This article describes the chain of care--key steps that
occur in the process of obtaining medical care that determine
members' satisfaction with their health care experience--and discusses
how patients' health care experience is shaped by physicians,
both in their individual interactions with patients and collectively
in their health care teams and departments. The article challenges
us to adopt a view in which delivering a superior care experience
is the most visible, compelling factor likely to differentiate
Kaiser Permanente (KP) from its competitors in the health care
marketplace.
Introduction
"Starbucks took the lowly coffee bean, a commodity,
and elevated it to an experience. Health care has taken the
most important human experiences and reduced them to the level
of a commodity."
--Brian D. Wong, MD, National Director, Healthcare Strategy,
Arthur Andersen, LLP
Although few people may find the experience of visiting their
doctor as gratifying as a visit to Starbucks, service quality
greatly affects patients' satisfaction with their health care
experience as well as their ratings of physician knowledge and
competence. A recent JAMA article noted that "if high
quality service had a greater presence in our practices and institutions,
it would improve clinical outcomes and patient and physician satisfaction
while reducing cost."1:661
This article explores how understanding what members value in
their health care experience can positively affect not only members'
health outcomes and satisfaction but also clinicians' professional
satisfaction and the financial health of Kaiser Permanente (KP).
Costs of Service Quality to Kaiser Permanente
Some people do not understand why, in this era of constrained
financial resources, Kaiser Permanente (KP) is focusing on service
quality more than ever before. These people probably do not realize
that service problems cost KP millions of dollars every year through
dissatisfaction rebates, member attrition, and members delaying
their own medical care because of perceived or actual inconvenience
presented by the medical care system.
Under the terms of our purchaser performance guarantees and policy
of offering member dissatisfaction rebates, KP pays purchasers
and members directly when members experience service problems.
Performance guarantees provide reimbursement to employers when
specific service measures (eg, appointment access) fall below
agreed-upon levels. In 1998, KP Northern and Southern California
Regions had performance guarantees totaling $17.5 million in reimbursements.
In California, member dissatisfaction rebates (eg, reimbursed
copayments) totaled approximately $1.3 million in 1998. To realize
how significant this amount of money is, one must realize that
our organization must earn at least $65 million in revenue before
sufficient surplus funds are available to pay the $1.3 million
in rebates. In this context, rebates constitute a substantial
financial outlay.
Even more important, many members who choose to leave KP cite
service issues as the primary reason. Replacing these members
is costly. In 1998, more than 65,000 members who left KP cited
service problems as the chief reason,2 and the marketing
cost of acquiring one new member is approximately $340; thus,
KP spent more than $22 million in 1998 to replace these members--a
result which by itself achieved zero growth. If we were to include
members who listed service problems as a secondary reason for
leaving KP, this amount would be nearly double. Nonetheless, this
marketing cost to replace dissatisfied members is small in comparison
with the revenue lost by KP when these members switch to other
health plans.
Members who leave KP are young, likely to report being in excellent
or very good health, and likely to be relatively new members.2
When members leave, KP loses the revenue represented by these
members' premiums. At a mean individual premium of $150/month,
members who left KP in 1998 because of service issues decreased
revenue in 1999 by $118 million. During a 20-year period--the
mean length of membership for satisfied members who stay with
KP--the revenue lost from members who left in 1998 because of
poor service quality would total $2.35 billion.
In addition, reluctance to engage a system in which it is time
consuming to make an appointment or in which timely appointments
are not readily available may cause patients to delay treatment
and thus delay diagnoses and cause poor outcomes.1
The costs of these delays are unknown.
Value and the Health Care Experience
Members evaluate KP at every interaction and judge the value of
their health care experience in terms of four critical attributes:
health outcomes, service quality, monetary price, and nonmonetary
costs. The value of the health care experience as it relates to
these four attributes can be depicted by the equation
Value of Health Care Experience = (Health Outcome + Service
Quality) / (Price Paid + Nonmonetary "Costs" to Member)
where health outcome is traditionally defined as clinical
quality.
