So, to start off our first set of lectures, we're going to welcome Dr. Nitika Srivastava. Dr. Srivastava is currently an assistant professor and medical director of the GI Clinic at Harbor UCLA. She's an alumnus of the ASG Leadership Education and Development Program, also known as LEAD, and currently serves on the ASG Quality Assurance and Endoscopy Committee. And so, Dr. Srivastava, the audience is yours to educate us. Thank you. Great. Thank you so much for that kind introduction. Today, I will be addressing patient satisfaction, and I will discuss how to measure and maximize it. And I will address ways in which we can think about using telemedicine in our endoscopy practices. I have no financial relationships to disclose. So, here's an outline of what I will be discussing today. I'll define what patient experience and patient satisfaction means. I'll discuss the importance and benefits of improving the patient experience. I'll review some of the ways in which we can measure the patient experience. I'll highlight some interventions around improving the patient experience in your endoscopy unit. I'll also be discussing diversity, equity, and inclusion considerations, which are a huge important aspect of the patient experience. And finally, I'll be discussing how we can use telemedicine to improve the overall patient experience. So, let's first start with a definition. What is patient experience? The Agency for Healthcare Research and Quality defines patient experience as the range of interactions that patients have with the healthcare system, including their care from health plans, from doctors to nurses, staff in the hospital, physician practices, and other healthcare facilities. As an integral component of healthcare quality, patient experience includes several aspects of healthcare delivery that patients value when they seek and receive care. At its core, the patient experience encompasses the entirety of interactions that patients have with the healthcare system, including a range of people, such as physicians, nurses, and staff. So, this is not just the interactions between patients and endoscopist nurses, but also the front desk staff, patient transport personnel, and so on. Put in another way, it refers to a number of health system characteristics that really shape how a patient's care is delivered, communicated, perceived, evaluated, and valued by patients and their families. The patient experience can be significantly impacted by multiple factors that are important to patients, such as timeliness of appointments, easy access to information, and good communication with healthcare providers, which includes intangible factors, such as emotional support and respect from providers and staff in the healthcare system. So, why is the patient experience important? Well, understanding patient experience is a crucial step if we want to deliver better patient-centered care. And remember that patient-centered care is one of the fundamental components of quality in healthcare. Measuring the patient experience allows us to make sure that we are delivering care that is respectful and responsive to preferences, needs, and values of our individual patients. And I also want to emphasize that while patient-centered care is a component of quality healthcare, the goal of measuring and maximizing the patient experience is not to specifically improve clinical outcomes, although this often does occur as an additional benefit of the process. And I'll discuss this in a further, in just a bit. So, what is patient satisfaction? It is important to emphasize that the patient experience and patient satisfaction are not the exact same things, but they, of course, are tied together. Think about patient experience as being essentially what happens to patients as they interact with the healthcare system, while patient satisfaction is determined by whether a patient's expectations about a healthcare encounter were met or not. Two people can receive the exact same care, but if they have different expectations for how that care should be delivered, they can have very different patient satisfaction. For example, two patients are seen for their screening colonoscopies in your unit. One patient expects medical appointments to always be on time, while the other expects there to be long delays based on her past experiences. If you are running 30 minutes behind, the first patient will be unsatisfied from the perspective of timeliness, while the second patient may actually be satisfied that her appointment wasn't delayed by over an hour, as she was expecting. There is clearly intrinsic value for our patients in an optimized patient experience, but beyond improving the experience from the point of view of our patients, I want to put forth the premise that there are some other concrete reasons why we, as providers, should want to improve the patient experience. There are a number of benefits that improved patient experience convey, include improvements in efficiency, safety, patient behaviors, clinical processes, clinical outcomes, and importantly, financial benefits, so let's go ahead and discuss some of these further. Improved patient experience may lead to better healthcare efficiency and safety. Some aspects of patient-centered care may improve efficiency by helping to reduce unnecessary healthcare use. One saline example for us would be having better bowel prep instructions, which may result in better bowel preps during our procedures, which reduce the need for repeat colonoscopies