Making the Case for Quality

October 2013

Doctors, Nurses Overcome

Workplace Hierarchies

to Improve Patient Experience Scores in Phoenix ER

by Adam Wise

Doctors and nurses have worked together for centuries, saving and prolonging countless lives in healthcare facilities around the world. And as in so many other professions featuring rich and deep-rooted
histories, hierarchies created long ago have been assumed by modern-day caregivers.

At a Glance . . .
A vision team composed of
Banner Health physicians
in Arizona was tasked with
studying how staff could
improve patient experience
scores while also
reducing litigation risks.
Using the define, measure,
analyze, improve, and
control (DMAIC) approach
and Pareto analysis of
patient experience data,
team leaders learned
that some patients were
unhappy with what
they perceived to be a
lack of communication
between clinicians.
The vision team instituted
a number of process
improvements to please
patients, including an
on-demand survey
program to capture patient
concerns before discharge.
Patients are now 89
percent less likely to
file a complaint when
a physician or nurse
addresses any concerns
prior to discharge.

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So it was no surprise when emergency medicine leaders in Phoenix, AZ, initially struggled in trying to
improve their medical facilitys patient experience scores. But by focusing on the heart of the matter,
and successfully selling a culture of quality to staff, they helped employees overcome social norms to
achieve success for the organization and, most importantly, the patient.

About Banner Health and the Emergency Physician Insurance Program

Banner Health, a nonprofit healthcare provider, encompasses 24 acute-care hospitals and healthcare
facilities in seven states (Alaska, Arizona, California, Colorado, Nebraska, Nevada, and Wyoming)
while employing more than 36,000 individuals. Located in Phoenix, Banner Good Samaritan
Medical Center is a Level One trauma hospital that provides services to more than 60,000 patients
annually. The Emergency Physician Insurance Program (EPIP) is a partnership between Banner
Health, Emergency Professional Services, North
Valley Emergency Services, and Progressive
Medical Associates. EPIP, established in 2003,
addresses challenges involving malpractice coverage, while reducing the cost of malpractice
coverage and overall risk found in five Banner
Health emergency departments.

Reducing the Risk of Litigation

Understanding the importance of positive patient
experiences, EPIP created staff leadership groups,
or vision teams, that sought to achieve better patient
interactions, communications, and outcomes while
also decreasing risk of malpractice. In 2010, EPIP
enlisted the help of Diane Rogers, an Arizonabased quality consultant who owns Contagious
Change, LLC, to help develop a long-term quality
improvement plan that included increasing patient
Gretchen Dallman, nurse manager, Banner Good
experience scores within emergency departments.
Samaritan emergency department.

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Each vision team focused on specific ways to improve services within Banner
Health emergency rooms. The five teams focused on the following areas:

Physician recruitment
Information technology
Risk reduction
Innovation
Patient experience

Charged with improving patient experience scores within Banner Health

emergency departments, Dr. Moneesh Bhow, medical director at Banner
Good Samaritan Emergency Department, and the rest of the Patient
Experience Vision Team, began a near two-year process of digging into
the patient survey data. Tasks included analyzing patient complaints and
identifying ways to improve services. The ultimate goal was to not only
improve the day-to-day experience of patients within the emergency
departments, but to ultimately reduce the risk of malpractice lawsuits. But
Bhow quickly recognized an integral piece to the puzzle was missing from
the physician-only vision team.
Initially I thought it was wasting a lot of peoples time, Bhow said,
because I thought the nurses were equivalent partners in this project and
they needed to have an equal voice in moving our initiatives forward.
Unfortunately, not all of my fellow team members were as excited about
my idea as I.
At Good Samaritan, like many medical facilities, Bhow said a culture
exists that creates a sort of separation between doctors and nurses. Part of
the problem we have in most of our emergency departments is that it was
very much the docs will do their thing and the nurses will do their thing,
he said. Whether we were aligning or forming synergy wasnt part of it.
Nurses probably spend a lot more time with patients than physicians do,
so I felt it should be a joint goal for both sides to be part of it.

