1. 38 GROUP PRACTICE JOURNAL x AMGA.ORG MARCH 2015
As a Board-certified orthopedist and hand surgeon,
I was disappointed recently when the quality of my
follow-up care after prostate surgery fell quite short of
the hospital care I received. I elected to go 450 miles
from home for the surgery because of the reputation of
the surgeon and the hospital, and it was a very positive
experience. In the hospital, every member of the surgi-
cal team “managed up” the experience and expertise of
everyone else on the team and demonstrated great care
for my physical and emotional well-being.
Under CG-CAHPS, high-performing
medical practices will be better reim-
bursed for Medicare and Medicaid pa-
tients than low-performing practices,
which will be penalized.
However, when I returned for my follow-up ap-
pointment at the surgical office, it was obvious that my
surgeon and his advanced practice professional (APP)
were both unfamiliar with my concerns and had not re-
viewed my written responses to their intake questions.
I’d been anxious to better understand the significance
of the tumor breaching the capsule—or whether it was
possibly a surgical artifact—given my recent normal
prostate-specific antigen (PSA) test. And, I wondered
whether the mild residual urinary incontinence I was
experiencing was considered normal at this stage.
However, the APP wasn’t even aware I’d had a recent
PSA test, and the surgeon did not address my concerns.
How could my hospital and office practice experiences
differ so radically?
Closing the Gaps
The aim of CG-CAHPS—or Clinician & Group
Surveys–Consumer Assessment of Healthcare Providers
and Systems—is to close these kinds of gaps. The Cen-
ters for Medicare and Medicaid Services is now using
this patient survey to incentivize medical practices to
improve the outpatient experience, much like Hospital
CAHPS (H CAHPS) is doing for hospital inpatients.
Under CG-CAHPS, high-performing medical prac-
tices will be better reimbursed (for Medicare and Med-
icaid patients) than low-performing practices, which
will be penalized. As early as 2015, these (or similar)
survey scores will provide the foundation for changes
that potentially impact up to 70 or 80 percent of reim-
bursements for those practices impacted by value-based
purchasing. (For more detail about the different types
of practice surveys, view the CG-CAHPS 101 webinar
at www.studergroup.com/IPCclinic.)
CG-CAHPS is not about “smile school” but rather
about getting back to the core of what we do as provid-
ers: delivering quality outcomes for patients. Strong per-
formance on the CG-CAHPS survey is usually associated
with decreased liability risk, improved clinical outcomes,
and reduced provider burnout. While it’s technically just
a score, it serves as an important barometer for deter-
mining the quality of the patient experience we deliver.
Patient’s Eyes and Voice
Just as we use lab tests to help determine whether
a patient has an infection (like a high white cell count),
so too can CG-CAHPS help us understand where
we can best focus our efforts to improve the patient
experience, because it represents the patient’s eyes and
voice. Just as the patient’s white cell count generally
goes down when we treat the infection successfully, so
too will CG-CAHPS results improve when we treat the
underlying issues in the practice.
It’s important to understand that CG-CAHPS data
is already publicly reported at www.medicare.gov/
physicancompare.gov. Do you know what your patients
are saying about their experiences in your office? Your
communication? Your follow-up on test results? How
helpful and courteous your office staff are?
Patients don’t live in our world and don’t share our
training, so they cannot differentiate among providers
on the technical quality of care. They see only bits and
pieces of what we do and they assess quality based on
their experience.1
If we don’t provide patients with a
CG-CAHPS Is Here
New Tools Improve the Patient Experience
BY JEFF MORRIS, M.D., M.B.A., FACS
March_2015_mech.indd 38 3/11/15 2:47 PM

2. MARCH 2015 AMGA.ORG x GROUP PRACTICE JOURNAL 39
positive experience, we place both our practice reputa-
tion and market share at risk, particularly in today’s era
of viral blogs and Facebook posts on wait times.
