"We knew this was going to be disruptive and innovative, and that was a big part of the program's design," says Jonathan Slotkin, M.D., director, spinal surgery at GHS Neurosciences Institute, director of spinal cord injury research and medical director of Geisinger in Motion, Division of Informatics, whose team developed an app patients could download to expedite their refunds – or offer praise to their care teams. "We certainly thought that we were as much trying to disrupt ourselves as we were trying to innovate for others. We planted a large flag in the ground for Geisinger associates around patient experience and compassionate and dignified caring. It was a wake-up call for all 30,000 Geisinger associates and it worked."
Geisinger found the refund program boosted communication between the patients and patient experience advocates; there was a 23 percent increase in communications which included:
• Complaints: 71 percent
• Requests for assistance: 24 percent
• Compliments: 5 percent
Most of the complaints were about patient experience; the medical quality complaints were in the minority. One in five of the complaints were related to difficulties in making outpatient appointments and 8.7 percent were related to financial issues. Another 8.4 percent of the complaints were about difficulty accessing medical information or results and 7.7 percent were associated with provider behavior or attitude.
"What we really hear from patients is about the ability to access care and get reliable appointments quickly; the ability to reliably and rapidly obtain results and information; and the dignity that patients are treated with," says Dr. Slotkin. "The care environment was another occasional source of complaints — the noise, food and waiting. There are people who think we should only focus on quality, but we are trying to make the case that quality and patient experience are linked. If you only focus on quality, you miss the lion's share of the patient concerns. Even just 10 years ago, 'consumerism' was considered a bad word in healthcare. But other sectors, such as retail and financial services, have shown us that earnest and well-executed efforts towards improving customer experience will also improve service quality. "
The data also showed the environment of care can impact the patient's sense of recovery, pain control and data recovery. Geisinger centers that were focused on improving the patient experience were also more likely to be centers of quality.
"We are trying to rigorously study the connection between experience and quality. We know intrinsically that there is a connection and now we need to demonstrate it in our hands," says Dr. Slotkin.
The health system provides an average of 122 refund requests each month and averages $464 per request. In the first year, the health system spent around $680,000 in refunds. Geisinger hired two-and-a-half new positions to support patient feedback as well as two new administrative staff members and one employee responsible for addressing concerns brought to the CEO's office.
There is a national trend to focus on data collection and measurements as a scientific approach to change, but this approach often includes punitive measures. In some institutions, the punishment is tied to compensation.
"Geisinger has been of the philosophy that through times of change, we want our staff to feel safe. Participating in Geisinger's initiatives won't result in retribution," says Dr. Slotkin. "One thing our leadership team did was level the pay for providers, making sure they were paid at a reasonable rate for their specialty, and removing any sense that there would be punishment if their efforts fell short. The culture that leadership wanted to instill is that of a social contract. The people of Geisinger want to participate and be part of a learning organization."
Several other institutions have contacted Geisinger with questions about implementing a similar refund program, but this isn't a one-size-fits-all program; each hospital and health system is working with different factors to improve patient care.
"This is what has worked in our hands and culture. If other institutions feel there are other mechanisms out there, we encourage them to pursue those as well," says Dr. Slotkin. "There are methods other hospitals are exploring to drive this kind of change. We have observed that effort to change the culture in an abstract way can move too slowly, like steering a large cruise ship, but efforts to improve behavior can move much more quickly, and those efforts can improve culture."
In the future, Dr. Slotkin and his team will measure the potential impact the refund program could have on medical malpractice claims against the health system.
"There is a possibility that the seed of discontent can grow into tremendous discontent, but if you get at it early, it might not grow," he said.
Read more about the program in Harvard Business Review.