In the mature, highly competitive Northwest US health care
market, the Kaiser Permanente Northwest (KPNW) Region has adopted
a central focus of exceeding members' expectations of health care
services. This article introduces readers to the KPNW Customer
Service Collaborative, an activity organized in 1999 to solidify
service quality as a core value throughout the Region.
| "Providing
excellent customer service is no longer optional for us in
Kaiser Permanente. Our members and customers expect to be
treated with respect, honesty, and integrity. They also expect
us to function as highly committed, customer-focused teams
within our integrated health care system.
Working together, I am confident we can
meet or exceed these expectations for service excellence."
--Barbe West
Regional President, Kaiser Foundation Health Plan Northwest
"Improving service requires all
members of the health care team to understand what our patients
want and need, and communicate effectively among themselves
about how to meet those needs. No one can sit on the sidelines;
it requires the commitment of all."
--Allan Weiland, MD
Regional Medical Director, Northwest Permanente, PC
|
Introduction
Kaiser Permanente Northwest (KPNW) leadership is committed to creating
a service-oriented culture that permeates all levels of the organization.
Given that the highly competitive and mature managed care environment
in the northern Willamette Valley and in Southwest Washington has
virtually eliminated KPNW's historical price advantage, attention
to meeting and exceeding members' expectations of the health care
experience has become a central focus for the Region. More specifically,
dimensions of the care experience as described by the Picker Institute
(an organization that has spent many years exploring the experiences
of patients who have been treated in a variety of clinical settings)
provide the KPNW Region multiple opportunities to assess current
activities and to improve on them.
KPNW senior leaders recognize that a significant cultural shift
is needed to understand these expectations and to organize services
accordingly. This recognition has led the leadership team to identify
several organizational components that are necessary if KPNW is
to be a leader in service excellence:
- Knowledge of what constitutes an excellent care experience;
- Management modeling in which senior and middle managers
model excellent customer service behaviors;
- Employee satisfaction and empowerment in which employees
are engaged, mobilized, and empowered to maximize their performance
contributions and intrinsic work satisfaction;
- Skills and competencies in which senior leaders, middle
managers, clinicians, and employees have the capability to provide
excellent service;
- Systems such as training, recognition/reward, and care
delivery systems in place to support service quality;
- Strategy for becoming an organization known for service
excellence; and
- Structure to support benchmarking activities and sharing
of ideas; and a compensation and incentive system that reinforces
all of the above.
Historical Foundation for the KPNW Customer
Service Collaborative
In 1998, the Institute for Healthcare Improvement (IHI)-- an independent,
nonprofit organization--invited 28 health care organizations to
participate in a new, national collaboration titled "Improving
Service in Health Care." KPNW participated in this collaboration,
which challenged participating organizations to rapidly reshape
customer service in areas important to customers. KPNW responded
to the challenge by implementing a pilot project in one geographic
area in the Region: the Salem Primary Care Service Area (PCSA).
The Salem PCSA is one of six service areas within the Region and
consists of two primary care medical offices, one specialty care
medical office, and a centralized call center. Salem is located
50 miles south of Portland and serves approximately 48,000 members.
The support provided by the IHI Collaborative and the substantial
attention given to improving customer service in Salem led to
major improvements in customer service in the Salem PCSA. From
August 1998 to November 1998, the Salem PCSA achieved a statistically
significant increase in overall satisfaction (72.6% to
81.8%, p = 0.01); the percentage of patients paneled with
a primary care provider (PCP) increased from 57% to 63%; the percentage
of patient visits with the patient's PCP increased from
64% to 70%; and member concerns decreased by 31%. In addition,
a nine-question employee satisfaction survey was distributed to
KP clinicians, nurses, and receptionists in the Salem PCSA in
April 1998 (before the start of the Collaborative), and again
in November 1998; responses to six questions on that survey showed
statistically significant improvement in employee satisfaction
between April and November.
These successes led to formation of the KPNW Customer Service
Collaborative, whose ambitious goals were 1) to increase overall
customer satisfaction with service in the inpatient and ambulatory
care settings by 30%; and 2) to increase by 50% employees' and
physicians' ability to provide excellent customer service as perceived
by the employees and physicians.
