s coolidgep braunA few weeks ago I had an appointment with a physician whose office is located in a new ambulatory facility built by one of the very good hospitals in my city. I was excited to see how this organization designed its new facility and interiors to create a positive patient experience. They sell themselves as “personal” physicians.

When I walked into this newly constructed facility and experienced the space, however, it made me feel like turning to leave. I stayed only because I needed to see the highly recommended physician. Before I even experienced the staff or the processes, I had a negative experience, and that negative first impression triggered by facility design followed me through my entire visit and into my responses on their patient experience survey.

The lesson is that a facility designed without careful consideration of the patient experience can contribute negatively to experience and strongly affect patient responses to satisfaction surveys. This applies to existing facilities, those in line to be renovated, or new constructions.

An alternative to consider when attempting to positively influence patient perception is to first identify and thoroughly understand the intent, and to create a facility that will reinforce your brand and provide a positive, unique, purposefully designed experience.

By defining the intent for the experience, we are able to examine and create facilities as positive contributors facilitating our ability to improve perceptions. With this intent in hand, the approach for facility design will be properly informed and will provide for guided responses to the exterior and interior architectural design. These design details include the desired emotional response elicited by the space, arrangements for positive patient interaction and flow, and elements such as furniture, artwork, intuitive direction, signage, and color.

Most important is to consider how the patients will feel when they are in the space. Emotion is a major factor when people consider their experiences. Does the space evoke feelings of safety, security, and calmness, or does it increase feelings of anxiety, fear, and confusion?

Secondly, examining the messages your spaces send in support of the journey through the facility and in support of positive patient processes is essential. Simple details in the design can enhance the experience and tell the patient a story of warmth, comfort, and thoughtfulness. These can be powerful enhancements to the experience.

The experience story continues with whether processes are organized and efficient. Facility design can effectively support organized and efficient processes; however it is the backbone of the experience intent that guides the processes and then guides the design.

We rarely think of our structures as storytellers or messengers of experience and our brand, but in fact, facility design speaks loudly to patients.

Again, remember that the important first step in facility design is to actively and thoughtfully articulate the experience you want patients to have and then purposefully design it into the structure and interiors.

The following provides a framework for how you might look at your current facility or next facility project designed around a desired patient experience intent:

  1. Prepare
    1. Conduct research through literature review and through examination of best practices in experience design
    2. Investigate experience design and branding principles
    3. Complete an organizational self-assessment
  2. Collaborate/Explore/Create
    1. Discern and develop all aspects of the experience. Include how you want the patient to feel and the emotion you want to illicit.
    2. Translate the human experience into branding principles
    3. Prepare an intentional experience declaration
    4. Develop the story structure for the experience
      1. Examples of the patient journey through key steps in the healthcare delivery process
      2. Prepare vignettes for what it means for types of individuals or types of patients
  3. Design
    1. Prepare an analysis of the current experience situations with the patient experience intent
    2. Identify the top 10 (or more) design implications with the greatest impact, keeping in mind that you want to connect at the emotional level
    3. Create the experience story through graphic representations fulfilling the intended experience – these will serve as a guide for the facility design

About the Authors

Sylvia Coolidge Moore is an experienced hospital executive (COO) leading operations across a range of organizations from large to medium-size for over 20 years. As the COO, she has led organizations to adopt performance improvement and patient safety as key organizational priorities. She has guided boards, executives, management, and staff through education and understanding of high-reliability, no-harm healthcare, pay-for-performance requirements, and the financial rewards and penalties imposed by the Centers for Medicare & Medicaid Services (CMS). She has led the adoption of a high-reliability, no-harm healthcare culture commitment, organizational assessment, and cultural change priorities and actions. Additionally, she has led organizations to significant improvement in the areas of value-based purchasing (VBP), hospital-acquired conditions (HACs), and readmission reduction parameters of the CMS pay-for-performance system. Most recently she established a private consultancy service (FE3 Catalytics) focusing on her two passions in healthcare: high-reliability, no-harm healthcare and the patient experience.