Service quality refers to how care is delivered, ie, clinical
interaction with patients and their families. Research has shown
that this clinical interaction--the service quality aspect
of patient care--strongly affects clinical outcomes, patient adherence
to prescribed treatment regimen, symptom resolution, functional
health status, and physiologic measures of health.3-6
Price paid includes the premium (whether paid by employer
or individual subscriber) and copayments (paid by the member for
individual services).
Nonmonetary costs to members include time spent
waiting on the phone to make an appointment; time spent waiting
in the waiting room and in the examination room to see a clinician;
time spent waiting in the laboratory to have tests done and in
the pharmacy to have prescriptions filled; and the inconvenience
inherent in attending the appointment (eg, taking time off work,
traveling to and from the appointment, and parking at the medical
office).
Member and patient satisfaction surveys allow us to identify
specific aspects of the health care experi
ence that matter most to members. Several specific factors correlate
most strongly with members' overall satisfaction with the care
they receive at KP7,8:
- Interest and attention of the physician/practitioner;
- Having a primary care physician/practitioner (PCP);
- Being able to see the PCP;
- Time spent with the physician/practitioner;
- Time spent waiting in the examination room;
- Time spent waiting in the waiting room;
- Time spent waiting on the phone to schedule the appointment;
- Days wait for the appointment.
These factors are key elements of members' health care experience.
When analyzed from the patient's perspective, these elements describe
the chain of care--steps in the process of obtaining medical
care. When members evaluate their overall satisfaction with KP,
this chain is only as strong as its weakest link. In other words,
a member's total health care experience can be affected by any
problem in one part of the chain of care.
Role of Clinicians in Creating Health Care
Value
To members, the most important factor in the chain of care is
the interaction with their physician or health care practitioner.
Data from KP Colorado patient satisfaction surveys8
show a 95% correlation between patients' ratings of "knowledge
and competence" of the provider and "courtesy and respect"
shown by the provider. This correlation shows that patients assess
the clinician's medical skill largely in terms of the clinician's
interpersonal skills. In other words, patients evaluate how
much clinicians know on the basis of how much clinicians are perceived
to care.
Patients' ratings of the physician or other health care practitioner
are further affected by additional elements in the chain of care:
Time spent waiting in the examination room. The KP Colorado
data show that ratings of physicians and other health care practitioners
are affected by the amount of time patients wait in the examination
room8 (Figure 1). As waiting
time in the examination room increases from one minute (or less)
to more than five minutes, patients' ratings of the clinician's
"knowledge and competence" drops 6%! Conversely, reducing
the time spent waiting in the examination room from five minutes
to one minute or less increases patients' ratings for "knowledge
and competence of the provider" by 6%! Longer waiting time
in the examination room also reduces patients' satisfaction with
the time they later spend with the provider8 (Figure
2).
Patient familiarity with the provider. Data from Northern
California9 show that patients rate physicians or other
health care practitioners as much as 30 percentage points higher
when the provider is the clinician who provides most of the patient's
routine care than when the patient is not familiar with the provider
(Figure 3). Patients who are familiar
with the provider (ie, patient has seen the provider before but
receives most routine care from another person) give the provider
intermediate ratings.
Choosing the physician. A study done by the KP Northern
California Division of Research and published in JAMA in
199710 found that patients who chose their PCP were
16% to 26% more satisfied with their physician (as shown by nine
measures of satisfaction with the physician) than patients who
were assigned to their PCP.
Accordingly, whereas the clinical interaction between provider
and patient is the greatest factor in patients' satisfaction with
clinicians, other factors often not under the clinician's direct
control greatly affect how highly the clinician is rated by the
patient.
Role of the Physician in Improving the Health
Care Experience
Because members evaluate KP at every interaction, improving members'
health care experience requires improving each link in the chain
of care. These aspects of members' experience with KP should be
the focus of our attention and should guide our improvement efforts.
Regional and interregional work has started to address key systems
issuesa that impede KP's ability to deliver health
care experiences and outcomes that set quality standards for American
medicine.
As important as systems issues are, even more important are the
individual, team, and departmental actions that affect each patient's
health care experience. For example, because patients evaluate
how much clinicians know (ie, the most important factor in the
chain of care) on the basis of how much clinicians are perceived
to care, careful attention to effective communication skills with
each clinical encounter will make a difference.
