Sunday, March 7, 2021

Zachary Walston's COLUMN

How Do We Define Success In Healthcare?

The answer often differs depending on who you ask

Measuring success can be a tricky endeavor. It is quite relative as there are many domains of success and interpretations of outcomes; it is not always a binary outcome.

One patient may view success as meeting their goal of running a 5K pain-free in under 25 minutes. Anything less is a failure. Another patient may view success as simply finishing the race, even if walking breaks were required.

We don’t all live by the Ricky Bobby mantra of “If you ain’t first, you’re last.” How does everyone else in healthcare measure success?

If you ask a researcher, success may be exceeding the minimally clinically important difference (MCID) or achieving a greater level of change relative to a control (with acceptable p-values and confidence intervals of course).

If you ask Medicare, success is determined when a patient is “functional” (because that isn’t muddy at all…). If you ask a therapist, it may be 0/10 pain, full range of motion, 0% on the Oswestry Disability Index, or a beautiful single leg pistol squat with absolutely no compensation, pain, or difficulty.

But what if the patient doesn’t care about any of those things. How do we juggle the markers of “success” for all relevant stakeholders?

There is not a simple one size fits all answer. What I will try to untangle are the factors that influence how satisfied a patient is with physical therapy.

Why does this matter? Patient satisfaction has a substantial impact on both current and future performance. How a patient perceives their care can dictate the success of interventions, their compliance with care, how they speak about their providers in public, and potentially future reimbursement.

So, patient satisfaction is kind of a big deal.

THE DOMAINS OF PATIENT SATISFACTION

Patient satisfaction questionnaires target many different domains. At PT Solutions, the practice I work for, we ask patients their satisfaction with the treatment they received, the information provided about their condition, their input on goal settings, access to the physical therapy facility, and the availability of convenient appointments. I then receive a scorecard containing all individual scores and the overall satisfaction — an average of the five questions.

This provides us a substantial amount of information and allows us to tease out potential issues and highlight areas of strength.

Quick note, patient satisfaction scores are only valuable if we act on the data. Treating data as a “fun fact” is essentially useless and does not allow us to grow as clinicians. Of course, the data must be accurate.

Ulterior motives and biases can impact the answers patients provide and when the clinician provides the surveys. For example, if a clinician asks a patient how satisfied they are with face to face, they are more likely to receive a positive report. Most people do not like confrontation. This is different for outcome measures.

Outcome measures are designed to highlight functional areas of difficulty. These are best completed with the clinician present. Incorporating Patient-Reported Outcome Measures (PROM) throughout a plan of care has the potential to promote shared decision making between patients, their families, and clinicians.

PROM assessment heightens the provider’s awareness of patients’ health concerns and facilitates communication regarding available medical evidence for optimal treatment options. Geroge et al found patients who were satisfied with symptoms reported higher physical function, lower pain intensity, and less symptom bothersomeness (great word chosen by the authors) at six months.

The two strongest absolute and unique predictors of patient satisfaction with symptoms at six months were whether treatment expectations were met and change in symptom bothersomeness.

Patient satisfaction is most associated with items that reflected a high-quality interaction with the therapist — such as time, adequate explanations, and instructions to patients.

Environmental factors such as clinic location, parking, time spent waiting for the therapist, and type of equipment used are not strongly correlated with overall satisfaction with care.

HOW DO WE GET ACCURATE SATISFACTION DATA?

Clinicians work on their craft daily. They take courses, read the research, engage in clinical conversations, and reflect on past treatments to improve their care. All of these strategies certainly improve the care provided to patients, but they don’t guarantee satisfaction, and outcome scores will improve.

There is an art to administering outcome and satisfaction measures. Here are the strategies I have learned over the past few years as the National Director of Quality and Research for PT Solutions.

A quick caveat, this is not meant to artificially inflate your scores. Furthermore, the goal of obtaining outcomes and satisfaction scores is not simply to inflate the ego and display your awesomeness to everyone.

