The Patient and Consumer Experience—The Core and Progress Duality for Successful and Sustainable Transformation

J Clin Pathways. 2022;8(2):20-25. doi:10.25720/jcp.2022.03.3

Over the last decade, healthcare costs have continued to rise in the United States while outcomes have been stagnant and, in some cases, declined. The idea that the patient and consumer experience (PCE) improves patient outcomes and drives revenue has motivated hospital systems, pharmaceutical companies, PBMs, pharmacies, payers, and government decision makers to develop strategies around patient- or consumer-driven care. However, implementation has been a struggle as stakeholders try to define, measure, and improve the patient experience. In fact, measurement instruments have created angst in the medical community as their results have been linked to compensation, and individual practitioners feel helpless to improve them. This article proposes a vision for the future of the patient/consumer experience and can serve as a blueprint for organizations to develop and implement a strategy that is not only effective but also aligns with the values of their organizations and communities.  

The Agency for Healthcare Research and Quality defines the PCE as the range of interactions that patients and consumers have with the healthcare system. This can range from their care and interactions with doctors, nurses, team members, and staff in the healthcare system, physician practices, other healthcare facilities, and their health plans, to an increased focus on wellness, prevention, and health, virtually or in person. It also includes several aspects of healthcare delivery that patients and consumers value highly when they seek and receive care, such as getting timely appointments, easy access to information, and good communication with healthcare providers.¹ Therefore, a wide array of individual and systems level structures affect the patient experience, all of which must be addressed to create an impact.

For many consumers and patients, accessing the fragmented healthcare system causes confusion, from the opaque costs of services and treatments to complicated insurance designs, leaving many dissatisfied with the system and reporting poor experiences. Overall, health systems have generally lagged behind other industries in the area of the consumer experience. In 2018, health plans had a net promoter score (a widely used measure of customer satisfaction) of 19%, 6 percentage points lower than every other business sector except for utilities.² Also, studies are now showing the consistent positive associations between the patient experience and health outcomes, with satisfied members five times more likely to renew their health insurance coverage than their unsatisfied peers.^3-5

In 2020, two events further contributed to the accelerated need to address PCE efforts in healthcare. The first was the COVID-19 pandemic, which highlighted the impact of inequitable experiences and the resultant adverse impact on patient and consumer outcomes.⁶ The second was the Centers for Medicare & Medicaid Services (CMS) ruling, consistent with other recent, consumer-centric regulatory changes to Medicare Advantage (MA) plans. CMS is elevating the role of the customer experience in evaluating MA plan quality scores, by increasing the customer experience–related metrics from 32% of the total weight in 2020 to 57% by 2023, hence making the customer experience an imperative for many health systems and plans moving forward.⁷ 

Clearly, health systems have not been very successful at improving the patient experience but are increasingly exploring numerous ways to improve and transform the PCE in healthcare. How can the healthcare system pivot to be more effective in this quest to transform the PCE? According to Jim Collins, the author of the famous leadership book Built to Last, enduring and great (and transformative) organizations exhibit a dynamic duality. On the one hand, they have a set of timeless core values and purpose that remain constant over time and provide the organization with continuity and stability; and on the other hand, these organizations have a relentless drive for progress guided by their values and purpose — for continuous change, improvement, innovation, and renewal.⁸ This duality can be summed up as, preserve the core and stimulate progress and can serve as a framework for organizations to successfully improve, scale, and sustain the PCE transformation within an organization.

