Thank you Anna. So as you just said we're going to turn now to a discussion of patient experience and satisfaction which are actually key aspects of quality in our units. I'd like to start with a few polling questions relevant to my coming talk. All right, first question, what aspects of the experience in endoscopy, do you believe your patients would consider the most important to them, pick one. Procedure wait time. Personal manner of the endoscopist. Pre-procedure communication about the results of the procedure. Pre-procedure discussion of the risks and benefits. Comfort during the procedure. All right, so we have a range of answers, and I'll get into this further in my upcoming talk but I will say that. Stay tuned, but what physicians and nurses might consider the patient would, or would expect a patient to consider most important, maybe actually quite different from what patients themselves actually considered to be the most important aspect of their experience. So with regard to utilization of telemedicine in your endoscopy unit, this includes both phone calls as well as video visits, including pre-procedure discussion and for bowel preparation optimization, which statement most accurately reflects what you do in your unit. So we don't use utilize telemedicine at all. We started utilizing telemedicine during the pandemic. We utilize telemedicine pre pandemic and we've continued. Wow, really interesting. So, essentially a three way split. I think most of us, if not all of us have been used utilizing telemedicine heavily in our outpatient clinics for the last couple of years, but it is really great to see that people have started utilizing telemedicine around endoscopy. And as I'll discuss here in just a bit. This is actually a really sort of relevant and new way to utilize telemedicine. Why don't we get into the talk? This session will address patient satisfaction and I will discuss how to measure it and maximize it. And I'll also address ways in which we can think about using telemedicine in our endoscopy practices. I have no disclosures that are relevant to this talk. Here's what I'll be covering in this talk. I'll define what patient experience and patient satisfaction mean. 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 then highlight some interventions around improving the patient experience in your endoscopy unit. I'll discuss DEI considerations, which are a hugely important aspect of the patient experience. And finally, I'll discuss how we can use telemedicine to improve the patient experience. Let's start with the 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, and from doctors, nurses, and staff in hospitals, 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 endoscopists and nurses, but also front desk staff, patient transport personnel, and so on. Put another way, patient experience 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, and includes intangible factors such as emotional support and respect from providers and staff in healthcare. So why is 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 the preferences, needs, and values of our individual patients. And I do 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 that further in just a bit. It's important to emphasize that patient experience and patient satisfaction are not the exact same thing. They are, of course, tied together. But 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 met, two people can receive the exact same care, but if they have different expectations for how that care should be delivered, then they can have very different patient satisfaction. I'll give you an example to illustrate this. 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're running 30 minutes behind, the first patient will be unsatisfied from the perspective of timeliness, while the second patient will actually be satisfied that her appointment wasn't delayed 60 or 90 minutes 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, including improvements in efficiency, safety, patient behaviors, clinical processes, clinical outcomes, and importantly, financial benefits. Let's discuss those 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 salient example for us would be having better bowel prep instructions, which may result in better bowel preps, which then reduce the need for repeat colonoscopies due to inadequate preps. In terms of safety, there are studies 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 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 high risk for falls. We can also see a benefit in patient behavior. 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 have mainly been analyzed in the context of hospital-related clinical outcomes, but which we could reasonably expect to hold true to some extent in our endoscopy units as well. These include clinical processes. For example, hospitals with the highest HCAHPS scores perform significantly better on CMS's care measures for acute MI, CHF, pneumonia, and surgery than hospitals with the lowest HCAHPS scores. Similarly, patients' overall ratings of their hospitals have been positively associated with hospitals' performance on CMS's process measures for pneumonia, CHF, and acute MI. And we can see improvement in clinical outcomes. 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 readmissions in some disease states. 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 less healthcare utilization. Improved patient experience, importantly, may also have financial benefits for providers and organizations. This includes reimbursement. Patient satisfaction scores with the HCAHPS and CGCAHPS surveys are tied to reimbursement, and I believe this is coming relatively soon for OASCAHPS, which is the outpatient surgery and ASC version of CAHPS. Additionally, we all know that there's been an explosion in terms of online consumer information about hospitals, endoscopy centers, and endoscopists, some of which is driven by social media. These platforms revolve around the patient experience, so social media or website reporting of patient experience can have a downhill impact on how likely other patients are to come to your center for their care, for instance. This really gets to the issue of patient retention. Patients with a good experience are more likely to return to your institution than if they had a bad experience. That just makes sense. Additionally, patients who had a bad experience are generally more likely to share their experience with others than are patients who had a good experience. Importantly, it's also been shown that those organizations with higher patient experience scores actually have substantially higher employee job satisfaction, which in turn leads to less turnover and absenteeism. This makes sense. Everyone wants to work in an institution or unit where patients are treated well and are happier. And you also build a reputation