Paul is an architect, Founder and President of BraunDesign. Through BraunDesign, Paul provides healthcare organizations with consulting services for experience & brand design, planning, conceptual design, programming and project management.  Paul’s entire career has been devoted solely to serving healthcare organizations either as a full time staff member or as a managing partner in an international architectural and design firm.  He has a strong track record of successfully delivering large complex projects, establishing project processes that inspire innovation, purpose and fulfillment. Expressing the intended human experience through architectural design is both a passion and a talent that Paul uniquely brings to clients. He assists clients in defining their desired patient experience and then assures that this experience comes alive through the exterior and interior design. Paul is a graduate of the School of Architecture and Urban Planning at the University of Wisconsin-Milwaukee.

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r fortinip lipesThe patient experience of care domain is every bit as important in the ambulatory care sitting as it is in the hospital. While information gathered through Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys is invaluable, nothing can replace in-depth, face-to-face meetings with patients to really get at the heart of what they want from their providers and practice staff. How do you tailor care delivery to meet the needs of individual patients without asking? 

According to a recent article by Mike Miliard for Heathcare IT News, healthcare organizations looking to move past meaningful use and toward value-based purchasing are investing capital in platforms that better support patient engagement. In fact, population health and patient engagement topped projected purchasing plans for 2016. Patient experience was also identified as a top priority across all healthcare settings, from physician practices to hospitals to long-term facilities, by a benchmarking study, State of Patient Experience 2015: A Global Perspective on the Patient Experience Movement, released by The Beryl Institute in August 2015.

Bon Secours Medical Group (BSMG) uses many methods to advance patient-centered medical home care and facilitate the move from fee-for-service to fee-for-value within its practices. One of the newest, the formation of patient and family engagement councils within practice locations, is being used to provide a forum for improved information-sharing between patients, providers, and staff, hopefully improving both the delivery of care and the patients’ satisfaction with the delivery system.  

The participating practices within BSMG optimize the care model by facilitating two-way communication between patients and providers through quarterly meetings held at the applicable practices. Meetings follow a pre-published agenda and include a verbal survey of membership about specific practice administrative and clinical concerns and experiences. Patient feedback is recorded in summary for review by the project team and all members of the applicable practice. The information then is prioritized and used by the practice members and project teams to establish action plans to address top concerns through appropriate remedial activities.

Objectives include improved communication between patients and practice staff, the correction of deficiencies within a practice, increased patient knowledge regarding available resources (both within the practice and within the community), and increased patient knowledge about specific disease management through ongoing education, if appropriate. It is hoped that meeting these objectives will improve patient satisfaction scores on surveys by 5 to 10 percent over a two-year period. 

Patient and family engagement council membership is seen as an honor by the participants, who are personally invited to serve by their primary care physician and the administrator of their medical home. Members serve a one-year term, with an option of remaining on the council as advisors after that term expires. Several councils are working to improve the care delivery system for patients with chronic conditions such as diabetes and obesity. Just understanding and having access to auxiliary clinical services has been seen by patient members as sufficient reason to participate. Members leave the councils with a greater knowledge of the role played in their care by their physician, nurse navigator, registered dietician, and/or pharmacist. They also share with fellow members and learn and grow from the experiences and insights of their peers. Their suggestions are then shared across the practice, allowing all the patients of the applicable practice to benefit from the experience of the representative sample. 

Skilled facilitation is provided at each meeting to ensure that all voices are heard and that passionate discussions remain respectful. Staffers are encouraged to remain neutral while receiving constructive feedback regarding possible deficiencies within the practice. All participants, patients and staff members alike, approach the sessions as an opportunity to improve service. What staff may see as adherence to compliance or just good procedure, patients may view as rude. One example was discussed early in the formation of a new council at a very large, very busy practice. Staff had posted a stop sign near the check-in desk in an attempt to have those in line stand back while the patient being served was registered. The staff’s only desire was to provide privacy. However, many patients of the practice found the sign offensive and suggested a simple wording and location change for signage that would accomplish the same desired outcome – privacy for all those checking in for an appointment. 

The physicians within the Bon Secours Medical Group who participate in patient and family engagement councils welcome the opportunity to spend quality time with patients outside of the typical visit. The councils provide physicians an opportunity to focus on an issue or disease state with a core group of eager participants. One physician recently developed a council for patients with a diagnosis of obesity. Not only will this group meet and share treatment options in addition to general clinical and administrative concerns, but the physician champion has set up “walks with the doc” to promote healthy, safe exercise among her patients. Registered dieticians will discuss and share healthy cooking tips, and all meals served during meetings will be appropriate to support good nutrition and weight loss.