Preserve the Core and Stimulate Progress to Transform the Patient and Consumer experience

In efforts to further improve and eventually transform the PCE in healthcare, many organizations are investing heavily in tools and practices such as technology, performance improvement processes, more meaningful patient reported measurements, and policies, to name a few, while others are looking to learn from nonhealthcare industries that have transformed the patient experience into multi-billion dollar industries. Many others are focusing on the basic purpose of healthcare by strengthening teams through revisiting their core values and focusing on a noble cause such as the patient experience.⁹ And yet, others are working to combine various PCE tactics and strategies to achieve the needed improvements and transformation. As organizations move forward with their quest to transform, adopting the duality of core values and progress may be the leverage for success in deciding how to get from where they are now to their preferred PCE future.¹⁰ 

Preserve the Core: Purpose of Healthcare—Healing and Wellness 

This quote by Jason A. Wolf reflects a core purpose for the existence of healthcare organizations—healing and well-being—the healing care patients are fundamentally looking for each and every time they encounter the healthcare system and personnel. Technology, refined processes, facilitation policies, and accountability measures are essential but cannot improve the patient experience alone, no more than a hammer can make a king’s chair without the skills and craftmanship of the carpenter. When patients encounter the healthcare system, at the most basic level, they are in need of empathy and compassion, patience, active listening, and respect. They are looking for that relationship and human connection as we work to improve their health conditions. According to Dr. David Feinberg, CEO of Cerner Corporation, “keeping people healthy is about a focus on well-being, around changing the systems and structures of health and about access and affordability to care and services that can impact longer term care issues. If we separate out social determinants of health or population issues as something else we do outside of caring and the experience we provide we minimize voices, we shrink the possibilities of experience and we limit the ultimate capacity of care.”¹¹

Stimulating Progress: Tools to Improve the Patient Experience

DD is a 48-year-old woman with diabetes and hypertension who has just signed up with a virtual-first integrated healthcare system. The “front door” for her nonemergent care is digital and effectively provides the timely and accessible care she needs, ranging from a video visit or phone call to an in-person doctor visit. The cost of her treatments, procedures, prescription options, and lab work, including copays and coinsurances, are transparent and visible to her on her healthcare app, prior to her receipt and agreement to nonemergent care. The daily monitoring of her blood sugar, blood pressure, as well as her preventative care, medication monitoring, and diabetes outcomes are all done leveraging wearables and other remote tools from the comfort of her own home or site of choice, supported by an around-the-clock digital community of care coaches and providers. She is able to see her metrics in an easily digestible format whenever she chooses, and she is alerted to any changes in trends, positive or negative, to motivate behavior change. Her treatments and lab work can be administered at a site no more than 5 miles from her house, and her prescriptions, either 30 or 90 day, are delivered via mail from the retail pharmacy in her local town. DD also has the choice to be connected with her healthcare team 24/7 or be completely disconnected, but knowing that her digital team has her back allows her to have peace of mind. 

DD’s nonemergent care leveraging technology for a more seamless and convenient experience is increasingly becoming a component of healthcare as organizations invest in tools and practices to improve the PCE. In the technology sector, health systems and new healthcare entrants are implementing virtual and digital initiatives to change consumer expectations and patient experiences around their health and healthcare, including where, when, and how to access the healthcare system. Telehealth, virtual care, and wearables have been seen as critical enablers contributing to the improvement of care coordination, connectivity, and patient empowerment, engagement, and experience. Other entities are leveraging technology to empower patients around self-management and wellness tools. According to CB Insights’ State of Telehealth Q2’21 Report, the top three areas where healthcare organizations are investing to improve the patient experience include telemedicine (75% of survey respondents), Electronic Health Record (EHR) interoperability (64%), and patient portals or digital messaging systems (56%).¹² However, which tools and practices should organizations be investing in to optimize PCE? Which ones are best aligned to an organization’s PCE gaps, goals, and strategies? 

Organizations have also invested time and resources into process improvement initiatives to improve operational efficiencies and processes and a myriad of performance measures to bring insights and transparency to PCE. Currently, measures used to describe the patient experience fall into two broad categories: the highly complex measures such as Consumer Assessment of Healthcare Providers and Systems (CAHPs), Net Promotor Scores (NPS) and other patient and consumer satisfaction surveys that have significant lag periods and are not very actionable for organizations nor understandable by patients. On the other hand, there are the unvalidated, overly simplified review and rating systems found on the web that may be skewed and even unreliable. As organizations start implementing or optimizing processes and technologies to improve PCE, they will need to determine what lead measures will be needed in addition to the lag measures required by CMS and other external agencies. These lead measures will need to provide timely data that are actionable to enable systems to more effectively respond and pivot to improve PCE.