Formation of the KPNW Customer Service Collaborative
Modeled after the IHI Collaborative, the KPNW Customer Service
Collaborative was designed to begin addressing the organizational
components necessary for service excellence and to shift the organizational
culture toward recognizing service quality as a core value. The
Customer Service Collaborative is based on the premise that continuous
learning drives continuous improvement. In February 1999, multidisciplinary
health care teams were invited to explore ways to listen and learn
from customers; to design small, site-specific improvements; and
to rapidly adjust activities on the basis of customer feedback.
Participation in the Collaborative was voluntary so that success
within the Region would stimulate other teams to improve their
customer service also.
 |
| Figure 1. Organizational support structure
for KPNW Customer Service Collaborative. |
Structure and Operational Model Used by the KPNW Customer Service
Collaborative
Of the 16 applications received, 13 multidisciplinary teams were
selected from primary, specialty, and inpatient care service areas
to participate in the Customer Service Collaborative. All but two
of these were naturally occurring work teams. Teams were selected
on the basis of their excitement about improving customer service.
A strong organizational structure was created to support the
teams' work in improving customer service (Figure 1). In addition
to the team co-leaders (one physician and one RN), each team is
supported by:
- Local operational leaders who address barriers, provide needed
resources, and reinforce change at the local level;
- One senior leader, who removes barriers to team progress and
reinforces change at the organizational level; and
- A process consultant and a measurement consultant, who provide
fundamental skills and tools for effectively implementing change.
In addition, all Collaborative teams were encouraged to meet
on a weekly basis. Most teams had a core group (5-7 multidisciplinary
team members) who met every week for one to two hours over the
lunch hour and then met with the other members of the patient
care module once per month at a regularly scheduled module meeting.
Planning and Measuring Improvement Using a
Rapid-Cycle Approach
The Collaborative teams were encouraged to use a simple yet powerful
accelerated improvement model, as described in The Improvement
Guide: A Practical Approach to Enhancing Organizational Performance1
(Figure 2). This rapid-cycle, "trial and learning" approach
to improvement is an adaptation of continuous quality improvement
(CQI) methods designed to both shorten turnaround times and make
incremental changes at an accelerated pace. This approach has
also been identified as the "quality in daily work"
approach, in which clinicians and employees monitor their own
performance and adjust it accordingly.
 |
Figure 2. Model for planning and measuring rapid-cycle improvement.
(Reproduced by permission of the author and
publisher from Langley GJ, Nolan KM, Nolan TW, Norman CL,
Provost LP. The improvement guide: a practical approach
to enhancing organizational performance. San Francisco: Jossey-Bass
Publishers; 1996. p.10. (The Jossey-Bass business & management
series).) |
In the rapid-cycle improvement approach used by the Customer Service
Collaborative, teams were continuously encouraged to try activities
on a small scale by using the Plan-Do-Study-Act (PDSA) cycle,
1
which teaches teams to try a small-scale change (for example, trying
an activity with only one or two physicians using one or two examination
rooms; or trying the activity with the next three patients). After
observing the consequences of the activity, the team modifies the
change on the basis of what is learned. If the cycle is successful
as shown by appropriate measures, the next cycle may test the same
change on a larger scale or under different circumstances (eg, on
a different time of day or day of the week). If test results are
unsuccessful, the team can try a different improvement activity
and thus not waste time and resources on an unsuccessful activity.
Before solidifying aims or goals for the Collaborative, the teams
were encouraged to look at customer service from the perspective
of patients. On the basis of responses from many focus groups,
customer interviews, and national surveys, the Picker Institute
(Boston, Massachusetts) identified eight "dimensions"
of care that are especially critical from the patient's perspective.2
These dimensions of care helped to ensure that the Collaborative
teams' work toward improving customer service would make a difference
to patients.
Measurements in the Collaborative are derived from results of
locally administered surveys distributed by each team to members
when they come into the office for a visit. Members return the
completed surveys in confidential drop boxes before leaving the
building. The surveys include six questions that are standardized
to enable comparison across teams and three to six questions selected
by each team to measure team-specific improvement activities.
At the start of the Collaborative, teams were supplied with a
computer and a customized data entry and analysis program to enable
teams to track their survey results frequently and independently.
 |
| Figure 3. KPNW Customer Service Collaborative Web site,
designed and implemented as a vehicle for team communication. |
Shared Learnings
In addition to three one-day conferences offered throughout the
nine-month Collaborative, teams were continuously linked through
a KPNW Customer Service Intranet site (Figure 3) that offered a
wealth of current information to participating teams and outside
observers and served as a vehicle for team communication. One team
increased involvement among the Collaborative's entire patient care
module by posting to the Web site all customer service meeting minutes,
member satisfaction survey results, employee satisfaction survey
results, direct patient and employee quotes, tributes to exceptional
employees, team photographs, and all customer service improvement
activities.
