Patient experience Knowledge, Strategies and Operation

Patient Experience
Knowledge, Strategies & Operation
Prepared by: Mr. Mouad Hourani. RN, Mph.
Quality Improvement Department
Mar.2017
Mouathhourani@yahoo.com
00966537789641

Introduction
• Defining Patient Experience (PE)
Currently, there are several definitions of patient experience which
the positive patient experience is defined by the Department of
Health as:
“Getting good treatment in a comfortable, caring and safe
environment, delivered in a calm and reassuring way; having
information to make choices, to feel confident and feel in control;
being talked to and listened to as an equal and being treated with
honesty, respect and dignity”.
(DoH, 2009)

Patient
Experience
Medical
Management
Nursing
Management
Executive
Management
Human
Resource
Business
Office
Material
Management
Finance
Patient
Experience (PE)
Interdepartmental
Integration

1. Develop SOS draft
2. Approve by Leadership
3. Develop PE committee
4. Develop and Approve (by the committee):
• 1. SOS 2. PE – TOR. 3. Job descriptions. 4. Operational Plan. 5. PE strategy.
5. Finalize the HR and other related administrative actions.
6. Allocate the resources:
• 1. Staffing. 2. Location (Offices). 3. Provide furniture and all other office requirements. 4. Start the
operation of the department.
7. Implement the strategy.
8. Monitor the implementation
9. Report the feedback and then modify on strategy if required.
10. Continue department operation.
Steps of developing Patient Experience Department:

1. Department Vision
Striving to be the area’s leader in patient experience and clinical outcomes.
2. Department Mission
To enhance the quality of life of those we serve through superior healthcare provision and
comprehensive patient journey.
3. Department Values
3.1 Quality:
We maintain the highest standards and achieve them by continuum measuring and
improving our outcomes.
3.2 Innovation:
We welcome change, encourage invention and continuum seek better, more efficient ways
to achieve our goals.
Vision, Mission and Values:

3.3 Teamwork:
We collaborate and share knowledge to benefit patients and fellow caregivers for the
advancement of our mission.
3.4 Service:
We strive to exceed our patients’ and/or fellow caregivers’ expectations for comfort and
convenience.
3.5. Integrity:
We adhere to high moral principles and professional standards by a commitment to honesty,
confidentiality, trust, respect and transparency.
3.6. Compassion:
We demonstrate our commitment to world-class care by providing a caring and supportive
environment for our patients, patients’ families and fellow caregivers.
Vision, Mission and Values:

Introduction of the PE department
The patient experience department is accountable to the general director of
hospital. It is responsible for promoting the use of patient experience
concept, philosophy, principles, and practices throughout the Hospital
through getting good treatment in a comfortable, caring and safe
environment, delivered in a calm and reassuring way; having information to
make choices, to feel confident and feel in control; being talked to and
listened to as an equal and being treated with honesty, respect and
dignity.

Patient Experience expectations
• People who use healthcare services would expect an experience of care and treatment as
following:
Patient Experience expectations
Welcoming Distinguished Kind Respectful
Gentle Safe Personal Compassionate
Informative Sensitive Comforting Understanding
Caring Helpful Reassuring Supportive

Perception Pre-care
Patient
Care
Post Care
Patient Experience Journey
ServiceofCulture

Suggested Patient Experience Dept. Location in the
Org. Structure (1)
General
Director
Executive Director
of Patient
Experience
Patient Experience
Development
Administration
Data Intelligence
and Survey Section
Patient Rights and
Relations
In-Patient Rights
and Relations
Section
Innovation Center
(Clinical and care
Model, Technology,
Service and Idea
Management)
Training and
Education Section
Quality Improvement
and Patient Safety
Office
Out-patients and
ER Rights and
Relations
Patient Advocacy
and Ombudsman
Section

General
Director
Executive Director
of Patient
Experience
Patient Experience
Development
Administration
Data Intelligence and
Survey Section
Patient Rights and
Relations
In-Patient Rights
and Relations
Section
Innovation Center (Clinical and
care Model, Technology, Service
and Idea Management)
Training and Education
Section
Quality Improvement and
Patient Safety Office
Out-patients and
ER Rights and
Relations
Patient Advocacy
and Ombudsman
Section
Suggested Patient Experience Dept. Location in the
Org. Structure (2)