One of the newer councils at Bon Secours is in formation at a large, rural pediatric practice. The payor mix for those served at this practice is 75 percent Medicaid, 25 percent private insurance. A large number of these pediatric patients are cared for by extended family, particularly grandparents. Providers and staff are anxious to learn better ways to serve this population. One physician recently discussed the need for extended access. Her concern will be addressed at a patient family council meeting – when do extended hours make sense? For example, if many primary caregivers do not wish to drive after dark, do evening hours make sense? Is this an issue in a rural environment with dark country roads? Perhaps more so than in a city or suburban area? The benefit of having councils specific to each practice is highlighted by this simple example.    

Whether at the practice level or at the system level, the voice of the customer will continue to help drive change within medical practices. Healthcare is no longer the top-down, “physician-only” controlled organization it may have been in the times of the horse and buggy. Today’s healthcare teams are complicated organizations made up of many members, all focused on providing patients with the best possible experience while improving health and controlling cost. A true challenge of the triple aim is and will continue to be achieving the ability to detect and appreciate the small but significant changes that patient and family engagement councils bring to the table. Patient-centered care must allow for the voice of the patient in all its possible forms to be heard, and councils are just one of many very important components.  


About the Authors

Robert Fortini, PNP, VP and chief clinical officer for Bon Secours Virginia Medical Group Home Health and Hospice, is responsible for facilitating provider adoption of electronic medical records (EMRs), plus coordinating clinical transformation and facilitating advances in population health initiatives. Robert has extensive experience in operations and clinical policy development, and experience in workflow reengineering and CQI in ambulatory care. He recently advanced Bon Secours’ efforts in “Good Help for Life” by leading efforts in advance care planning and behavioral health integration into primary care, promoted access via expansion into the retail clinic and telehealth arenas, and developing a workforce equal to the task. 

Patti B. Lipes is a graduate of Averett University with a bachelor’s in business administration degree. Prior to joining Bon Secours, she served in leadership roles at HA-LO Branded Solutions and Reynolds Metals Company. Her areas of expertise are market development and business operations. As senior clinical operations project administrator for Bon Secours Virginia Medical Group, Patti is responsible for coordinating and facilitating project plans within the knowledge areas of analytics, patient-centered medical home care, population health, and quality. Patti holds the Project Management Professional (PMP) certification and is a Lean Six Sigma Green Belt. She is certified in mass care, disaster services, and shelter management through the Red Cross and worked in Mississippi and Louisiana with City Impact following Hurricane Katrina.   

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EDITOR'S NOTE: This article is the first in a two-part series regarding the Inpatient Prospective Payment System Proposed Rule for the 2017 fiscal year.

The Centers for Medicare & Medicaid Services (CMS) released the display version of the Proposed Rule on April 18. The recommendations would become effective on Oct. 1, 2016. Comments on the Proposed Rule are due to CMS by 5 p.m. EST on June 17, and they can be posted on http://www.regulations.gov. There are a total of 1,585 pages in this Proposed Rule. The Final Rule is scheduled to be released on Aug. 1, according to information disclosed during the March meeting of the CMS Coordination and Maintenance Committee.

Now to cover some of the highlights of the newly released Proposed Rule:

A documentation and coding adjustment has been recommended at the level of 1.5 percent, which is an increase over last year’s adjustment of 0.8 percent. The Proposed Rule also includes a notice regarding an adjustment to IPPS rates by removing the 0.2-percent reduction to the IPPS rates (suggested in 2014) due to the latest changes to the two-midnight rule policy. There is also the suggestion of increasing the standardized amount, hospital-specific rates, and national capital federal rate by 0.6 percent.

There are also suggestions regarding the Readmission Reduction Program. Coronary artery bypass graft (CABG) procedures may be added beginning in the 2017 fiscal year.

Changes have also been suggested for the Hospital Value-Based Purchasing Program. For 2019, two measures may be revised; for 2021, one measure is to be updated, and two new measures are to be adopted; for 2022, one new measure is to be adopted.

Hospital-acquired conditions (HACs) have been another focus of change. It is proposed that Patient Safety Indicator (PSI) 90 – the Patient Safety and Adverse Events Composite – be refined and adopted. There is also a suggestion for changing the program by moving from the decile-based scoring methodology to a continuous scoring methodology.