Similarly, numerous studies show that a poor
patient experience correlates with high liability risk.2
Patients usually do not take legal action based on real
quality of care concerns, but, more often, based on
quality of communication (e.g., the provider was rude,
did not accept phone calls, did not listen or seem to
care). Communication is key3
—even with unfavorable
clinical outcomes—to retaining patient trust and reduc-
ing lawsuits.
Burnout is rampant among healthcare providers.4
When patients have a positive experience because we
have communicated well, shared an effective care plan,
and made progress toward wellness through a shared
mutual agenda, we feel a sense of renewed purpose,
worthwhile work, and making a difference in our work.
We connect with hearts and minds and are far less
likely to suffer professional burnout.
Three Tools
In coaching many group practices nationwide,
Studer Group has found three tools particularly effec-
tive for improving multiple domains that measure the
patient experience on the CG-CAHPS survey: (1) AID-
ET®
, (2) Individualized Patient Care, and (3) Integrated
Office-Based Skills Labs. These tools build patient trust,
align providers, staff, and patients with respect to treat-
ment goals, and improve patient adherence to treatment
protocols.
1. AIDET Builds Trust and Reduces Anxiety
AIDET is an acronym for “Acknowledge, Intro-
duce, Duration, Explanation, Thank you,” a communi-
cations awareness tool:
■■ “A” stands for Acknowledge the patient. This
tells patients that you care about them and dem-
onstrates respect (which are asked about on the
CG-CAHPS survey). By making eye contact and
sitting down, you begin to connect on a personal
level and build a positive relationship.
■■ “I” stands for Introduce. Share something posi-
tive about yourself and your team that gives the
patient confidence in your competency.
■■ “D” is for Duration. Describing how long the
exam or test will be or how long the wait will be
reduces anxiety.
■■ “E” is for Explanation. Explain your findings,
about the pain involved, or what will happen
next. Always use words the patient can under-
stand and avoid jargon. Use the “teach-back”
method and ensure the patient is understanding
by asking questions in an open manner (i.e.,
“What questions do you have for me?” rather
than “Do you have any questions?”).
■■ “T” stands for Thank you. Always close with
your appreciation for the opportunity to care for
the patient and for partnering in their care plan.
As Rodney Tucker, M.D., associate professor and
director for the Center for Palliative and Supportive
Care at the University of Alabama at Birmingham, has
said, “AIDET® is like a gift to physicians because it
tests and validates ACGME [Accreditation Council for
Graduate Medical Education]-required core competen-
cies like professionalism, interpersonal/communication
skills, and patient-centered care.” It also improves
group practice performance in every domain of CG-
CAHPS survey questions, including doctor communica-
tion and courtesy/helpfulness of staff.
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3. 40 GROUP PRACTICE JOURNAL x AMGA.ORG MARCH 2015
As healthcare providers, we owe it to our patients
to ensure we communicate in a way that reduces anxiety.
Calm, engaged patients are more likely to align with and
listen to their provider for adherence to treatment plans.
In fact, physicians who are rated high on empathy usu-
ally achieve better clinical outcomes than their peers.5
AIDET is not a checklist, so be sure to adapt it for
the person using it, for the patient being seen, and for
the setting, but use elements of AIDET®
every time with
every patient. An example of AIDET for a provider
might sound like this: “Ms. Jones, we have covered a
lot of information in the last few minutes, so what can I
explain better for you, and what questions do you have
for me?”
Or:
“Thank you for coming in today, Mr. Brown. It was
important for us to make sure that your diabetes is
under good control. And thank you for being so good
about your diet and taking your medications as pre-
scribed.”
Every member of your team has an important
role to play in the patient experience! For example,
a receptionist might begin with a thank you (“Mr.
Minerman—Thanks for coming in today.”) and then
introduce her/himself and “manage up” the providers’
expertise to a new patient (“I know you’re new to this
practice, and I welcome the opportunity to take care
of you. I’ve been here for 12 years and have worked
with Dr. Smith the entire time. He’s a great physician.
You’re going to be in very capable hands.”) She may
save the AIDET “Duration” for the end of the encoun-
ter (“Thanks for completing these forms. We will come
get you in 10 to 15 minutes for the initial evaluation by
Lisa, our nurse practitioner.”).
