The Patient Experience

Putting the patient first


Methodist International sponsored and hosted a panel discussion, with leading figures in the healthcare industry in the UAE, to look at and assess what can be done to improve the patient experience in hospitals and medical centres in the region. Callan Emery, editor of Middle East Health, acted as moderator. This is their conversation.

Callan: What guidelines or methods do you consider pertinent to avoiding medical errors to ensure patient safety and quality of treatment?

Linda: Getting an organisation focused on how to reduce the risk of error is difficult if you approach it in fragmented ways. We have seen that when tasked with one particular goal, such as accreditation by JCI or other accreditation systems, the motivation and awareness of the healthcare providers and support staff is focused on the importance of reducing risk and medical error. And because it is all-encompassing, not just clinical, you have an opportunity to develop an organisational culture. The main objective is that we are here to provide safe patient care, and that has to be a passion.

Patricia: We have found that concepts such as time outs in the OR assure that there is extra attention paid to ensuring that there are no medical errors.

Lauren: Communication is absolutely key. What the most effective organisations have done around the world is to establish tactical approaches that allow people to have methods by which they can communicate with their groups. We recognise that there are multiple languages spoken here, so in order to achieve our patient safety goals and aspirations, it is very helpful to find ways to be prescriptive, to find ways to communicate with each other and to allow a structure to be designed to enable caregivers to communicate effectively among themselves and patients.

Callan: What do you think is the best way to establish effective communication structures?

Pietie: We have established clinical hospital committees that are truly multidisciplinary (doctors, nurses, management, etc) that address clinical issues. We also have a hospital event management system in place to monitor the occurrence of adverse events and have also implemented an infection control programme in all our facilities. We participate in credible international outcomes databases, such as Oxford Vermont Neonatal database, APACHE scoring system in Intensive Care units and others, and we thereby benchmark our outcomes to improve the quality of care delivered.

Linda: Many of us have used accreditation as a pathway to achieving better patient safety standards, and to improving the patient experience, but it is only when clinical staff and support staff begin to understand ‘why’ we have embarked on this path, rather than simply doing the necessary things to achieve accreditation, that they catch on. That’s when they really start to add input to the cause and don’t think of it as a burden on their shoulders. That is when it becomes a part of their way of thinking. This is the culture.

Chris: As a doctor used to practising in the UK – and I think this is relevant to other foreign doctors practising here – you have to have a cultural understanding of the patients you are treating. You need to take a step away from your own culture and try to understand the patients you are seeing. The way things are done here is often different from the way they are done in the UK. Patients here may have a different core understanding of what healthcare is, what to expect from healthcare and understanding disease processes.

Callan: What do you think you can do to assist understanding within this cultural diversity?

Chris: Be here for the long term. Flying in doctors does not allow for a relationship to be built. Talk to your patients, improve relationships.

Callan: Let us look at quality of treatment in the patient experience. Can you expand on this?

Omar: This is a subject that is sometimes taboo in the industry – that is the opposing forces of the business side versus the clinical side, which is healthy, but the people at the top must understand that it’s only good business if clinical outcomes are at the core of the business.

Pietie: Quality is important. There has to be practical ways to enable staff to adhere to the systems in place. The Surgical Safety checklist (developed by WHO) that is used in the operating theatre is a practical example of steps that are taken to avoid wrong side surgery, for instance.

We feel very strongly that results should be available to the public and we actually publish our data, such as mortality rates, infection rates, operations, readmissions etc. These clinical indicators are seen as a proxy to the quality of care. I think having knowledge of these statistics is important for patients to enable them to choose a reliable healthcare provider.

Sarper: Yes, in addition, we want to avoid the ‘never events’, such as operating on the wrong patient or deaths from medication errors. We need to look at the tools involved. If the correct culture is in place in terms of leadership and presence, what are the tools that we can use to prevent these events? How can we merge these tools with information technology and design?

Lina: In terms of patient safety and ensuring that implemented procedures are adhered to and tracked, information technology can be a very effective tool. An example would be the patient identification file to ensure that the right patient is identified and given the right medication with the right dose at the right time.

Callan: Architecturally, how can you improve patient safety and the patient experience?