To improve their clinician encounters with patients, clinicians
should use the Four Habits of Highly Effective Clinicians11
with each patient:
- Invest in the beginning: create rapport quickly, draw out
the patient's concerns, and plan the visit with the patient;
- Elicit the patient's perspective: ask for the patient's ideas,
elicit specific requests, and explore the impact on the patient's
life;
- Show empathy: be open to the patient's emotions, be aware
of your own reactions, and convey empathy both verbally and
nonverbally;
- Invest in the end: deliver diagnostic information, provide
education, involve the patient in making decisions, and complete
the visit by summarizing, checking for acceptance, and reassuring
the patient of ongoing care.
These communication behaviors are discussed in detail in this
issue of The Permanente Journal.11
A growing literature on physician-patient communication documents
the correlation between effective physician-patient communication
and improved health outcomes,12 patient satisfaction,13
and clinician satisfaction.14-16 Stated differently,
clinicians can improve not only their patients' satisfaction and
health outcomes but also their own professional satisfaction with
their work by using the Four Habits at every clinical encounter.
Role of the Health Care Team and Clinical Department
in Improving the Health Care Experience
Health care teams that produce high patient satisfaction minimize
the amount of time patients wait in examination rooms and effectively
manage waiting room time.17 As the KP Colorado data
show, minimizing the time spent waiting in the examination room
increases patients' ratings of the clinician's knowledge and competence
as well as patients' satisfaction with the amount of time spent
with the provider--two areas that contribute greatly to patients'
overall satisfaction with their health care experience.
Departmental processes that both allow members to choose their
PCP and enable patients to be seen by their PCP when they seek
care will improve patient satisfaction. These aspects of the chain
of care affect patients' ratings of overall satisfaction with
the health care experience as well as patients' ratings of clinicians'
knowledge and competence.
Conclusion
Each of us can take the following actions that contribute to giving
every patient a superior health care experience:
- Fully understand how service problems affect KP's affordability
and patients' perception of clinicians' competence.
- Identify the factors that matter most to our patients (ie,
aspects of the chain of care):
- Knowledge and competence of the clinician (directly correlated
with courtesy and respect);
- Having a primary care practitioner whom the patient has
chosen;
- Ability to see own primary care practitioner (or, at least,
another clinician whom the patient has seen before);
- Quality and quantity of time spent with the clinician;
- Time spent waiting in the examination room (including extent
to which delays are minimized and communicated);
- Time spent waiting in the waiting room (including extent
to which patients are kept informed and occupied);
- Time spent on the phone to schedule the appointment;
- Days wait for the scheduled appointment.
- Use effective communication skills with every member, no matter
how difficult the encounter may be. Be aware of and sensitive
to cultural and lifestyle differences. Attend a clinician-patient
communication workshop.
- Lead by example in the patient care setting. Provide an environment
that encourages ancillary staff to give top priority to the
patient's health care experience.
- Discuss in a team or department meeting how to improve one
aspect of the chain of care, such as reducing examination room
wait time or increasing the ability of patients to see their
PCP. Implement suggestions and track the results.
- Engage and challenge KP leaders to address "system"
issues (eg, telephone wait time, access) that affect members'
health care experience.
If improving patient satisfaction can improve our patients' health
outcomes, KP's financial success, and clinicians' professional
satisfaction, we owe it to ourselves and our patients to take
the actions that will enable us to deliver a superior health care
experience.
a The KP Interregional
Care Experience Project will focus on how key aspects of the delivery
system (Call Centers and primary care models) should be designed
and operated to support KP's physicians and employees in delivering
a superior care experience.
Acknowledgments: Coauthors Doug Bonacum, MBA,
Martin Gilbert, MD, and Lisa Koltun, MS, HSA were members of the
Advanced Leadership Program-1998 class; many of the ideas presented
in this paper were developed by the members of the 1998 Advanced
Leadership Program (ALP). Leslie Francis, MBA, MHA, compiled the
patient satisfaction data. Samuel Yates, BA, reviewed the manuscript.
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