Case Study: How Employee Engagement Affected Outpatient Satisfaction Scores
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Healthcare administrators face the unique challenge of improving employee engagement and patient satisfaction, two factors that are deeply intertwined. In a tight labor market with more open jobs than potential employees1, retaining great talent has never been more important. Furthermore, studies show that engaged employees are more productive and more likely to remain with an organization2.
Engaged employees also tend to deliver better care, which translates into stronger patient satisfaction scores. These satisfaction scores directly affect hospital reimbursement through CMS’s HCAHPS program3. And as patients become increasingly savvy, sharing their experiences online, the connection between employee and patient satisfaction becomes even more acute. Departments that invest in employee engagement, such as through shared governance models, have demonstrated measurable improvements in staff engagement and patient experience4.
The Issue: Low Patient Scores
The connection between patient and employee engagement became especially relevant at High Point Medical Center, where outpatient satisfaction scores in the Fluoroscopy Department lagged behind peers. The comparison was based on the specific question, “Would you recommend this facility to others?” Another callout was the question “Did staff explain things in a way you can understand?”
It is worth noting that the providers explaining the procedures in Fluoroscopy are the same providers explaining procedures in Interventional Radiology (IR). The IR department had the highest score for “staff explained things.”
Identifying Additional Issues
All imaging departments at this facility previously opted out of patient reminder calls. There were issues with patients showing up to the incorrect site because the academic medical center’s name was also the company name listed in the message. Patients with multiple appointments received a reminder for each individual appointment and were confused about what time they needed to arrive. Multiple patients were showing up at the same time: some were late, some were on time, and some patients were very early
Time was wasted waiting to see if someone would show up for their appointment, making it difficult to add inpatient studies between outpatient appointments. As a result, the schedule was routinely behind, and technologists were stressed out and very frustrated. Patients were frustrated with longer wait times, too.
Troubleshooting
The data that came from the Patient Satisfaction survey did not lead to a clear root issue or solution. Troubleshooting in our departments generally happens amongst the team during weekly huddles. This issue was brought forward, and we asked the team: What was happening that would make the fluoroscopy patients feel they were not receiving clear explanations when the IR patients were very satisfied?
We showed the team the data and asked for comments, ideas, and questions. No one understood what was causing the wide gap in scores. One fluoroscopy technologist was particularly stressed about now-show and late patients and asked if they could start calling these individuals with reminders. This was one of the easiest and most immediate “YES” responses I’ve ever had as a leader to a teammate’s suggestion.
Creating a Plan
The newer technologists were shocked, some horrified at the suggestion of reminder calls. The discussion about patient satisfaction quickly pivoted to these concerns. The team wanted to ensure they would not inadvertently violate HIPAA and had questions about what could be left on voicemail. The newest teammates were the most nervous about knowing what to say if the patient or family asked follow-up questions. How could the team see the patient’s phone numbers easily and then track which patients were called?
A written script was offered until the team became more comfortable with what needed to be said. They were assured it was perfectly acceptable to tell a patient they did not have an exact answer but could put them on hold to find out. I also volunteered to be by their side to offer support, if needed, while they made phone calls.
If the patient needed to cancel or reschedule, we could immediately transfer them to the scheduling team. The electronic medical record has a Department Appointment Report (DAR) that can be customized to include the patient’s name, appointment type, scheduled time, and preferred phone number. While these were simple solutions, in the moment while emotions were high, the team appreciated having these options to ease their fears.
Standard work was created after collaborating with the technologist who proposed the idea. The script and DAR report were created and shared with the team. The technologist created a binder with protocols and other helpful hints, and the script was added to the book.
As people rotated into fluoroscopy, the DAR report was saved to their logins for easy access. Techs would print out the DAR and use the paper to keep notes on who they called, if they spoke to a person, if they left a message, or if there was no answer. If someone was called away mid-task, it could easily be picked up by another teammate. Then they would turn in the document to me to create perceived accountability.