as an employer of choice because you have more satisfied employees and good job retention. Finally, there are very good data to illustrate that lower patient experience scores are associated with a greater likelihood of being accused of malpractice. In fact, in one study, every one-point drop along a five-point patient satisfaction scale led to a more than 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. I discussed the definition of patient experience and talked about the benefits of improving it. Now I want to transition into how to assess and measure the patient experience. We touched on the fact that there are a number of ways in which patients can report their experience, both informal and formal. The numerous informal measures to capture the patient experience are growing in popularity, not unlike hotel and restaurant reviews, and patients do 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 look at online reviews in deciding where to seek care, and more than one-third of those patients had chosen to avoid a physician based on what they had read in those reviews. There are a number of formal patient experience surveys that are available, and I suspect that most, if not all, of you are using one of these. The two most common such surveys are the CAHPS and Press Ganey surveys. The CAHPS survey, which is the Consumer Assessment of Health Care Providers and Systems Survey, was developed by the AHRQ and initially was used in hospitals and clinics. We discussed that CAHPS is tied to reimbursement from CMS, and these scores are publicly reported. There are three versions of CAHPS. The hospital-based survey, or HCAHPS, the clinician and group survey, or CG-CAHPS, which is used for outpatient clinics, and the outpatient and ambulatory surgical patient CAHPS survey, OAS-CAHPS, which is, of course, relevant to many of us. OAS-CAHPS collects information about patients' experiences of care in hospital outpatient surgery departments and ASCs. It has 37 questions, which encompass five domains. These include pre-procedure, about the facility and staff, communication about the procedure, recovery, and the overall experience. At the same time, some units may be using Press Ganey, which is proprietary. Unlike with CAHPS, there is no mandate for public reporting, and there is now an ambulatory surgical center Press Ganey survey. Finally, some of our societies have developed their own endoscopy unit surveys, including the ASG's patient satisfaction survey tool. Overall, there are some key elements shared between each of these surveys. They include a focus on access to care and information, provider communication, provider rating, and finally a recommendation of the practice. This is the ASG's patient satisfaction survey tool. I want to make a few points about these patient experience measurement tools. It's very important that the tool that you use encompasses the entire patient experience. I think many of us as providers inherently focus on the procedure itself, focusing on pain control and perceived endoscopy skill, whereas we know that for patients multiple other aspects carry significant weight in determining their overall endoscopy experience. These include pre-procedural issues, such as waiting time and the bowel preparation process, intra-procedural aspects that we may not always think about, including cleanliness and amenities of the facility and wait time in the endoscopy unit, and then very importantly, post-procedural aspects of care, including explanation of the procedure and results and communication of pathology results. Many of the surveys that we use in endoscopy are based on modifications of already existing patient satisfaction measurement tools. Because many of these are used for a wide range of outpatient surgical and endoscopic procedures, they may not be ideal in terms of measuring the patient experience in endoscopy specifically. I will say that as we learn more about how best to measure patient experience, new patient reported experience measures will likely be developed specifically for endoscopy, which will allow us to maximize our ability to assess the patient experience in our endoscopy units, so be on the lookout for those. So I think this is a good point to transition to a discussion of what patients themselves think are important in their overall endoscopy experience. We do have some data to guide us here. This list shows those elements that we know are strongly correlated with the patient experience in endoscopy. Again, we know that there are important differences between what patients themselves actually see as important as compared to what physicians and staff think patients see as important. I want to highlight the last bulleted point here. Physicians tend to underprioritize pre-procedure discussion. Several studies have shown that the written explanation about the procedure, clear communication by providers, and shared decision making before the procedure is performed are all regarded as more important by patients than by nurses and gastroenterologists. This table shows data examining some predictors of improved patient experience in endoscopy. It emphasizes that the personal manner of endoscopists and nurses are strongly associated with better patient experience, and these factors are actually more important than patient perception of an endoscopist's technical skill, which I think is probably surprising to at least some of us. What are some tangible ways to improve the patient experience? These are Picker's Eight Principles of Patient-Centered Care, which are widely recognized fundamentals that are used to create a positive experience for patients. In using these principles, we can develop a number of interventions to improve the patient experience in healthcare, including in our endoscopy units. These are just a few examples of these sorts of interventions. There are survey tools, which we talked a lot about already, which we use to objectively assess and improve the patient experience. Patient rounding, which in the endoscopy unit can mean having direct discussions about a patient's care with the care team and involving the patient in those discussions. It's just shared decision-making. We can coach staff in better patient communication skills. We can use team huddles, where everyone involved in the patient's care is aware of the overall goals of care for that patient. Rewards and recognition programs for staff can be helpful. These help engage the entire staff in the goal of optimizing the patient experience. We can implement procedures for informing patients of waits and delays so they're actively aware of what's going on. Guaranteeing care and service recovery programs can also be very helpful, and I'll detail these further. Let's delve into some more specific ways in which we can improve the patient experience in the endoscopy unit. One is ease of access to