due to inadequate preps, and I know all of us have been there. In terms of safety, there are studies that are showing that positive patient experiences have been associated with a lower prevalence of inpatient care complications, particularly DVT and pressure ulcers. In our endoscopy units, we can think of examples that can promote a culture of patient safety, such as taking extra precautions to decrease the chance of falls in our patients who are identified to be at higher risk for falls. We can see a benefit in patient behavior as well. Better patient-reported experiences have been shown in multiple studies to be a factor that is positively associated with patients' adherence to physician advice. Other benefits of improved patient experience include benefits that mainly have been analyzed in the context of hospital-related clinical outcomes, but we can reasonably expect to hold true to some extent in our endoscopy units as well. These include clinical processes. For example, hospital with the highest hospital consumer assessment of healthcare providers and systems scores perform significantly better on CMS's Care Association for hospital performance, such as congestive heart failure, pneumonia, and surgery. Similarly, patients' overall ratings of their hospitals have been positively associated with hospital performances on CMS process measures for things such as pneumonia, congestive heart failure, and acute MI. Clinical outcomes are also better. There have been studies that have shown that better patient satisfaction scores have been correlated with objectively improved outcomes in some areas, including lower mortality for acute MI patients, as well as fewer readmission rates. In summary, in addition to the intrinsic value from the patient's perspective, better patient care experiences are associated with higher levels of adherence to recommended prevention and treatment processes, better clinical outcomes, better patient safety and efficiency, and, of course, less healthcare utilization. Now let's talk about some of the financial benefits of having improved patient satisfaction and experience. This also includes reimbursement. Patient satisfaction scores with HCAHPS and other surveys are actually tied to reimbursement. And I think this is also going to be true for outpatient ambulatory surgical centers as well, which most of us are practicing in. Some of us do endoscopy in hospital settings, others in ambulatory surgical centers. But I think these scores are really going to be tied to the reimbursement rates. These platforms revolve around patient experience. So social media or website reporting of patient experience can have a downhill impact on how likely other patients are going to come to your center for their care, for example. This actually gets to the core of the issue, which is patient retention. Patients with a good experience are more likely to return to your institution than if they've had a bad experience. Additionally, patients who have had a bad experience are more likely to share their experience with others than those that have actually had a good experience. Importantly, it has also been shown that organizations with higher patient experience scores actually have a higher employee job satisfaction, which in turn leads to less turnover and less people missing work for other reasons. This makes sense because everyone wants to work in an institution or unit where patients are treated well and are happier. Also, as a provider, you will build a reputation as an employer of choice because you have more satisfied employees and better job retention, which does translate to better encounters with patients and thus leads to having patients have better experience as well. In addition, there is very good data to show that lower patient experience scores are associated with a greater likelihood of being accused in a malpractice suit. In fact, one study has shown that every one-point drop along a five-point patient satisfaction scale leads to more than a 20% increased risk of being named in a malpractice suit. I know we've all heard this before, but it bears repeating. The most important factor in predicting malpractice lawsuits is the quality of the relationship between the patient and the physician. So I have talked about the definition of patient experience and talked about the benefits of improving it, but now I want to transition into how we can assess and measure that patient experience. We touched on the fact that there are a number of ways in which patients can report their experience, both formal and informal. The numerous informal measures to capture the patient experiences are growing popularity, not unlike hotels and restaurant reviews, and patients do, in fact, use these resources to make decisions about where to get their health care, including their endoscopies. In a recent study of 2,000 patients, nearly 70% said they looked at online reviews in deciding where to seek care, and more than a third of those had chosen to avoid a physician based on what they read in those reviews. There are a number of formal patient experience surveys that are also available, and I suspect that most of you, if not all, are utilizing one of these. The two most common surveys, such as the CAHPS and PRESS-GAIMI. The CAHPS survey is the Consumer Assessment of Health Care Providers and Systems Survey, which was developed by the AHRQ and initially was used in hospital and clinics. We discussed that CAHPS is tied to reimbursement from CMS, and