The task of making phone calls was assigned to the fluoroscopy tech of the day, but they could ask a colleague for help or trade off. While the data was never used for real accountability, only for tracking outcomes of phone calls, knowing they had to turn it in helped motivate some teammates to call patients.
Immediate Outcomes
There were two very common responses when we spoke to patients. First was a list of questions: “I had no idea about this appointment. What is it for? Am I going to be put to sleep? Are you putting something down my throat?”
These appointments are commonly made with the outpatient office, who then gives the patient their arrival time and instructions. It was clear that some offices were not explaining what to expect in a way the patients understood. Some patients receive so many appointments at the same time that they get an endoscopy appointment mixed up with an upper GI or esophagram appointment. These questions were easily answered during the reminder call, as the patient could speak with a technologist that performs the exams and goes over all the pre-procedure instructions.
Coming out of these phone calls, we also learned that a number of patients thought their appointment had been cancelled, weren’t able to make it, or needed to reschedule. Anyone needing to reschedule was immediately transferred to the schedulers. Knowing that a patient couldn’t make their appointment saved us time. The team could coordinate with the inpatient nursing teams and get inpatient exams done earlier in the day, particularly for the patients with orders to withhold food/drink until after the study.
In reviewing the first few weeks of data with the team, there were two days that had a number of no shows. When discussing in a team huddle, we learned that no one made reminder phone calls on those days because the main fluoroscopy tech was off. The team expressed how stressful those days had been; and because the trial was working so well, they knew how much better those days could have gone. This was an excellent call out by the younger generation of techs. The experience really helped them step up and face their hesitation of calling patients.
Tools and Concepts
The team was able to quickly pivot during our huddle thanks to the educational efforts of the facility’s (then) chief operating officer (COO) and the department director’s prior knowledge of LEAN Six Sigma methodology. That foundational knowledge helped cultivate a culture of LEAN thinking in the department and the teammates felt comfortable sharing their ideas and concerns in the moment.
The COO led a biweekly meeting called Embedded Coaches, open to anyone who wanted to learn more about change management. This provided education on LEAN terms and tools to discuss and apply to ongoing projects in the hospital.
A points system was developed, which led to an internal certification. Some A3 projects were assigned to coaches from this group, and small projects were managed by coaches from within the project department. Coaches with more experience were assigned to help other teams with projects if there was not a coach on that team. The main goal for all projects focused on keeping a respect for the people doing the work being discussed.
An internal webpage was created to store document templates, as well as a list of terms and definitions. This made the information easily accessible to everyone. A few common terms the team uses are:
- Cross huddling: Teammate from one department attends another department huddle to share ideas, ask for, or provide feedback.
- Elevation: Escalating an idea through the chain of command.
- 5S: Sort/scrap, straighten, scrub, standardize, sustain; a method for maintaining a clean, uncluttered, safe workspace.
To track ideas generated during team huddles, the page also includes links to “idea cards.” These cards were placed on huddle boards to show the status or any updates for the change. A3 and Waste Walk templates are also available. As new teammates joined the Embedded Coaches group, the terms and tools would be revisited so everyone learned how to use them.
Outcomes
From January to April 2023, the number of no-show patients logged in the Electronic Medical Record (EMR) showed a monthly average of 11.25 patients. In the first half of May, only two patients were no-shows — a 30% reduction. Additionally, the average reimbursement for fluoroscopy procedures at our facility that year was $441.07. If seven additional patients were able to have their exams, that generated $3,087.49 of revenue that was not lost due to no-shows.
The Fluoroscopy Department kept track of each call and if they were able to speak to a patient or family member; if they had to leave a voicemail; if they were unable to leave a message (LM) or make reminder calls that day; and if the patient canceled or rescheduled during the reminder call. (See Figure 1.)
We also tracked each type of contact made for the no-show patients. (See Figure 2.) This information was more important in the beginning of the project. Most of the no-shows in the first three weeks were because no reminder calls were made the day before. That reflection on how those days went immediately convinced everyone why the calls were important, even though there was a lot of anxiety about making the reminder calls.