2. Individualized Patient Care
As the late Maya Angelou famously said, “People
remember how you made them feel.” Individualized
Patient Care (IPC) is patient-centered care. As Okla-
homa University (OU) Physicians Executive Director of
Clinical Operations and Community Health Services,
Holly Adams, M.H.A., FACHE, FACMPE, says, “Who
better to speak to the unique needs and sensitivities that
our patients have than the patients themselves?”
In a medical group practice setting, IPC is charac-
terized by a high-touch personal greeting and uses an
IPC card to elicit the patient’s objective for the visit.
The IPC card also prevents unnecessary calls post-visit
because key questions were answered. (To learn more
about OU’s experience with IPC in a large multi-spe-
cialty practice and improved CG-CAHPS results, watch
a brief video at www.studergroup.com/IPCclinic).
Because CG-CAHPS measures the care continu-
um—from before the patient encounter until well after
it ends—many medical practices find that pre-visit calls
are an effective way to begin IPC, and post-visit calls
effectively complete it. Pre-visit calls reduce missed
appointments by establishing trust and concern for the
patient and identify what is most important to the pa-
tient for that visit. This is then documented on the IPC
card for follow-up during the visit.
When patients arrive at registration, the front desk
staff acknowledges the stated concern or anxiety as
noted on the IPC and puts them at ease. From the pa-
tient’s perspective, this is evidence that the team is coor-
dinating care and patient-focused. This has a powerful
positive impact on how patients answer questions in
the communication domain of the CG-CAHPS survey.
JPS Health Network in Fort Worth, Texas, a 537-bed
acute care public hospital with 15 affiliated primary
care clinics and 100 contracted primary care providers,
asks every patient to complete an IPC card at check-
in. On the front of the card, the patient’s arrival and
appointment times are noted. On the back of the card,
patients are asked to check the reason for their appoint-
ment to ensure their needs are met, (e.g., prescription
refill, form for work, referral.) (Download a copy of
JPS’ IPC card at www.studergroup.com/physamples.)
In just four months after implementation of the IPC
card, JPS improved patient ratings for “overall rating
of provider” from the 23rd to 41st percentile compared
to peers.
3. Skills Labs Break Down Silos
Just as in baseball, hitting the ball out of the park
does not constitute a home run until the hitter touches
all the bases, so too must we touch all the bases with
every patient, every time, to ensure they always have
an excellent experience. Said another way, because the
patient experience is not based on a single interaction
with any one individual in the practice, the quality of
every interaction impacts the perception of every next
interaction during the patient’s visit.
If a patient has a poor experience making a tele-
phone appointment, she may be skeptical about the
quality of the practice by the time she meets her pro-
vider. Conversely, when the receptionist manages up the
expertise of the provider using AIDET®
, she’s prepared
for a positive experience.
The Integrated Office-Based Skills Lab is a diag-
nostic and validation coaching tool that breaks down
silo thinking in favor of teamwork so that the team has
an experiential understanding of how their interactions
impact the overall patient experience and how they can
March_2015_mech.indd 40 3/11/15 2:48 PM

4. 42 GROUP PRACTICE JOURNAL ❘ AMGA.ORG MARCH 2015
improve it. A receptionist may have never been in a
patient room, for example, while someone who works
in the back office has likely never seen what occurs in
the reception area. Integrated skills labs remedy that
by gathering the team together in a safe environment
(e.g., during non-patient hours) to trace through mock
patient encounters from registration to discharge, while
learning and validating the use of best practice commu-
nication tools like AIDET®
and IPC.
Alegent Creighton Clinic in Omaha, Nebraska,
has conducted 54 integrated skills labs to date over
18 months at 46 of the system’s 100-plus individual
sites. As a result, they’ve enjoyed a jump of 50 percent
or greater in five of the six CG-CAHPS domains (e.g.,
overall provider rating, helpfulness of office staff, thor-
oughness and completeness of exam). Integrated skills
labs move performance improvement quickly.