Many changes have been suggested for Hospital Inpatient Quality Reporting Program. Fifteen measures (13 electronic and two chart abstraction) have been recommended for removal. Two other measures may be refined. Four new claims-based measures have been brought forth. From an administrative perspective, public comment is being sought on new measure suggestions. A suggestion to submit all electronic clinical quality measures has been made, as well as a modification in the validation process. Another administrative modification to the Hospital Inpatient Quality Reporting Program functionality is to make updates to the process to request an extension to the submission process.

The last topic for this article is the Medicare Code Editor (MCE). There are some changes in the ICD-10-CM code list that will occur to the diagnoses listed under the age conflict, sex conflict, and unacceptable principal diagnosis codes. Another frequent issue that may be addressed through this Proposed Rule is the rejection of a few procedure codes. The removal of the vas deferens (or the ovary) will not be covered when the procedure is not for sterilization. Another frequent issue that has been reported by some facilities is the denial for endovascular mechanical thrombectomy procedures because the procedure code appears on the uncovered procedures list. CMS had noticed that there was a replication error in the non-covered procedure. A replication error represents that an error was created due to an attempt to replicate the codes in ICD-9-CM. Four endovascular mechanical thrombectomy codes are scheduled to be removed from the non-covered procedure code list.  

Next week’s article will outline some of the changes to the MS-DRG methodology. The Proposed Rule can be found online at https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-09120.pdf.

About the Author

Laurie Johnson, MS, RHIA, FAHIMA is the director of health information management (HIM) consulting services for Panacea Health Solutions Inc. She has conducted ICD-10 education sessions and documentation reviews for multiple organizations. Laurie also anchors the News Desk on Talk-Ten-Tuesdays. Prior to working for Panacea, Laurie worked for Peak Health Solutions and Optum.

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m mcmillanWith healthcare spending in this country at an all-time high, value-based reimbursement initiatives are continuing to gather momentum across the industry due to their ability to lower costs and improve quality measures. Bundled payments, value-based care strategies that feature payment of a flat price for care associated with a medical condition or event, is one approach that is quickly gaining ground in today’s quality-over-quantity healthcare environment.

In 2014, after more than 400,000 hip and knee replacement surgeries were performed, totaling upwards of $7 billion in hospitalization costs, the Centers for Medicare & Medicaid Services (CMS) recognized an opportunity to bundle these procedures in its efforts to improve patient care, and ultimately, to lower the overall portion of the nation’s healthcare budget spent on patients 65 and older.

And on April 1, 2016, CMS launched its long-awaited Comprehensive Care for Joint Replacement (CJR) model, specifically designed for Medicare beneficiaries to better support their transition from surgery to recovery for hip and knee replacement and other major leg surgeries. As part of the initial five-year test period, 800 participating hospitals and health systems across 67 geographic areas will be held financially accountable for the quality and cost of care during joint replacement procedures, beginning with hospital admission and ending 90 days after discharge.

What is the Intent Behind Creation of the CJR?

Hip and knee replacement surgeries are the most common inpatient procedures performed on the Medicare population today, and often they require an extended recovery period. But even though these surgeries are performed in high volumes, the quality and cost vary drastically from provider to provider, with hospitalization and recovery costs differing by more than $40,000 in some cases. With a number of different care plans featuring their own unique and sometimes conflicting instructions, patients and their caregivers often are left feeling confused about what to do, which can lead to high-cost re-hospitalizations and other undue complications.

Under the new CJR model, CMS is encouraging all involved providers– hospitals, specialists, and post-acute care providers such as rehabilitation and nursing facilities – to work together to provide coordinated, quality care at a reduced, transparent price over the course of the care experience.And even though the CJR model allows beneficiaries the freedom to choose their preferred providers and services, by eradicating cost discrepancies, the federal agency will be better positioned to determine whether or not bundled payments actually reduce Medicare’s overall spending on these procedures while preserving a high quality of care.