To further stimulate progress in the PCE journey, new rules have been introduced by CMS including mandates around transparency and interoperability. The transparency rules are intended to help patients and people get the care they need by helping them proactively know how much they will have to pay for healthcare services and support their financial planning, while the interoperability rules give consumers and patients better access to their health records and remove barriers that have prevented patient data sharing between healthcare professionals.¹³

Operationalizing the Duality: Sam

Sam G, the new Chief Experience Officer of a large integrated delivery network was tasked with transforming PCE in his organization as this was one of the top 3 organizational priorities due to the increasing impact of PCE on patient outcomes, access, total cost of care, reimbursement, and health equity. To determine what to focus on in the PCE, he assembled a small team of influential stakeholders (from clinicians to patient advocates) who helped him uncover what to focus on, obtaining a deep understanding of the PCE needs and challenges, and develop the compelling purpose embodying these challenges and the changes being proposed—linked to the organization’s mission and core values—that would be shared with all leaders, clinicians, team members, and support staff in the organization. 

This small team also helped develop the behaviors and resources that would be needed for success, as well as defined what PCE success would look like in the short- and long-term. With the support and sponsorship of the senior leaders, Sam, the small team, and his staff engaged with the organization on this new initiative, including the purpose for the change, training that would occur, roles and expectations of each team member; addressed barriers and concerns; and highlighted the short- and long-term measures of success. He worked with leaders of the various departments on the new permeating mindsets and behaviors necessary for success and sustainability, and the new recognition and rewards program that would emphasize these new behaviors. Sam also emphasized interdependency in problem solving and developing new ideas and tactics that would further promote behaviors to preserve the core while leveraging tools to stimulate PCE progress. Weekly, then biweekly, and then monthly, lead and lag measures aligned with the PCE initiatives were posted for all to see. Lead measures or predictors (such as assessing percentage of patients who had a provider discharge visit prior to leaving the hospital, got a 3 to 7 day clinician follow-up visit, received a follow-up call post-discharge, and/or a connection to community services to address social needs) and lag measures, such as annual CAHPS surveys, were shared down to the department levels and were compared with their local and regional competitors. 

Over a 9-month period, the organization saw measurable improvements: from patients recognizing the changes in clinician, staff, and support staff behaviors and countenances, to consumers experiencing more seamless and convenient care with the support of digital and remote tools, to improvements in both the lead actionable internal measures and the lag publicly reported measures. The next step included how to maintain and further improve on the PCE success, changing it from an initiative to becoming part of the culture. To do this, Sam and his team put reinforcing mechanisms in place to ensure continued success that could be scaled to other entities and sustained. 

Some of these mechanisms included: 

• Ongoing training for leaders, clinicians, team members, and staff on PCE-aligned behaviors, skills,and practices
• Implementation of workforce management tools and AI/digital solutions to streamline processes to give clinicians more time and emotional space for direct patient care, streamline workflows, and reduce burnout
• A cadence of accountability to review lead and lag measures and make changes as needed
• Changing the hiring practices to recruit clinicians and staff with the potential to embrace a wholistic quintuple aim mindset
• Recognizing and rewarding team members for implementable duality ideas
• Promoting people who embody the organization’s core values and purpose of healthcare, while at the same time, have the skills and a persistent drive for progress, never satisfied with the current conditions, but always looking for ways to change, improve, innovate, and heal on behalf of the patient and consumer
• Establishing support teams to monitor and address staff and provider morale
• Weaving the mission, vision, and values of the organization into the fabric of all PCE communications 

5 Conceptual Takeaways 

Reviewing the summary of Sam’s efforts to transform the PCE in his organization, what were some of the key takeaways that could be applied in any organization looking to improve or transform their PCE? Below are 5 key takeaways that can be leveraged to make this duality real.