Onno: As an architectural company we design to international standards and it is generally a requirement from the client that the hospital gets accredited, so we also liaise with the Joint Commission, which sets certain design standards. So, from a design point of view, usually it’s covered by implementing the appropriate standards. However, one thing I have learned through my dealings with various user groups is that it is very important when you start designing a project that the user group is diverse in terms of roles and cultures. It’s really important that you have someone there from each field to add input including doctors, nurses, facilities management and general management. If you get the right structure in place at the start of the project, you will cut out a lot of mistakes.

Publishing hospital data

Chris: Pietie, you were touching on publishing reports and I wanted to ask if this is helpful? What is the benefit of producing a detailed list of who’s the best and who’s the worst?

Pietie: Our intention is to improve quality; proper data is also a useful management tool and alarming statistics such as an abnormally high mortality rate in one of our facilities will assist us to intervene early and avoid adverse events or outcomes. We encourage employees to report adverse events and the intention is not to blame or shame them, but to improve the quality of care. That is our philosophy. Transparency is important and, as mentioned earlier, we participate in open databases across the world.

Linda: Thank you for bringing that up. There is a fear among organisations about publishing their data. As I have seen in different international healthcare organisations there is a huge, gaping hole in terms of opportunities to benchmark against other facilities. I believe that there is definitely a need for organisations to input their data into a pool and then have access to publications of other facilities to understand their comparative position, and then be able to implement the necessary measures to improve that position, to improve the patient experience. Without this you do not know if you are on the right track.

Patricia: Using clinical quality data and sharing it with the staff is a very powerful motivator, primarily because people go into healthcare as a calling, not to become a millionaire, and nobody wants to do a bad job or to hurt or harm a patient, but if there’s no data, you’re just talking anecdotes; it becomes very difficult for healthcare providers to understand what they need to do to improve. And to have a goal, or something, to indicate that ‘we did this and look at our improvement’ is needed.

Sarper: Being based in the USA, we come from a culture where publishing data is the norm. When it comes to publishing data, questions about the quality of the data, the terminology, etc. can also arise. At Methodist, we are also part of the University Health Consortium, which is a group of hospitals and academic medical centres in the US which uses a third party to collect data and analyse it.

Onno: We as designers would love to have access to this information because I think we could learn a lot from it. It can also assist us with our designs.

Callan: What methods have you put in place to “personalise” the patient experience in your facility?

Patricia: We’ve initiated several customer service training sessions with our staff and they are very basic, simple ‘human being’ kinds of things that seem to make quite a difference. Some include establishing eye contact with the patient immediately, saying your name and saying the patient’s name correctly, is very important. It really is important that the critical early interaction is positive, whether it’s direct human interaction or if it’s over the telephone; people can hear you smile through the phone.

Omar: From our perspective, we just recently launched our first facility and throughout the entire planning process, we approached this with the patient experience at the core of the facility. In the planning process we looked at the entire patient journey from the view of a clinical operator, or as somebody from the hospitality industry would view it, even down to asking the necessary questions, when the patient first comes in, to find out their likes and dislikes, such as temperature, lighting, music, and so on. The objective is to provide a highly personalised experience, to the extent that we even have a concierge at the front desk to greet the patient and track patient waiting time and movement in the clinic.

Linda: Communication is key, once again. Whether it’s eye contact because of different cultures and languages, ongoing communication is certainly huge and the aspect of personalising the experience and understanding that they are not just a patient, but that someone recognises ‘who I am’. The impact of long waiting times, for example, can be greatly reduced if someone simply goes to that person to say “we know you’re still here and we apologise because we have not yet got to you”.

At Al Corniche Hospital we are working on implementing a service excellence programme based on the Johns Hopkins model. It ensures people understand the importance of communication and the human touch aspect is crucial.

Pietie: We have tried to create a personalised experience with either a call or SMS to remind patients about their appointment. We also conduct a patient satisfaction survey with approximately 10 questions about their experience in terms of the doctors, administrative process, waiting time, etc. We evaluate these responses on a monthly basis and the customer relations department follows up to address problems and improve the total patient experience.

Patricia: Patient survey tools are an excellent way to find out what your clientele is thinking and sometimes you will find out things that you didn’t know were going on in your own hospital. It is an eye opening experience. We do the same thing, we give the feedback to the leaders at the department level, and performance improvement initiatives are enacted as a result.