endoscopy. Setting expectations is also very helpful. Remember, 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, you want to try to shorten wait times and commit to timeliness. Of course, delays are an unavoidable part of life in our endoscopy units, but if you communicate that delays are happening to patients as opposed to leaving them in the dark, they tend to have a better experience because they know what to expect. Texts to patients in the waiting room to communicate delays is one way in which some units have managed this. The personal manner and etiquette of physicians and staff is key. We've seen this before, but again, this is one of the most important factors determining the overall experience of patients in all realms of health care. Try to minimize procedural discomfort during endoscopy as much as you can. Talking to patients and families promptly after procedures is very important, and simply saying thank you to express appreciation for that patient choosing your unit is very simple, but it can go a long way. Some units have given patients thank you cards to express appreciation that they chose to obtain their GI services at that unit. 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 found. This has a number of potential benefits for the patient experience, including increasing confidence in care, allowing us to share our knowledge, reducing anxiety and misunderstandings, allowing opportunity for questions, and reinforcing patient and family education. Service recovery programs can be very helpful. No matter what you do, problems are going to arise in your endoscopy unit. You may be behind schedule, a piece of equipment may be unavailable, or a patient 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 during a patient's healthcare experience. The AHRQ outlines a six-step process to assist with service recovery. These include apologizing and acknowledging the problem, listening, empathizing, and asking open questions, fixing the problem quickly and fairly, offering atonement, following up, and importantly, remembering your promises. An emphasis on improving the patient experience lends itself extremely well to considering 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 do need to be sensitive to issues surrounding race, gender identity, and ethnicity. By working on delivering care through the lens of DEI, we can help maximize the patient experience. We do know that social determinants of health, including language barriers, health literacy, and challenges with bowel preparation, among other factors relevant to DEI, including care coordination and transportation issues, are important impediments to some of our patients getting screening and diagnostic colonoscopies, for example. This is a recent multicenter study demonstrating that some of our patients may have gender preference for their endoscopist or endoscopy teams. In this study, a substantial minority of patients expressed an endoscopist gender preference, and a quarter of these patients would avoid colonoscopy if it cannot be done by an endoscopist of their preferred gender. A higher percentage of these patients preferred a same-gender endoscopy team member than a same-gender endoscopist, actually. So the study authors concluded that having an endoscopy unit environment with multi-gender endoscopist availability and having multi-gender endoscopy teams may directly result in improved colorectal cancer screening rates. Here is a list of common sense interventions that we can use to improve the patient experience from the perspective of DEI. If possible, it's helpful to have diverse endoscopy teams and diverse endoscopists in our units. Ideally, we have educational materials on GI conditions and procedures and colonoscopy preparation instructions available in common languages that patients who come to your unit speak other than English. We should have live or virtual interpreter services available for both pre- and post-procedure discussions with patients and their families. We want to try 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 competence 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. And these are just a few examples, and this is by no means a complete list. Again, I would encourage all of you to really focus on DEI as it relates to the patient experience in your endoscopy units. I now want to speak about opportunities to utilize telemedicine in our endoscopy units. Most of us likely did not utilize telemedicine heavily prior to March 2020, but with the COVID-19 global pandemic, telemedicine became the new normal overnight. I suspect many, if not most of us, are actually using telemedicine in our clinic, but could there be a role for telemedicine in the endoscopy unit? In my final 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 preparation 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 these were favored over direct-access advanced endoscopy. And two studies conducted during the COVID-19 pandemic found that pre-procedure phone consultation or telemedicine consultation decreased endoscopy no-show rates while also maintaining high satisfaction rates for both patients and doctors. These data suggest 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 a face-to-face consultation in terms of patient satisfaction and perceived quality of care. None of the patients in the telehealth group requested additional face-to-face follow-up, and the overall level of satisfaction for providers was higher for telehealth than for face-to-face visits. So we've all become very familiar and adept with telemedicine, and we now have the infrastructure in place to easily do these sorts of visits, and I would encourage you to explore using it in your units, especially as we know that it can enhance the patient experience in multiple ways. You can take a number of different approaches to 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 have patients do face-to-face visits ordinarily. You can also use it to make sure patients understand their bowel prep instructions and other pre-procedure instructions, including periprocedural management, antiplatelet, and anticoagulant medications. And you can consider using it to discuss unexpected or significant findings with patients after procedures, which are often cases when a simple pathology letter won't suffice. 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 benefits. Multiple tools are available to assess the patient experience, including the CAHPS and PRESS-GANI surveys. Use these tools to measure patient experience in your unit and identify areas that can be improved. You want to prioritize DEI in your unit, as this is a surefire way to improve your patient's experience and satisfaction. And consider using telemedicine to complement your endoscopy practice.

patient experience

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improving patient experience