Gretchen Dallman, a nurse manager within the emergency department, agreed that motivating the two
sides to work together and create positive experiences
was a cultural change that was not going to be easy or
happen overnight. Change is difficult, she said, with
skepticism being one of the largest obstacles. Ive
had the opportunity to work in a lot of different emergency departments in my career, she said. I have
seen teams buy into culture changes and work well in
some places, and not so well in others.
As they expected would happen, the vision team
received push-back from skeptics within their department when they started to share with colleagues their
plans to improve the patient experience. People in
emergency medicine want immediate results. They
dont want to wait a year on this. So when you bring
this idea to them, they arent very patient to talk about
making improvement over the course of a year,
Dallman said. But through the meetings weve had,
Ive been given a lot of confidence by my team members, and we also hold each other accountable when
were out there leading by example.

Digging Through the Data

Part of the initial skepticism within the rank and
file related specifically to the data. One process
Banner Health uses to collect patient experience data
is through traditional surveys. Two weeks after a
patients departure from the emergency department,
the hospital sends a paper survey in the mail featuring
a variety of questions, which includes asking the individual to rate the emergency department on a scale of
1 to 10. Nines and 10s are the only scores graded as a
positive outcome, while staff does not receive credit
for scores under a nine. Questions related to the overall staff and patient care providers are rated on a scale
of 1 to 4never, sometimes, usually, or alwayswith
the department receiving credit only when rated positively (always).
Seeing that their patient experience scores were
not up to snuff, leaders conducted a rigorous data
analysis using quality tools that included the define,

Dr. Moneesh Bhow, medical director at Banner Good Samaritan

emergency department.

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Eventually convincing his colleagues, Bhow helped

the team acknowledge the integral role nurses play
in the day-to-day experience of their patients and
how any meaningful, positive change within the
department would be achieved in concert with their
co-workers. Is this a deep-rooted problem with the
profession? I think so, Bhow said.

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Figure 1 Complaint analysis

Point of service

17

150

12

200

181

16

Frequency

Frequency

200

Patient survey

250

21
40

100

30

39

io
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of
Pr

Problem category

Problem category

Problem analysis

Frequency

100

100%

90

90%

80

80%

70

70%

60

60%

50

50%

40

40%

30

30%

20

20%

10

10%

Communication Professional
practice

Pain
management

205

na
lp
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Clinical care

Delays

Environment

Other

Process
Split flow

Process
Discharge

Safety

Percentile

250

0%

Problem category

measure, analyze, improve, and control (DMAIC) approach

and the Pareto chart (see Figure1) to understand why some
patients were upset with their level of service received.
Figure2 shows how patient comments were classified for
analysis. Rogers said the patient experience team needed to
identify the key drivers of the overall patient experience via
mailed surveys and patient complaints filed to the hospital,
but at the same time not get bogged down by numbers. The
DMAIC model deals with processes, metrics, outcomes, she
said, but we wanted to make sure we married it with the
human part of creating positive experiences with people and

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continue to point out how they made a difference in the peoples lives they are affecting.
Part of the problem, though, was the lag time from when the
patient left the facility to when staff received feedback, which
limited the hospitals responsiveness. It typically takes six
to seven weeks before a patients feedback reaches hospital
staff from the third-party vendor. And secondly, such data
comes from a very small subset of the total patient population.
Department staff struggled with the concept of drawing any
grand conclusions from such small sample sizes.

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Good Samaritan might see 5,000 patients per month, and they
might get 30 surveys back, Rogers said. That was the whole
thing; they didnt believe the data. To the physician who is asked
to change their practices because of these 30 peopleits not a
tool that engages them upfront. Also, many of the docs believe
that only the unhappy people fill out the surveys, so the people
who had an OK visit arent going to.

stages of the entire patient experience: the lasting impression.

Satisfied patients are less likely to sue, so the real benefit of a
point-of-service program is the real-time conflict resolution, he
said. If a patient has any questions, a provider goes back into the
room to address them before leaving the department. This impacts
the patient experience and also provides us with data to help leaders focus and engage their improvement efforts in the future.