these scores are publicly reported. There are three versions of CAHPS. There's the hospital-based survey, the clinician and group survey, and now there's actually an outpatient and ambulatory surgery patient survey as well, which, of course, is relevant to most of us, as I described before. This survey actually collects information about patients' experiences of care in the hospital outpatient surgical center, as well as the ambulatory surgical centers as well, and actually has 37 questions that encompasses five domains, which include pre-procedure, information about the facility and the staff, communication about the procedure, recovery, and the overall experience. At the same time, some of you may actually be using the PRESS-GAIMI, which, unlike the CAHPS, is not actually required for public reporting. There is also an ambulatory surgical center PRESS-GAIMI survey that is out and available as well. Finally, some of our societies have developed their own endoscopy unit surveys, including AS... Sorry, can you hear me? Including ASGE. We can hear you. Okay. Sorry. I accidentally thought I muted the mic here. Including the ASGE survey, which I'll be showing in the next slide. And so there are some key elements that are shared between each of these surveys, as I've highlighted here. They include a focus on access to care and information, provider communication, provider rating, and finally, a recommendation of practice after the procedure. And I'd just like to share this. This is the patient satisfaction survey that we put out by the ASGE. I'll just give you a moment here to look. So I wanted to make a few points about these patient experience measurement tools. It's very important that the tool you use encompasses the entire patient experience. I think most of us inherently focus on the procedure itself, focusing on pain control and the perceived endoscopy skill, whereas we actually know from all of the data and studies that are out there that what is important for patients is actually different than what we as providers think. So for patients, the things that are important include pre-procedural issues, such as waiting time for the procedure, as well as bowel prep instructions. Intra-procedural aspects that we may not always think about, including cleanliness and amenities that are available at our endoscopy units, as well as the wait time in the endoscopy unit. And very importantly, post-procedural aspects of care include explanation of the procedure and results, as well as communication of the pathology results, which is highly important to patients. I know many of you probably have had the experience where you've seen a patient in clinic that have said that they've had a procedure done before and they don't really know what their pathology results are and things like that. So it's really important as providers that we make sure that our patients really do understand what procedure they obtained, as well as the results of the procedure. The other thing to mention is that many of these surveys that we can use in endoscopy are based on modifications of already existing patient satisfaction measurement tools. Because many of these tools, however, are used for a wide range of procedures, including other surgical procedures, they may not be ideal in terms of measuring the patient experience in endoscopy specifically. I will say, though, as more and more individuals are interested in this area, and as we learn more about what patients are truly looking for to have a good experience during endoscopy, I think we will see more endoscopy-specific surveys and tools that will be out there. So be on the lookout for those. So I think this is a good time to transition to a discussion of what patients think is important in their overall endoscopy experience. We do have some data to guide us here. The list shows that those elements that we know are strongly correlated with the patient experience in endoscopy. And this includes the technical quality of care, comfort and tolerability of the procedure, the personal manner of the endoscopist and nurses, the endoscopy unit environment, the wait time including both the endoscopy appointment and the approved procedure wait time, and, as I mentioned before, adequate explanation of the procedure, free and post-procedure communication with the physician as well. I think one thing to kind of highlight here is that we as physicians, I think, tend to underprioritize the pre-procedure discussion, but several studies have actually shown that a written explanation about the procedure through communication by the providers as well as shared decision-making prior to the procedure performed are all regarded as more important by patients than by nurses and by physicians. This table here shows data examining some predictors of improved patient experience in endoscopy. It emphasizes that the personal manner of the endoscopist and nurses are strongly associated with a better patient experience. And these factors are actually more important than the patient perception of an endoscopist's technical skill, which I honestly think is surprising, at least to me and most of my colleagues that I had asked this to, just because I think we always focus on the skill of the physician. But for patients, that actually turns out to not be the main factor when they're highlighting their experiences. So here are some tangible ways to improve the patient experience. These are eight principles of patient-centered care, which are widely recognized fundamentals