“For the most part, participants are curious or a bit
nervous at the outset, but 99 percent will express how
much they learned by the end of the skills lab,” notes
Larry Brown, M.D., FAAP, FACP, a practicing internal
medicine and pediatrics physician and medical director
of service excellence at Alegent Creighton. “The team
concept is key in an ambulatory setting because of the
false walls that exist between front office staff, nurses,
and providers. Skills labs allow everyone to see the en-
vironment and individual encounters from the patient’s
perspective. Also, they remove the excuse that the
scores are poor due to the performance of a particular
individual, certain patients, or the vendor survey. The
team understands our score depends on everyone work-
ing together.”
At Alegent Creighton Clinic, a skills lab typically
includes up to 20 individuals (including four to six pro-
viders) and lasts approximately one hour. Individuals
at all skill levels—from physicians and advance practice
clinician providers to radiology technicians and front
office receptionists—are expected to attend. A mock
patient scenario is entered into the electronic health
record teaching model. Observers follow the mock
patient through all touch points during the visit, noting
written observations on an evaluation form, and then
highlight what went well as well as opportunities for
improvement, during a facilitated group debrief.
Data are summarized and shared with the clinic
manager, who follows up with information on tools or
articles that address opportunities for improvement.
“Providers can be humble, so we frequently need to
connect the dots for them between the importance of
narrating their patient care and managing up their
expertise with reducing patient anxiety and ensuring
better clinical outcomes,” adds Dr. Brown.
Suggested Reading
A Framework for Integrated Office-Based Skills Labs.
At www.studergroup.com/skillslabframework.
Enhanced Verbal & Non-Verbal Communication Skills, Using
AIDET®
& Key Words. At www.studergroup.com/AIDETbasics.
Morris, J., M.D., M.B.A., FACS, Hotko, B., R.N., M.P.A.,
and Bates, M., M.P.H. Jan. 2015. The CG-CAHPS Handbook: A
Guide to Improve Patient Experience and Clinical Outcome. Gulf
Breeze, FL: Firestarter Publishing. ISBN: 9781622180073.
Comfort Levels
Communicating differently is not always comfort-
able for staff and providers at first. But there can be no
progress, success, or achievement in life without some
level of discomfort. It’s important to get comfortable
being uncomfortable if you want to advance to the next
level. It may take a little time to become comfortable
with these tools, but you and your patients deserve it.
References
1.J.T. Chang, R.D. Hays, et al. 2006. Patients’ global ratings of
their health care are not associated with the technical quality
of their care. Annuals of Internal Medicine, 144(9): 665–672.
2.G.B. Hickson, C.F. Federspiel, et al. 2002. Patient complaints
and malpractice risk. JAMA. 287(22): 2951–2957.
3.Chang, Op. cit.
4.T.D. Shanafelt, S. Boone, et al. 2012. Burnout and satisfac-
tion with work-life balance among US physicians relative to
the general U.S. population. Archives of Internal Medicine,
172(18): 1377–1385.
5.M. Hojat, D.Z. Louis, et al. 2011. Physicians’ empathy and
clinical outcome for diabetic patients. Academic Medicine,
86(3): 359–364.
Jeff Morris, M.D., M.B.A., FACS, is a Studer Group
physician coach and speaker and coauthor of The CG-
CAHPS Handbook: A Guide to Improve Patient Experi-
ence and Clinical Outcomes.
EHR Blues: A Barrier to Connecting with Your Patients?
Sometimes the electronic health record (EHR) becomes an impedi-
ment to engaging patients because of the way in which we position
it both physically—between the physician and provider—as well in
the patient’s mind. We may “manage it down” by sharing our frustra-
tion or wishing we could go back to paper.
Instead, set up patient rooms so providers can sit next to patients to
view the EHR together. Use key words to emphasize benefits around
quality and safety. For example, “This is difficult for me because I
don’t type very quickly, but it’s a really excellent tool. See how your
x-rays and all your records are here? In the old ‘paper days,’ it was
often difficult to get access to these at one time, but here you can see
that your primary care doctor and surgeon have both documented
everything in one place.”
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