Activities Designed to Improve Service
With the assistance of the Collaborative support structure and
regular team meetings devoted to customer service, all Collaborative
teams have been actively pursuing their aims. To date, more than
100 customer service improvement activities are underway. Categorizing
these improvement activities into Picker dimensions of care has
clearly shown that most of these activities are clustered in two
of the Picker dimensions: the Access dimension and the
Information and Education dimension (Figure 4). Two other
dimensions--Emotional Support and Respect for Patient
Preferences--may be considered more subjective because they
involve somewhat ambiguous aspects of the delivery system. The
five Picker dimensions of care include Access; Respect
for Patient Preferences; Continuity and Coordination of
Care; Information and Education; and Emotional Support.
- Access to Care: Patients want access to care and therefore
become frustrated by the barriers they often encounter (eg,
telephone triage or voice mail systems, scheduling difficulties,
overzealous "gatekeepers," or restrictions imposed
by the managed care system).2
- Respect for Patient Preferences: Patients describe
feeling a sense of anonymity and loss of identity in hospital
and clinic settings and a strong need to be recognized and treated
with dignity and respect as individuals. They also express worry
about how their sickness or treatment might affect their lives,
and they want to be both informed about and involved in medical
decisions.2
 |
| Figure 4. Service improvement activities as emphasized
by KPNW Customer Service Collaborative and categorized
according to the five Picker dimensions of care. |
- Continuity and Coordination: Patients have a unique
vantage point on the process of care. Their perceptions of the
competence and efficiency of their caregivers are shaped, in
large part, by how well clinical care, ancillary and support
services, and "frontline" care are coordinated. Patients
often do not understand institutional and functional boundaries
and have difficulty navigating the health care delivery system
effectively.2
- Information and Education: Patients often express the
fear that information is being withheld from them or that they
are not being completely or honestly informed about their illness
or prognosis. In particular, they emphasize the need for information
about their clinical status, progress, and prognosis; information
about the processes of care; and information that helps them
manage by themselves away from the clinical setting.2
- Emotional Support: The fears and anxieties provoked
by illness can be as debilitating as its physical effects. In
particular, patients express anxiety about their illness and
fears about possible outcomes or long-term prognoses; worries
about the effect of their illness on their ability to care for
themselves or for their dependents; and concerns about the costs
of medical care or the implications of the illness on their
family's income.
Table 1 summarizes some KPNW Collaborative
improvement activities included within each dimension of care.
The critical key to all the improvement activities is use of the
rapid-cycle methodology.
Early Findings of the KPNW Customer Service
Collaborative
Tests for statistically significant differences in continuous
and categorical data were done usingt tests and X2
tests, respectively, at the 95% confidence level. All analyses
were done using SAS (SAS Institute, Cary, NC) software.
Patient Surveys Distributed by the Collaborative
Teams
On the Collaborative surveys administered by teams at the point
of service, three of the five standardized survey questions have
shown statistically significant improvement from April 1999 to
July 1999 (Table 2). Significant
improvement has been seen in patients' satisfaction with the interest
and attention shown to them by nurses and medical assistants (p
= 0.0001), satisfaction with how well the provider listened (p
= 0.0001), and overall satisfaction with their medical care experience
(p = 0.0017). No significant change was seen in patient's satisfaction
with the time it took to obtain an appointment (p = 0.134) or
in the percentage of respondents who report that they received
instructions or next steps at the end of the visit (p = 0.218).
Results at the team level are summarized (Table
3). Comparing the April and July overall patient satisfaction
scores shows that two teams achieved a significant increase (p
= 0.0236 and p = 0.0009): one team almost achieved a significant
increase (p = 0.0921), and one team almost achieved a significant
decrease (p = 0.07); the other teams did not show a statistically
significant change in overall patient satisfaction during the
first four months of the Collaborative.
Comparison with Results of KPNW Medical Office
Visit (MOV) Survey
Results of the patient survey distributed by the KPNW Customer
Service Collaborative teams were compared with the results of
another survey, the KPNW Medical Office Visit (MOV) Survey, which
is a mail survey administered by an outside vendor. Results for
the second quarter of 1999 were separated into Collaborative team
data and non-Collaborative team data. Whereas the Collaborative
teams scored significantly higher than non-Collaborative teams
on only one MOV question, the Collaborative teams scored higher
on 76% of the MOV questions, a finding greater than could be expected
by chance alone.
