Variation in Patient Experience Across the Clinic Day: a Multilevel Assessment of Four Primary Care Practices.

BACKGROUND: Patient satisfaction with healthcare is associated with clinical outcomes, provider satisfaction, and success of healthcare organizations. As the clinic day progresses, provider fatigue, deterioration with communication within the care team, and appointment spillover may decrease patient experience. OBJECTIVE: To understand the relationship between likelihood to recommend a primary care practice and scheduled appointment time across multiple practice settings. DESIGN: Retrospective cohort. PARTICIPANTS: A retrospective cohort was created of all patients seen within four primary care practices between July 1, 2016, and September 30, 2017. MAIN MEASURES: We looked at scheduled appointment time against patient likelihood to recommend a practice as a measure of overall patient experience collected routinely for clinical practice improvement by the Press Ganey Medical Practice Survey®. Adjusted mixed effects logistic regression models were created to understand the relationship between progressing appointment time on patient likelihood to recommend a practice. We constructed locally weighted smoothing (LOESS) curves to understand how reported patient experience varied over the clinic day. RESULTS: We had a response rate of 14.0% (n = 3172), 80.2% of whom indicated they would recommend our practice to others. Appointment time scheduling during the last hour (4:00-4:59 PM) had a 45% lower odds of recommending our practice when compared to the first clinic hour (adjusted OR = 0.55, 95% CI 0.35-0.86) which is similar when controlling for patient-reported wait time (aOR = 0.59, 95% CI 0.37-0.95). LOESS plots demonstrated declining satisfaction with subsequent appointment times compared with the first session hour, with no effect just after the lunch hour break. CONCLUSIONS: In primary care, appointment time of day is associated with patient-reported experience.

Attributes, Attitudes, and Practices of Clinicians Concerned with Opioid Prescribing.

BACKGROUND: Many clinicians who prescribe opioids for chronic noncancer pain (CNCP) express concerns about opioid misuse, addiction, and physiological dependence. We evaluated the association between the degree of clinician concerns (highly vs less concerned), clinician attributes, other attitudes and beliefs, and opioid prescribing practices. METHODS: A web-based survey of clinicians at a multispecialty medical practice. RESULTS: Compared with less concerned clinicians, clinicians highly concerned with opioid misuse, addiction, and physiological dependence were more confident prescribing opioids (risk ratio [RR] = 1.34, 95% confidence interval [CI] = 1.08-1.67) but were more reluctant to do so (RR = 1.13, 95% CI = 1.03-1.25). They were more likely to report screening patients for substance use disorder (RR = 1.18, 95% CI = 1.01-1.37) and to discontinue prescribing opioids to a patient due to aberrant opioid use behaviors (RR = 1.30, 95% CI = 1.13-1.50). They were also less likely to prescribe benzodiazepines and opioids concurrently (RR = 0.40, 95% CI = 0.25-0.65). Highly concerned clinicians were more likely to work in clinics which engage in "best practices" for opioid prescribing requiring urine drug screening (RR = 4.65, 95% CI = 2.51-8.61), prescription monitoring program review (RR = 2.90, 95% CI = 1.84-4.56), controlled substance agreements (RR = 4.88, 95% CI = 2.64-9.03), and other practices. Controlling for clinician concern, prescribing practices were also associated with clinician confidence, reluctance, and satisfaction. CONCLUSIONS: Highly concerned clinicians are more confident but more reluctant to prescribe opioids. Controlling for clinician concern, confidence in care and reluctance to prescribe opioids were associated with more conservative prescribing practices.

Creation of a Patient-Centered Journey Map to Improve the Patient Experience: A Mixed Methods Approach.

OBJECTIVE: To use a mixed methods approach to focus quality improvement efforts to enhance patient experience through human-centered design. PATIENTS AND METHODS: A mixed method approach began with returned Press Ganey Medical Practice Surveys from a large, multidisciplinary, outpatient medicine practice from July 1, 2016, through June 30, 2017, using correlation and gap analysis. The second phase deployed human-centered design approaches to process map patient journeys and generate opportunities for care improvement and to generate a theoretical framework for designing optimal care experiences. RESULTS: Our outpatient medical practices have the greatest ability to improve patient experience scores by focusing on how care teams deliver and educate patients on medications, instructions for follow-up care, and explanations about problems or conditions. By leveraging communication, the expertise of our care team members, and connection between patients and care team members, we can employ a variety of observed opportunities to enhance patient experience. Specific opportunities include leveraging tools in the electronic health record, fostering connection through empathy between patients and members of the care team, and capitalizing on the expertise of nurses on the care team. CONCLUSION: A mixed methods approach to the analysis and observation of clinical care and business operations allows for the detection of opportunities with the highest potential impact for improvement when resources are constrained.