Why CJR is Set Up to Succeed

While the CJR pilot may be the newest addition in a widening sea of value-based Medicare reimbursement initiatives, it is built for success. The universe of conditions that will be impacted is clearly defined and somewhat finite. Providers will be incentivized financially to deliver better outcomes and lower costs by coordinating care in a way that best meets patients’ needs, using technology and other strategies to enhance patient engagement. CMS also will share best practices and assist hospitals and health systems in improving care coordination and delivery by providing relevant utilization and spending data.

At yearly checkpoints over the course of the initial five-year program, participating hospitals will be evaluated based on a publicly known risk stratification methodology. Their actual spending for these episodes of care also will be compared to Medicare’s target price. And depending on how well participating hospitals perform against cost and quality measures during each episode of care, they may be eligible for additional payment through Medicare. Conversely, if these provider organizations do not meet the fundamental performance measures laid out in the CJR program, they may be forced to pay back a portion of each episode’s overall cost.

Also, with CJR bundled payments, hospitals are more likely to take preventative measures to ensure cost savings, such as reducing hospital readmissions and extended post-surgery hospital stays, as well as improving care transitions between medical settings.

How CJR Contributes to Value-Based Care

By the end of 2016, CMS aims to move 30 percent of all Medicare fee-for-service payments to alternative value-based payment models such as bundled payments. To meet this goal, hospitals will be required to assume greater accountability for the care they provide: a key tenet of performance-based payment models. Of course, those organizations that are currently participating in shared-risk contracts will have a modest advantage over competing hospitals, but the development of best practices will, in theory, lead to greater efficiencies, improved quality, and cost savings across all of the CJR program’s associated providers of care. For those parts of the country and those institutions that are not part of the first CJR wave, the likely downstream pressures will come from having to achieve similar quality benchmarks and price points set by their peers.

If effective, the complete and successful implementation of the CJR model will enhance and improve the quality and efficacy of care delivered to Medicare beneficiaries. By building on measureable benchmarks set out along a clearly defined timeline, the healthcare system will continue to move toward becoming an industry that continuously delivers high-quality, consistent care at reasonable, transparent prices while also promoting healthier living for the American public as a whole.

About the Author

Michael McMillan is senior vice president for strategic solutions for Valence Health, working with clients to refine approaches to implementing value-based payment and population health solutions.

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Tuesday, 12 April 2016 04:51

Brief Spotlights Improvements in Patient Safety

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m spiveyWhat has been good for hospitals’ bottom lines has been good for patients as well, according to a brief recently published by National Quality Strategy via its Priorities in Focus feature.

The brief revealed a 17-percent drop in hospital-acquired conditions (HACs) within the nation’s healthcare system from 2010 through 2014 – a development that resulted in an estimated 87,000 lives and $20 billion in costs being saved.

Those were the most striking figures featured in the Agency for Healthcare Research and Quality (AHRQ) 2015 National Healthcare Quality and Disparities Report Chartbook on Patient Safety, on which National Quality Strategy’s brief was partially based.

“(The Chartbook) showed an overall trend of improvement in patient safety,” the brief read. “Among patient safety measures with trend data available from 2001-2002 through 2013, over 60 percent showed improvement over time.”

“However, many disparities persisted,” it continued. “For about one-third of patient safety measures, high-income households received better care than poor households, and whites received better care than blacks and Asians.”

And despite the considerable 17-percent drop in hospital-acquired conditions, the issue remains prevalent nationwide – one in seven Medicare patients are harmed during a hospital stay, and each year HACs in particular remain a significant cause of morbidity and mortality.

“In an increasingly complex healthcare delivery system where patient safety depends on a range of factors, successful prevention of harm hinges on the effective identification and elimination of the potential for preventable error, avoidance of blame assignation while remaining accountable to outcomes, and transformation of the culture of medicine to ensure that patients receive high-quality care,” the brief read. “Prevention of medical errors saves lives and lowers cost – goals shared by all stakeholders across the system and a key to achieving the three aims of the National Quality Strategy.”

Those aims include the reduction of preventable hospital admissions and readmissions, the incidence of adverse healthcare-associated conditions, and harm from inappropriate or unnecessary care.

“The Affordable Care Act focused national efforts on improving these long-term goals to make care safer for all Americans,” the brief read.

 To read the brief in its entirety, go online to http://www.ahrq.gov/workingforquality/reports/nqs-priority-focus-patient-safety.pdf.

About the Author

Mark Spivey is a national correspondent for VBPmonitor. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..