Pietie: I have even considered a survey amongst some of the doctors to obtain their experience of the management, because I’m sure we make mistakes in our approach and we’d like to hear about it.

Omar: The patient experience is an essential trend now and comes back to the way healthcare is actually viewed by the patient. Physicians have to remain slightly emotionally detached from their patients, to protect themselves emotionally, and this affects the doctorpatient relationship. Invariably patients primarily remember the experience, and the treatment is secondary. They remember that they waited a long time or that they felt like a mere number. This is where the hospitality industry comes in. They excel in facilitating a happy client or customer experience.

Callan: I think that is an interesting point in terms of the doctor-patient relationship. Can you elaborate on that with your experiences? Do you think that a patient sometimes wants that emotion from their doctor but doesn’t get it?

Chris: I think we have to understand that the whole role of healthcare is not to keep people alive for a thousand years, but our role is to make people well again. But if they are not going to get well then trying to help them to feel better about themselves, to make them happier, is the next best option. I completely agree that how long they waited is the thing they remember much more than what the doctor told them about the disease. And so in terms of how happy they are, dare I say it, seeing a slightly substandard doctor, who is kind, communicates well and doesn’t make major errors, actually does better than having a doctor who may technically be the best surgeon in the world, but can’t communicate, can’t make contact with the patient and can’t get the message across.

Omar: I couldn’t agree more. I think humans have an innate ability to sense a smile or even sincerity, as previously mentioned, over the phone. You may be an excellent surgeon, but you may come across as being cold by trying to remain emotionally detached. The patient, on the other hand, may view that as ‘the doctor doesn’t care’ and ‘he’s just there to do a job’. There is a very fine line between these two, and there must be that give and take.

Lauren: I agree, I think you raised a very important point and that is ‘caring’. There are so many healthcare professionals that develop a hardness to protect themselves. So one thing that we’ve been thinking about systematically across the industry is how to put caring back in the process. To some extent it can be taught through communication courses. Some organisations that I have worked for in the US have come up with something called a ‘caring moment’, where you systematise for every nurse an approach that requires them to sit with a patient eye to eye and ask key questions.

Sarper: If I can reiterate on the tactics a bit more. About five years ago Methodist Hospital decided to move into the patient experience and, you can imagine, for a 90-year-old facility, it was a bit challenging to make that change. Obviously the challenges in the USA are different than here. Here we I think that everyone from the janitor up to the CEO has to have clinical quality at the core of what they do and they all have to know how it contributes towards the goal of patient safety and care. have to increase confidence first, then think of the patient as a guest in the hospitality sense rather than just a patient.

Callan: Onno, can the personalised experience be incorporated into the design of a hospital?

Onno: Ten years ago rooms looked very clinical and were purely designed to be 100% efficient. Now we are seeing a trend where hospitals are becoming more like hotels and patient rooms more like hotel rooms, with direct access to services as well entertainment systems and bar fridges.

It makes you wonder if hospitals need to employ hospitality consultants and managers to assist healthcare workers in dealing with patients. Certainly the last few hospitals I have worked on are themed and are more like 6 or 7 star hotel/hospitals, where the interior finishes are more hotel-like in quality and aesthetics.

More facilities are being provided in hospitals. Nowadays you’ll find banks, restaurants, shops and a day care centre. You can even get the opposite where medical clinics are now located in shopping malls. We feel that as designers it’s becoming a mixed-use project rather than purely clinical.

Middle East culture

Chris: When I see an Emirati patient I seem to be dealing with the family rather than just the patient – the interaction is different. When I see a 50- year-old Emirati woman, for example, I will never see that patient without a male member of her family in the room and, although culturally it is unacceptable for her to look me in the eye, she sits down and I still have to examine her eye. So the situation becomes incredibly difficult. She won’t look at me so I can’t examine her eyes. And when I talk to her the male relative answers the questions. When I am trying to explain the problem it’s the male relative who is listening. But when they walk out, who is happy? I feel I’ve had a good conversation with the male relative of the family, but not the patient.

Omar: I think this stems from the culture in the region. Firstly, the woman is not the decision maker. The patient is the mother or wife, but the customer is actually the son or husband who speaks on the patient’s behalf.