that are used to create a positive experience for the patient. At a global level, there are a number of dimensions that are central to patient-centered care. And using these principles, we can develop a number of interventions to improve the patient experience in healthcare, including our own endoscopy units. These are just a few examples of the sorts of intentions. So, for example, there are survey tools, which we have talked about already, which we use to objectively assess and improve the patient experience. Patient rounding, which in the endoscopy unit can mean having a direct discussion about a patient's care with the care team and involving the patient in those discussions, which would entail a shared decision-making process. Having a coaching staff to help better communicate with patients. We can also use team huddles where everyone involved in the patient's care is aware of the overall goals of care for that patient. Often, some places will use a reward and recognition program for the staff, which helps engage the entire staff in the goal of optimizing the patient experience. We can also implement procedures for informing patients of waits and delays so that they are actively aware of what is going on. And narrating care and services recovery program, which can be very helpful, and I'll go into more detail in the next few slides. So, let's delve into some specific ways in which we can improve the patient experience in the endoscopy unit. One is ease of access to endoscopy and setting expectations. Remember that patient satisfaction is largely driven by the patient's expectations. So, if you set appropriate expectations, you're more likely to have a satisfied patient. As much as you can try, try to shorten wait times and commit to those timelines. Of course, as we all know, delays are unavoidable part of our endoscopy units. But if you clearly communicate those delays to patients as opposed to leaving them in the dark, they tend to have a better experience because they know what to expect. Some organizations have utilized texting patients in the waiting room to communicate delays. The personal manner and etiquette of physicians and staff is key. We've seen this, but again, this is one of the most important factors in determining the overall experience of patients in all realms of healthcare, including the endoscopy unit. Also, minimizing procedural discomfort as much as you can. If you know that a patient has had a lot of pain during a prior colonoscopy and that colonoscopy was performed with moderate sedation in the past, then you can potentially try to use anesthesia in that particular patient if you deem it's appropriate. Also, talking to patients and their families after the procedure is really important. And simply saying thank you to express appreciation for that patient choosing your unit is simple but can go a long way. And some units have given patients thank you cards to express appreciation that they chose to obtain their GI service at that unit. Now, narrating care is a very helpful way to improve the patient experience. This is the process of introducing yourself to the patient and family and then explaining in patient-appropriate language what you're doing and why you're doing it. For example, you can tell a patient, we are doing your colonoscopy today for screening because you have a family history of colon cancer. We are going to examine your colon carefully and thoroughly. And if we find polyps, we will remove them. I will come talk to you after the procedure and let you know what we have found. This has a number of potential benefits for the patient experience, including increasing confidence in the care that they are obtaining. It also shares our knowledge with the patient, reduces anxiety and misunderstandings, allows opportunities for questions, and also reinforces patient and family education. And service recovery programs. No matter what you do, problems are going to arise in your endoscopy unit. This is inevitable. You may be behind schedule. A piece of equipment may be unavailable due to supply chain issues, or patients may be misscheduled with the wrong provider. Service recovery is about restoring trust and confidence in your ability as an organization to make things right when something has gone wrong with a patient's healthcare experience. The NCHRQ outlines a six-step process to assist with the service recovery. This includes apologize and acknowledge that a mistake was made, listen, empathize, and ask open questions, fix the problem quickly and fairly, offer atonement, follow up, and to make sure that you remember your promises that you made. Now I'm going to transition and talk more about diversity, equity, and inclusion as we care for patients in our endoscopy units. I think we all inherently know that in order to maximize the patient experience, we need to be sensitive to issues surrounding race, gender identity, and ethnicity. By working on delivering care through the lens of diversion, equity, and inclusion, we can help maximize the patient experience. We do know that social detriments of health, including language barriers, health literacy, and challenges with bowel preps, among other factors relevant to DEI, include care coordination, transportation issues, and are important impediments to some of our patients getting screened and diagnostic procedures, including colonoscopies. There's a recent multicenter study conducted that showed that some of our patients may have a gender preference for their