Knowing the mailed surveys had many limitations, the patient

experience team sought to further improve not only how the
hospital received feedback from patients, but also the ability for staff to respond to questions or concerns. The patient
experience team turned to innovation when it created a realtime, point-of-service survey program to improve the reaction
capabilities for the staff to make meaningful strides in helping
unhappy or distressed patients.

From the patient data analysis, vision team leaders also learned
a key indicator of anxiety for the patients focused on communication. They learned that many unhappy patients, regardless of
the care they received, felt there was a lack of communication
between doctors and nurses. To this point, the standard procedure for nurses and doctors was to exchange patient information
at the nurses work station.

Using third-party surveyors not involved in the patients care

typically pre-health college internsEPIP instituted an on-demand
survey system. The interns would visit patients, prior to discharge,
to ask questions that gauged not only their overall experience and
satisfaction with staff, but most importantly, if they had any questions or looming concerns before leaving.
Jake Lansburg, process engineer program director at EPIP, said
the focus of this project was to affect one of the most crucial

Before, the communication would happen behind the scenes

where the patient couldnt observe it, Dallman said. To
improve this perception, we changed the conversation to be more
of a discussion at the bedside so the patient could evaluate and
see for themselves the amount of communication occurring.
Bhow said moving the conversation created quick, positive
results. I was learning so much more about the patient in talking
with the nurses at the bedside, he said. We tried to spread the
message of the perception those conversations have, and ultimately, it just leads to better patient care.

Figure 2 Classification of free-text comments from patients

NRC comments
39. W
 ould you recommend this emergency
department to your friends and family?39287
Definitely no

Probably no
Probably yes
Definitely yes
40. Is there anything else you would like to say
about the care you received during this visit?

They could have been more

time efficient, I sat in the
waiting area for three and-ahalf hours before I got seen.

POS comments
*5. Do you have any concerns about your visit today?

Yes
No

Comment classifications
Classification

Detail

Clinical care

Treatment issues, appropriate care issues, etc.

Communication

Provider, nurse, ancillary staff communication issues,

lack of or delay in communication, ensuring patient is
aware and informed.

Delays

Delays related to ED visit.

Environment

Cleanliness, parking, noise, etc.

Other

Other issues not listed.

Pain management

Patient pain management, timeliness of pain

medication administration, pain control for patients.

Process Discharge

Delays in discharge, discharge instructions, follow-up,

aftercare instructions, etc.

Process Split flow

Intake, movement of patients, etc.

Professional practice

Professionalism and courtesy of providers and staff.

Safety

Patient safety concerns, medication errors, etc.

If Yes, please explain what your concern is:

Provider was very rude

NOTE: Comments with multiple components were duplicated and assigned classification for each problem category when necessary.

ASQ

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Happier Providers = Happier Patients

Beyond the data collection and analysis, the patient experience
team also focused on the emotional side of the equation, specifically as it relates to staff. While process improvements are
often needed in quality projects, long-term success can only be
achieved through widespread buy-in and support from staff.
At this point, a major focus of the improvement project was centered on engaging the clinician. Simply put, how the staff viewed
their world (including how they approached each day, each conversation) affected how the patients ultimately perceived their
clinicians and the quality of care they provided. This means a
culture change had to take place, Dallman said, so the vision team
turned its scope away from the patients and onto themselves.
I have to say that early on you have to be extremely dedicated
as a leader, Dallman said. It takes one person to stand there
confidently and to say, This is important, and this will work,
and slowly over time, it happens. Another person will stand up
and say that they feel it too, This was my experience, and why.
The grumbling happens, but in any conversation that you have
about what your objective is, even if its a negative conversation,
its still a conversation.
The staff, Dallman said, had to learn how to appreciate all
patients. In an emergency department, she said its easy to celebrate the victories of saving a persons life, but its harder to
appreciate the routine patient visits. She said the gap between
what a patient feels and what her staff knows to be true could
create sour feelings. We were scoring very well with the
patients who were really sick, who we knew really had to be
there, and we wanted to take care of those people, she said.
But the people with a sore throat, cough, or cold, we sometimes
feel like they dont belong in our department because were so
focused on treating life saving situations.
Dallman said she had to work with staff in stressing the importance of treating all patients with a smile and with empathy.
Since the general population is not equipped with the same
knowledge of medicine as the staff, the nurses and doctors often
have to help non-emergent patients in the department. For
instance, we know the difference between what a compromised
airway is and what isnt, Dallman said. The average person
doesnt understand thatthey see a little bit of change in breathing and their immediate thought is, This could be the end for
me. We must be respectful to them; theres no such thing as a
stupid ER visit.
While there wasnt one specific change that prompted pushback from staff, the overall attempt to improve the emergency
department psyche was met with skepticism by many employees,
Dallman said, which tested the will of vision team leaders. I try
not to let grumblings about my Pollyanna Plan to make things