Discussion
The most important consideration in interpreting these results
is that this is a mid-cycle report, not a detailed analysis of
a completed project. At the end of the Collaborative, the final,
complete results, including employee satisfaction data, will be
analyzed in depth, permitting more sound conclusions. Our findings
will be published in a subsequent issue of The Permanente Journal.
Aggregate results from the Collaborative surveys show promising
signs of success. The substantial improvement in Nurse/Medical
Assistant Interest and Attention, Provider Listening, and
Overall Satisfaction is encouraging given the many improvement
activities underway to address these areas. The lack of improvement
in Time to Appointment is not surprising given that none
of the Collaborative teams are addressing this area at this time.
Until now, Collaborative teams have been focusing almost exclusively
on aspects of the patient visit that are under the team's direct
control. The amount of time it takes to obtain an appointment
involves more global system issues and will be more challenging
for teams to address.
Results at the team level are more difficult to interpret given
small survey sample sizes. The consultants for the teams are helping
to diagnose problems and to remedy the situation so that the teams
will be able to continue monitoring their progress.
In addition, the teams are progressing at varying speeds. Some
teams discovered a need to address team dynamics before implementing
many customer service improvement activities and thus are not
yet in a position to significantly impact overall patient satisfaction.
Other teams started strong and are already producing substantial
results. Most teams are achieving results between these two extremes.
The MOV Survey results for the Collaborative teams compared with
the non-Collaborative teams provide additional preliminary evidence
that the improvement activities may be making a difference. Data
for the third and fourth quarters of 1999 will be analyzed and
compared in the same way to determine if Collaborative teams continue
to score higher than non-Collaborative teams in improving customer
service.
Learnings and Next Steps
Teams must function well together before a project of this magnitude
can be successfully undertaken; a key learning from the Collaborative's
work, therefore, is that involvement in the Collaborative can
help to identify underlying dysfunctional team dynamics.
To address the important issue of team dynamics, a portion of
the agenda for the second Learning Session was devoted to team
dynamics and communication. In addition, in future Collaboratives,
this topic will be addressed at the initial Learning Session,
and a structure for early intervention will be designed and implemented.
The support structure in place for each Collaborative
team has been effective for some teams and not as effective for
others. Two especially critical components are 1) the relationship
between team and consultants and 2) the consultants' comfort with
rapid-cycle measurement and improvement, team facilitation, and
team coaching skills. More formalized recruitment of consultants,
establishment of clear consultant expectations, and enhanced training
of consultants will be incorporated into the 2000 Service Collaborative.
In addition, other potential consultant staffing models will be
explored. Another critical component of the Collaborative is the
role of senior sponsors: Allowing teams to help define the role
of their sponsor has been extremely successful.
Local distribution and collection of member satisfaction surveys
has met with varying success among teams. Teams that recognize
the value of the member feedback are the most successful in terms
of collecting an adequate number of customer surveys per month
with a minimum of staff and member dissatisfaction with the survey
process. Teams have had difficulty moving toward alternative methods
of gathering customer feedback (eg, direct interviewing and focus
groups).
Use of the Customer Service Collaborative Web site has
varied greatly among teams. Some teams regularly review the information
posted on the Web site, a few use the Web site to communicate
their project activities, and some teams have not used the Web
site at all. The critical component in this communication-related
area appears to be the role of the consultant, and a more successful
approach might be to have a few select consultants assist all
teams in use of the Web site.
Despite the fact that this is a midcycle report, planning is
already underway for the 2000 KPNW Customer Service Collaborative.
The structure of the Collaborative is continuously being evaluated
for potential improvement opportunities.
Conclusion
The 1999 KPNW Customer Service Collaborative is showing early
signs of success. Although many modifications are planned for
the Year 2000 Collaborative, the main structure of the Customer
Service Collaborative will remain. KPNW senior leadership has
recently reaffirmed its endorsement of the model for moving KPNW
toward an organization known for service excellence.
Acknowledgments: The author would like to thank
Ron Potts, MD, Alide Chase, RN, Tom Janisse, MD, and Heidi Krolicki
for their valuable review of and recommendations for the manuscript.
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