Lauren: So then in this scenario, we should think about how we can educate the male member of the family to be a health advocate, and as diseases become more complex in this region and the social dynamics around healthcare choices change, we need to think about how we can educate the customer to help the patient.

Pietie: To help bridge the cultural divide, we provide a basic Arabic course to our staff, which focuses not only on the language, but also the culture.

Callan: Do you see an imminent shift in the way we treat patients due to the region’s rapid expansion in the next five years or so?

Patricia: One of the things that we have seen is a change in health insurance. For example, the number of patients visiting us with health insurance has doubled from 2008 to 2009 and we expect this to continue increasing. There is a very steep learning curve in terms of procedures, policies and marketing aspects related to health insurance. This will cast a whole new light on healthcare in Dubai.

Linda: The world of healthcare is becoming smaller. The expectations of patients are increasing because of better education, particularly for women, and because of greater access to information. This will drive us to be increasingly aware of patient safety and positive outcome issues, while remembering that the patient is a person.

People from the region are still seeking healthcare in the ‘West’. And the perception is that the level of care is better in the West. So I think we are going to see an increasing demand in the region for better quality care and improved patient safety. And in this part of the world, I can see that happening very quickly.

Callan: How do you think you can make it known to the public that this is happening here, to make it known that some places here offer quality healthcare that is on a par with some of the best in the West?

Linda: I think it harks back to the benchmarking and publication of data, and to have transparency about what is happening at the different organisations. The focus is going to come back to that. This is a challenge, from the business, clinical and the patient’s perspectives.

Sarper: We are seeing expansion of healthcare in the region; more facilities are coming online. There is new information technology and design technology that will change the way we provide care aside from patient safety. I think the more people talk about the patient experience and patient safety, the more it will increase exponentially in the curricula and training of healthcare professionals.

Omar: If you look at this region – let’s define it as the Middle East and North Africa – there are a few points to take into consideration with regards to the provision of quality healthcare:

a) There is a huge disparity in the quality of care across the region. This is shown by available statistics, facts and figures.

b) There are varying nuances and slight differences in culture across the region, which should be understood.

c) The level of competition among healthcare providers varies, yet it is this competition which drives the improvement of the quality of care. For instance, if you are the only healthcare provider in the country, what is the incentive to change, to improve your quality of care?

d) The level of sophistication of regulations and insurance.

e) The quality of practitioners available.

Lina: It may be just a new trend over the past year or so, but there has been the introduction of the cost aspect of healthcare. People have invested in building new facilities with a very high patient flow expectation and are now suddenly faced with the fact that they don’t have it. They face an extra set of challenges with insurance companies, with competitors, etc. So I see a lot of questions being asked about how we can save money by automation, cost saving processes, what are the tools that we can use to help us survive. The financial aspect is becoming increasingly important.

Pietie: I think there is a huge gap in the regulatory part of the insurance industry market. There is no central regulating or reporting body where the solvency rates, reserve ratios and other relevant data of the different insurance companies are published. A central body will be an important forum to negotiate proper tariffs for the entire industry especially for hospitals with a high inpatient cost structure.

Callan: In terms of automation of processes – such as financial records and patient records in hospitals and medical centres – how do you think this will affect the patient experience?

Lina: We [IBM] have a view of what’s happening in the region and where we see this going in the future. The patient record, or the patient history, as they say from birth to death on one system, which can be updated by the different healthcare providers, is the vision. We are still very much behind this vision of having one integrated medical record and people are taking steps toward this vision. Integrating the Electronic Health Record of patients, using telemedicine and implementing disease management is where we are headed, not only on facility level, but also on a city and country level. Now to get to that point it may take 5, 10 or even 20 years, but it is the implementation of this vision that will ultimately improve the patient experience.

Dina: While it may be true that technology and information technology are important for the patient, the one thing that the patient will continue to look for is quality of care. So before they can have confidence in the technology, they must first have confidence in the care provider, and that’s why people first look at the reputation of the doctors, before looking to technology.

Sarper: To add to that, it depends on how much and which technologies are valuable for the patients you are serving. You can then begin to look at your population demographics and develop a strategy to show that.

● This is the first of a series of panel discussions that Methodist International will be holding over the next year, providing a platform for discussion amongst leaders in the healthcare industry to collaborate and share insights. 

ate of upload: 26th Jan 2010

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