increased to over 90% by the fourth quarter. (See related story on how to set up functional improvement teams, p. 57.)
Here’s how the agency used the team approach to improve its patient satisfaction scores:
1. Huron Valley adopted the J. Edwards Deming model of total quality improvement, and formed teams to parallel the 11 functional improvement areas of the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL.
"The first thing we did, about a year ago, was to completely redesign our whole quality management program. We implemented a quality council and functional improvement teams," says Susan Johnson, acting director of quality management of the private, nonprofit agency, which serves southeast Michigan and parts of Ohio.
"We discovered we’re too small an agency to support 11 different teams and a quality council, so we looked at consolidating them and we now have five groups in our quality structure," Johnson explains. The five groups are: the quality council; rights and ethics; coordination and utilization; care planning and provision; and environment and education. Each group’s team members include corporate employees, managers, and field staff. The teams range in size from five to 13 employees. Some teams have asked outside experts to join. (See story on functional improvement groups, p. 58.)
2. The teams looked at the four areas that were rated low on the patient satisfaction survey, and each brainstormed to come up with ways to improve these processes.
Each area that needed improvement was addressed as follows:
— How patients were told about payment. "In the past, when the nurse opened a patient’s case, the nurse told the patient about how payment was going to be made," Johnson says.
But this sometimes led to confusion. For example, the patient might be unable to concentrate because he or she was still weak and had just returned home from the hospital. Or maybe the nurse didn’t know what the patient’s insurance would pay because the first visit was made on the weekend.
The team that examined this area decided the solution would be to develop a form that nurses could take to each patient when they opened a case. The form clearly states what services and disciplines were ordered by the physician, including frequency of visits and cost of services.
The form also gives the amount of payment authorized by the HMO or insurance company. If the patient was admitted on a weekend and the agency hadn’t been able to contact the insurance company, then the form would let the patient know what the insurer might pay for this type of treatment and how much money the patient might be responsible for paying.
"According to the Joint Commission, we have to give them a worst-case scenario in these instances," Johnson says.
Now that patients can refer to the written form, they report that they understand payment issues better, she adds.
— How nurses have explained patients’ medications and drug interactions. The care planning team told nurses during staff meetings that there was a problem with teaching patients about medication, and the team wanted the nurses’ input on how to solve it.
Using the nurses’ suggestions, the team decided to use drug profiles provided by a new software program recently purchased by Huron Valley as a basis for in-home education. The profile printouts resemble the medication sheets a customer receives when purchasing drugs from some pharmacies. The medication printout is given to the patient, and a copy is placed in the patient’s clinical record.
Finally, the team held an inservice to show nurses the new method of teaching patients based on the printout.
Again, Huron Valley’s surveys showed that patients understood their medications better after the team’s changes.
— How nurses explained the way a patient would be discharged. The problem here was that patients were having trouble understanding the discharge process. This was partly because the process was changing as payers became increasingly involved with decisions about when patients should be discharged. Sometimes the patient would have a last visit with a nurse before the nurse knew it was the last visit.
The care planning team suggested that nurses begin discussing discharge with patients earlier in the home care visits. Also, a patient handout listing support groups and community alternatives to follow-up care was developed. It reminds patients to see their physicians and go back to the clinic for follow-up visits, Johnson explains.
— How easily patients could reach staff between visits. When the agency learned patients were having problems in this area, it polled other customers and received similar feedback.
One reason for the problems was that the agency received more telephone calls as its visits doubled over a two-year period. Also, all the agency’s incoming calls were answered by a front-desk receptionist, who then transferred callers to someone in the agency or to voice mail.
Solving problems without spending money
The quality council decided to find ways to improve telephone communication without purchasing a larger system, because that wasn’t an immediate option. The team brainstormed and came up with some solutions.First, the team had existing phone numbers in the agency’s system assigned to specific customer groups so many calls could bypass the front desk.
Next, each customer group was shown the most efficient way to contact the office. For example, discharge planners were reminded to use the central intake number, and staff were given a direct line into the scheduling office.
Also, staff were asked to give patients more specific details on how to reach them between visits.
As a result, the number of calls coming into the front desk declined within weeks. This made it easier for the receptionist to manage incoming patient calls. Patient satisfaction improved, as well.
3. The team improved the agency’s cumbersome customer satisfaction survey.
The agency had been surveying patients for five or six years, sometimes with one division using a written survey and another using a telephone survey. Although the information was good, Johnson says, the team decided to make the information consistent and comparable across the agency. Also, the agency desired a higher response rate.
"That 21¼2-page survey looked great with wonderful questions, but patients wouldn’t send it back to us so it didn’t work," Johnson says.
The team decided the questions were the chief problem. Some were so complicated that even the staff couldn’t answer them confidently, Johnson says. One of these questions asked the patient: "How do you rate the efficacy of the care you were given?"
"Even staff had philosophical discussions about what efficacy’ meant," Johnson says.
First, the agency met with a statistician from the University of Michigan Health System, who specializes in surveys. That resulted in a six-page survey that even fewer patients returned. Then they held focus groups with patients, who said the forms were too long and no one would take that much time to fill them out.
So the team brainstormed on how to develop a one-page form that could be completed in five minutes or less. They developed and tested one form; when it didn’t work, they developed and tested another one.
"We asked ourselves, What do we want to know?’ and How do we ask it in a way that people will respond?’" Johnson says.
The team finally focused on the basics of home care, and on confirming that the agency was in compliance with Joint Commission standards. The new survey asked simple questions about the staff, including whether the staff acted professionally, arrived on time, and explained how payment was to be made. (See Huron Valley patient satisfaction survey, inserted in this issue.)
The survey’s return rate was 10% before the team changed the form; then it fell to 8% with the longer version. The return rate rose to about 40% after the one-page survey was used.
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