The purpose is to objectively assess your quality of care and make the necessary adjustments. You may apply guideline adherent care and have mastered your exercise prescription and manual therapy techniques, but if the patients are unhappy and prematurely ending the plan of care then the quality is not high.

Strategy #1: Obtain timely scores.

Patient evaluation worsens as the gap between encounter and completing the measure increases. Our memories become less clear as time passes. I would argue the most important indicator of whether your outcome data is accurate is the ‘days between status and discharge’.

This number represents how many days you treated a patient after obtaining their final outcome measure. The larger the number, the more days you treated and helped a patient without obtaining credit for the improvement. Additionally, patients (and clinicians) have poor long-term memory for our subjective experiences.

The longer a patient goes without a survey, the more they are guessing at how they previously felt.

Clinicians have to decide whether in-person or email surveys will provide more value. They both have benefits and drawbacks. In-person provides more immediate ratings and a larger volume of data, while emails rely on the patient open and answering the survey. However, a patient may feel less pressured to convey disappointment over email.

Strategy #2: Complete the specific actions from the outcome tool on the day a survey is administered.

If a questionnaire asks how difficult it is to walk a quarter-mile, then have the patient walk a quarter mile on the treadmill the day they complete the questionnaire.

Again, this limits the guesswork and provides a more updated assessment.

Strategy #3: Prep the patient but do not hover or bias them.

This strategy falls under ‘obtaining accurate scores’ not ‘maximizing your score, even if it is artificial’. If you hover over a patient during the survey, your body language or the way you ask a question (or your mere presence) may cause scores to be artificially high.

Patients are reluctant to disclose negative attitudes toward a health care provider because of a sense of dependency on patient-provider communication. This doesn’t benefit anyone. Instead, fully explain the survey and be available for questions.

FROM THEORY TO PRACTICE

Ok, your NVBs are top-notch, you are providing evidence-based care, and you are a master at collecting the data appropriately, what can go wrong? In many cases, it will be smooth sailing to world-class outcomes and satisfaction, but there are a few remaining barriers.

The malalignment of therapist and patient goals can be detrimental to satisfaction. It is imperative you are both on the same page with the goals and the methods for obtaining them. This is where motivational interviewing comes into play as this alignment may take weeks to obtain.

Another barrier is understanding what the patient values. They lack the knowledge to assess accurately the technical competence of health care personnel and therefore may only judge satisfaction on outcomes.

Others, however, may care far more about the ‘experience’ and weigh NVBs and the interaction with employees much higher. It is important to recognize these differences and assess them all.

A final thought on this topic is the impact the scores can have on our treatment choices. It can be tempting to provide whatever treatment a patient wants, regardless of the efficacy, to simply satisfy them. This can be a major driver of continued use of treatment with poor efficacy and limits both our progression as a profession and the long-term outcomes of a patient.

Patient satisfaction and outcome measures are by no means the pinnacle of assessment tools. However, they do carry immense value and can help guide improvement for the benefit of our patients and ourselves.

PATIENT ADVISORY

Medika Life has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your health care provider(s). We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy is not an endorsement by Medika Life

Dr. Zachary Walstonhttps://www.zacharywalston.com/

I am a Certified Specialist in Orthopedic Physical Therapy and the National Director of Quality and Research at PT Solutions Physical Therapy. My mission is to improve knowledge translation from research to clinicians and patients. I challenge the ways clinicians think and teach biases, heuristics, and critical thinking. My writing is focused on narrowing the information gap between patients and healthcare providers.

DR ZACHARY WALSTON

I am a Certified Specialist in Orthopedic Physical Therapy and the National Director of Quality and Research at PT Solutions Physical Therapy. My mission is to improve knowledge translation from research to clinicians and patients. I challenge the ways clinicians think and teach biases, heuristics, and critical thinking. My writing is focused on narrowing the information gap between patients and healthcare providers.

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