endoscopist or endoscopy team. In this study, a substantial minority of patients expressed an endoscopist gender preference, and a quarter of these patients would avoid colonoscopy if it could not be done by the endoscopist of their preferred gender. A higher percentage, however, preferred a same-gender endoscopy team member with a same-gender endoscopist. The study authors concluded that having an endoscopy environment with multigender endoscopist availability and having multigender endoscopy teams may directly result in improved colorectal cancer screening rates. And, you know, I know that female endoscopists are still rare. I think only about 16% of endoscopists in the U.S. are female. So this may not be available throughout most units. However, at least having someone on your team of the same gender as the patient may improve their experience. Here is a list of some common-sense interventions we can use to improve the patient experience from the perspective of DEI. If possible, it is helpful to have diverse endoscopy teams and diverse endoscopists in our units. Ideally, we have educational materials on GI conditions and procedures and colonoscopy preps available in common languages that patients who come to your unit can speak other than English. We should have live or virtual interpreter services available for both free and post-procedure discussions with patients and their families. We need to make sure that our waiting room signage and literature is sensitive to DEI concerns. We need to maximize accessibility for all of our patients. You may want to consider cultural competency training for providers and staff in your units as this type of training can go a long way towards allowing us to recognize and minimize our biases. These are just a few examples and by no means is a complete list. Again, I would encourage each and every one of you to really focus on DEI as it relates to the patient experience in your endoscopy units. Now, I wanted to speak about opportunities to utilize telemedicine in our endoscopy units. Most of us likely did not utilize telemedicine heavily prior to March of 2020, but with COVID, I think telemedicine has become a new normal overnight. I suspect many, if not most of us, are using telemedicine in our clinics, but is there a role for telemedicine in the endoscopy unit? In my final few slides, I want to make the case for procedural telemedicine and that it can actually improve the patient experience in endoscopy. We have some data showing that telehealth interventions can be used to improve bowel prep quality and polyp detection rate. Telehealth can also be implemented around the pre-procedure visit. We have recent data showing that patients found pre-procedure telehealth visits equivalent to face-to-face visits prior to an advanced endoscopy procedure and was actually favored over direct access advanced endoscopy. And two studies conducted during the COVID pandemic found that pre-procedure phone consultation or telemedicine decreased endoscopy no-show rates while also maintaining high satisfaction rates for both the patients and the physician. This data suggests that employing telemedicine pre-procedure is viable and can be useful. How about the use of telemedicine post-procedure? A recent study examined 50 patients diagnosed with colorectal cancer who underwent telehealth versus face-to-face follow-up. Telehealth was found to be equivalent to face-to-face consultation in terms of patient satisfaction and perceived quality of care. None of the patients in the telehealth group requested an additional face-to-face follow-up. The overall level of satisfaction for providers was higher for telemedicine than for the face-to-face interaction. So we have all become very familiar and adept with telemedicine, and we now have the infrastructure in place to easily do these types of visits. So I would encourage you to explore using it in your units, especially as we know it can enhance the patient experience in multiple ways. You can take a number of different approaches in utilizing telemedicine in your units. You can consider using it for pre-procedure consultation, especially for complex or more risky procedures, which are cases in which we often do a face-to-face visit. You can also use it to make patients understand their bowel prep instructions and other pre-procedure instructions, including periprocedural management of antiplatelet and anticoagulation medications. You can consider using it to discuss unexpected or significant findings with patients after procedures, which often a simple pathology letter won't be sufficient. So in closing, here are some take-home points from this talk. Patient experience encompasses the entire range of interactions that patients have with the healthcare system. Multiple factors influence a patient's experience within an endoscopy unit. Improving the patient experience has a number of important concrete benefits in several areas, including direct financial ramifications. Multiple tools are available to assess the patient experience. Use these tools to measure patient experience in your unit and identify areas that can be improved. Prioritize diversity, equity, and inclusion in your unit, as this is a surefire way to improve your patient's experience and satisfaction. Consider using telemedicine to complement your endoscopy practices. Thank you.

patient experience

patient-centered care

patient satisfaction

improving patient experience

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