Figure 3 shows the relationship between the type of call and if the patient came for their appointment, no-showed, or rescheduled. All of the different reasons why contact was not successful were combined into “unable to contact” for this graph.
Figure 2. Type of Contact for No Show Patients
Figure 3. Outcome of Patient Calls
Over the next several months, our total no show rates decreased by 41.4% and our patient volumes increased. Figure 4 highlights the number of no shows the year before, during, and after initiating reminder calls. The fluoroscopy schedule runs efficiently. Patients are on time and we can fit inpatients into known schedule gaps. The team was less stressed and said so in their huddles. More importantly, the team knows we take their suggestions seriously and are now more likely to speak up and make suggestions for improvements.
Figure 4. Fluoroscopy No Shows Over Time; Reminder Calls Start 4/25/23
As a bonus, we generated additional revenue. Using the 2023 average reimbursement amount for fluoroscopy procedures on our campus of $441.07, the estimated uncaptured revenue for 2022 due to no shows was $75,000, or $6,250 per month. In 2023, that value dropped to $47,000. The extra 10 minutes of work making calls per day generated approximately $28,000 a year.
The best outcome was totally unexpected. The team ended up increasing their outpatient satisfaction score for the question “Would Recommend Facility.” (See Figure 5.) Patients and their families genuinely appreciated having the opportunity to speak with a technologist that could answer their questions before the appointment. The average score for January through April 2023 was 77%. The average score from April 24, 2023, to December 31, 2023, was 84.7%. To achieve a 6.9% gain in survey results is incredible, even when there is a detailed effort dedicated to that outcome. For that to happen unexpectedly was a wonderful reward and testament to the team’s hard work and dedication to providing excellent care for their patients.
Figure 5. Outpatient Satisfaction Scores 2023
Conclusion
The discussions in team huddles were successful because of the culture already in place for the department and the hospital. With consistent reminders of ongoing continual improvement projects, we were able to keep a mindset of constant curiosity. The openness that curiosity brings allows for a safe space for ideas to be freely shared and discussed among the team. I always allow for folks to drop notes in my office with ideas in case anyone is nervous about speaking in the group. I bring these suggestions up anonymously, even if I’ve had in-depth discussions to understand their point of view. People who used to be nervous to share will now freely speak up because they see how we approach new ideas.
Creating the best workflow that meets the needs of the team, while keeping a focus on the patient and the patient experience, requires a full team effort. We are only be as successful as our least engaged teammate.
References
- Bureau of Labor Statistics, U.S. Department of Labor, The Economics Daily, More job openings than unemployed people since May 2021 at https://www.bls.gov/opub/ted/2023/more-job-openings-than-unemployed-people-since-may-2021.htm (visited November 06, 2023).
- Harter J. The right culture: not just about employee satisfaction. Gallup.com. Published April 12, 2017. https://www.gallup.com/workplace/236366/right-culture-not-employee-satisfaction.aspx
- Centers for Medicare & Medicaid Services. HCAHPS: Patients’ Perspectives of Care Survey | CMS. Cms.gov. Published 2020. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/hcahps-patients-perspectives-care-survey
- Duemig, Micah, MSN, RN,N.E.A.-B.C., N.P.D.-B.C., Hicks, Amy, DNP, RN, ACCNS-AG,O.C.N., N.E.A.-B.C., Price, Karen,B.S.N., R.N., & Piantino, Melanie,M.S., D.A.B.R. (2024). ON FIRE FOR PATIENT CARE AND THE PRACTICE ENVIRONMENT: IGNITING INTERPROFESSIONAL SHARED GOVERNANCE IN RADIATION ONCOLOGY. Oncology Nursing Forum, 51(2), 119C,120C. https://wake.idm.oclc.org/login?url=https://www.proquest.com/scholarly-journals/on-fire-patient-care-practice-environment/docview/2961738044/se-2