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better worry me because more and more people started to believe

this was the right thing to do, she said. Everyone wants to be
treated nicely and feel that they are cared for.
Rogers said regardless of the setting, employees can become so
entrenched in the day-to-day work that they lose focus of the
big picture. The challenge is we lose sight of why we went
into healthcare in the first place, she said. We challenged the
docs and the nurses to turn their observation skills on and to
see how their own attitudesabout their colleagues, patients,
and work lifewere contributing to a positive or negative day.
We actually challenged them to look for what was positive.
One other process improvement the patient experience team incorporated was including story time within preshift meetings. This
change involved staff members sharing tales of patient care victories, large and small. We get drilled with so many numbers, data,
and stats, that sometimes we lose focus on what were trying to
achieve, she said. One person told a story about how he talked a
suicidal gentleman off the edge of our parking garagejust things
to engage the staff and remind them the reason why we exist.
When we started talking about the experiences and the care that
they provided, it changed the whole perception.

Results
While survey data helped the patient experience team identify
improvement opportunities within the department, the pointof-service program specifically has helped curb the risk of
litigation, Lansburg said. Comparing when service recovery
(when the provider returned to the room following the pre-exit
survey to address any looming concerns) took place in 2012, to
when it did not take place, the results were staggering.
Patients were 89 percent less likely to file a complaint compared to circumstances where the provider didnt re-enter
the room. That has a huge financial impact to the hospital,
Lansburg said. [For] the labor hours of going through the charts
and calling the patient back following a complaint, we estimated
a savings to the hospital of about $400 per complaint avoided.
Rogers added the improved survey data is important, but numbers cant tell the entire story. The culture change is difficult
to measure because the change comes through people, not
processes, metrics, or outcomes.
Bhow said he noticed his staff turning the corner in early 2013,
when the tone of email communications changed from complaints to compliments. While he still tries to be creative in
making the project new and exciting for his staff, he has seen
massive buy-in from doctors and nurses.
Ive heard conversations of people saying, Oh, its not that
bad, and they try doing what they can to help change the

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conversation, Bhow said. At that point, it almost becomes

a herd mentality, where it becomes cool to be on the boat as
opposed to off the boat.
Dallman said her plan is to always focus on the positive. When
you see a staff member who doesnt want to play in your sandbox, your first thought is to turn the frown upside down, but you
waste so much energy that you miss all the people on the sidelines who have come along so easily, she said. Eventually, that
one doctor or nurse will feel outnumbered, and maybe at that
point in time theyll need to make a change.

For More Information

Learn more about Banner Health and its 24 healthcare
facilities in the western United States.
Explore all the programs and services offered by Good
Samaritan Medical Center.

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Discover Diane Rogers method for strategic improvement

within healthcare organizations by visiting Contagious Change.
For more case studies on continuous improvement in
healthcare, visit the ASQ Knowledge Center at asq.org/
knowledge-center/case-studies.

About Contagious Change, LLC

Based in Mesa, AZ, Contagious Change, LLC helps healthcare
organizations establish repeatable analysis, design, and execution
methodologies to achieve performance improvement and risk
reduction goals. Diane Rogers, who owns Contagious Change,
seeks to motivate and inspire individuals and organizations to
achieve new potentials together.

About the Author

Adam Wise is an ASQ staff writer.

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