1. Define Problem:

• Reestablish the organization’s core values and mission
• Identify the specific PCE problem and gaps within the organization using surveys, focus groups, community needs assessments, and studies
• Establish this PCE initiative as an organizational priority through senior leadership sponsorship
• Develop a compelling purpose for change and identify objective baseline metrics to support message

2. Influential Team: Assemble a small team of influential stakeholders to

• Refine the PCE purpose aligned with the mission and vision of the organization
• Identify the new behaviors, mindsets, resources, and tools necessary for success
• Define what success would look like in the short and long-term
• Get their buy-in and contribute to the development of the communication plan to all clinicians and staff 

3. Entire Organization

• Involve the entire organization in the initiative from clinicians to leaders, clinical staff, and the support staff from housekeeping to the receptionists 
• Communicate initiative, address barriers and concerns, and define roles and measures of success
• Provide training, development, and upskilling aligned with the outcomes expected

4. Successful practices and behaviors

• Showcase successful practices that exhibit the duality 
• Highlight short-term wins frequently (especially in the beginning) and consistently to encourage teams
• Recognize and reward new behaviors and practices aligned with the duality
• Establish frequent meetings for a cadence of accountability to review data, measures, address challenges and barriers, make changes to the plan as needed, and further encourage the team

5. Reinforce Mechanisms 

• To prevent the PCE initiative from going by the wayside, put processes in place that will reinforce the new practices and embed them in the culture of the organization

Examples of Duality Successful Practices: Opportunities for Collaboration 

Below are some tangible practices and tools that embody the duality of core and progress to support transforming PCE and can be collaborative opportunities for stakeholders across the healthcare ecosystem (not all inclusive):

1. Patient Journeys

• The Patient Visit Journey Map: addressing humanistic pain points and challenges from accessing the system → before the visit → during the visit → post visit with aligned solutions to optimize consumer and patient access and experience. For example, improving ease of getting an appointment, having patients fill in data online prior to visit, which goes into the EHR, identifying social determinants of health factors prior to and during patient visit, and always showing compassion and humanizing technology
• The Patient Treatment Journey Map: providing opportunities for racially or culturally concordant care → addressing humanistic pain points and challenges from diagnosis → treatment → follow-up and monitoring with aligned technical and process solutions 
• Wellness and Prevention Consumer Map: address barriers to screening and prevention utilizing digital tools and neighborhood or home screening resources
• Care Transition Programs 

2. Communication

• Shared Decision Making and Motivational Interviewing Tools: training on communicating within the organization and with patients to create a healthy emotional environment
• Virtual Care Communication Skills: training on how to communicate successfully and engagingly virtually, understand the nuances of communicating virtually vs in person, and the advantages and disadvantages of both

3. Economic

• Integrated Patient Assistance Hubs: To facilitate a seamless patient experience in the healthcare system that supports patients, reduces inequities, identifies and addresses social determinants of health, and reduces strain on clinicians
• Pharmacist Medication Therapy Management Program: addressing medication use across the care continuum to reduce patient costs and improve outcomes and satisfaction
• Easy to use medical and pharmacy pricing systems: allowing consumers, patients, and members to search for treatments and medications to determine coverage, explore alternative options, and calculate how much they will pay out of pocket based on the current spending associated with their plan and deductible, with the availability of in-person support

4. Technology

• EHR Documentation: Techniques to document and at the same time be engaging and personable to the patient that are supported by AI and machine learning
• Telehealth: integrated into the workflow for regular follow-ups and to use national portals in times of intensified health system use (flu/COVID season, natural disasters) to prevent delays in care and increase capacity
• Digital Therapeutics: technology to monitor patient health to allow for more telehealth for both patient and clinician flexibility

As leaders focus on improving and transforming PCE or even other aspects of the organization, understanding the interplay between core and progress is fundamental to successful, scalable, sustainable, and systemwide change. The goal is not to seek a mere balance between core and progress; the goal in transforming is to be both highly ideological and highly progressive at the same time, like the yin and yang of Chinese dualistic philosophy: each element enables, complements, and reinforces the other.⁸ It is the core purpose—the North Star—that will motivate and bring teams together, guide PCE priorities and resource and tool selections, and provide a base of continuity around which the organization’s PCE initiatives can evolve, innovate, and change, making a difference in the care and experience of millions of patients and consumers like DD, in the case mentioned previously. 

By being clear about what is a core value (and therefore relatively fixed), an organization can more easily seek variation and movement in all that is not core. The drive for progress enables the core ideology and purpose of the PCE, for without continual change, forward movement, and reinforcing mechanisms to sustain and institutionalize progress, the PCE initiative will languish in an ever-changing world of competing priorities.⁸ Just like Sam, having tangible manifestations of the core PCE purpose and drive for progress is critical for success. According to Jim Collins, “intentions are all fine and good, but it is the translation of those intentions into concrete items—mechanisms with teeth—that can make the difference between having a visionary company and [PCE culture] or forever remaining a wannabe.”⁸  

References

1. Agency for Healthcare Research and Quality. Patient experience Accessed February 7, 2022. https://www.ahrq.gov/topics/patient-experience.html

2. McKinsey & Company. New stars ratings for Medicare Advantage prioritize customer experiences. Accessed February 7, 2022. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/new-stars-ratings-for-medicare-advantage-prioritize-customer-experiences

3. Doyle C, Lennox L, Bell D. A systemic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3:e001570.

4. Prakash B. Patient satisfaction. J Cutan Aesthet Surg. 2010;3(3):151-155

5. Andrews L, Cordina J, Kumar R. Great customer experience: a win-win for consumers and health insurers. McKinsey & Company. Accessed February 7, 2022. https://healthcare.mckinsey.com/sites/default/files/Great_customer_experience.pdf

6. Moreno MR, Sherrets B, Roberts DJ, Azar K. Health equity and quantifying the patient experience: a case study. Patient Experience J. 2021;8(2): article 13.

7. Centers for Medicare & Medicaid Services. Contract Year 2021 Medicare Advantage and Part D Final Rule (CMS-4190-F1) fact sheet. Published May 22, 2020. Accessed March 2, 2022. https://www.cms.gov/newsroom/fact-sheets/contract-year-2021-medicare-advantage-and-part-d-final-rule-cms-4190-f1-fact-sheet

8. Collins J. Preserve the Core/Stimulate Progress. Accessed February 7, 2022. https://www.jimcollins.com/concepts/preserve-the-core-stimulate-progress.html

9. Tribal Leadership. https://www.triballeadership.net/. Accessed February 7, 2022.

10. Collins J. Preserve the core/stimulate progress. Accessed February 7, 2022. https://www.jimcollins.com/concepts/preserve-the-core-stimulate-progress.html

11. Wolf JA. Expanding the possibility of human experience – a conversation with David Feinberg, MD, VP Healthcare, Google Health. Updated September 3, 2021. Accessed March 2, 2002. https://www.theberylinstitute.org/blogpost/947424/376205/Expanding-the-Possibility-of-Human-Experience--A-Conversation-with-David-Feinberg-MD-VP-Healthcare-Google-Health

12. Drees J. 3 areas providers are investing the most for patient experience. Becker’s Health IT. Published July 30, 2021. Accessed March 2, 2022. https://www.beckershospitalreview.com/healthcare-information-technology/3-areas-providers-are-investing-the-most-for-patient-experience.html

13. Centers for Medicare & Medicaid Services. Policies and technology for interoperability and burden reduction. Accessed February 7, 2022. https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index