Hours of operation:
• 24/7 for patient rights and relation.
Or:
10:00AM to 07:30PM for coverage of Week-end (Rotation) for patient
satisfaction section.
• Office hours (48 hrs. / Weak) for administrative services.
Duty Hours

• External Customers:
1. All Out and In-patients and their families.
2. Surrounding communities.
3. Health Insurance Company – Payers.
4. Out-sourced contractors.
5. Suppliers.
• Internal Customers:
1. All eligible employees in Hospital.
Internal & External Customers

Responsibilities, Accountabilities and Duties
1. The Board of Directors
The Board of Directors provides a leadership to create a culture that is involving and
inclusive and supports:
A. The development of a broad understanding of the business case for and the benefits
of patient, carer and public engagement and experience.
B. The incorporation of engagement and experience into all aspects of decision making.
C. The mainstreaming of patient and public engagement and experience by embedding
the principle in personal and organizational objectives.
D. The demonstration of principles and aims of the patient and carer experience
strategy by actions as well as words.

2. Patient Experience Committee:
As Patient Experience Committee needs to welcome local people including
patient, carers, public and staff to be involved and have their say on how Trust
services are developed. One of the primary ways of achieving this is through the
Patient Experience Committee which comprises of appointed individuals and
elected Foundation Trust members from different parties (public, patient, carer
and staff). The Committee share ideas and make suggestions and support Trust
initiatives. The Committee has designated patient and carer champions as part of
the Patient Experience Committee.

3. Executive Director of Patient Experience
The Executive Director of Patient Experience is the lead for patient and carer
experience. As chair of the Patient and Carer Experience committee they will work
closely with the Trust’s Patient and Carer Governor Champions to deliver the
strategy.
4. Director of Nursing:
The Director of Nursing is responsible for ensuring robust systems and processes
are in place to maximize safety and quality based on patient and carer feedback.

5. Patient Experience Team:
The Patient Experience Team captures patient experience feedback through
complaints, Patient Advice and Liaison (PALS) and Friends and Family Test
feedback. The team is responsible for reporting on this activity and facilitating
organizational learning and improvement.
6. All our Staff:
All of our staff are responsible for ensuring our patients and their carers have a
positive experience of care from the Trust.

7. Quality and Patient Safety Committee (QIPS):
The Quality & Patient Safety department has the role to oversee and coordinate all
aspects of quality improvement (patient experience/patient safety & clinical effectiveness),
assurance and clinical governance activity and delivery. The Committee will ensure that
the voice of Patient and Carers is routinely sought on the quality & safety of our
services.
8. Patient and Carer Experience TRUST Group:
The Patient and Carer Experience Group’s purpose is to ensure that there is a culture
of continuous, positive improvement to patient/user and carer experiences and that this
remains core to the Trust’s business. The Group exists to:

A. Develop & drive a range of methodologies to capture and learn from patient & carer
experience.
B. To make a difference to patient/user experience through working with our staff and external
stakeholders such as our commissioners, local service users and other patient groups.
C. To actively work with key stakeholders members patient/user representatives – to consider them
as a critical friend and to explore ways in which the Trust can respond positively to their
views.
D. To ensure that we develop a culture of patient/user participation on our improvement projects
and groups so that their voices can be heard and that their views make a difference to the
work that we do.
E. To ensure delivery of the Trust patient and carer experience strategy and strategic objectives.

9.Training and education personnel
The Organizational Development Strategy will incorporate training specific to
patient experience, commencing on Induction and following through to Continuing
Professional Development, examples include:
1. Communication & listening skills/customer care.
2. Privacy & Dignity awareness.
3. Patient and public involvement techniques: Observations of Care, Story Telling etc.
4. Patient safety/infection control.

6. Equality and diversity/awareness of legislation
7. Equality Impact Assessment
8. Information and metrics
9. Leadership development
10. Transforming Care
11. Responding to complaints: Putting Things Right
 An overarching education framework will need to be developed.

Communication with other departments
A. Internal communication methods:
1. Hospital intranet and outlook.
2. Bulletin boards and Memos.
3. E-mails.
4. Rollup and brochures.
5. Hospital telephone.
6. Verbal communication.
7. Regular departmental & committees meeting.
8. Newsletter.
9. Written policies, procedures and protocol.

B. Communication with other departments/hospitals:
1. Hospital intranet and outlook.
2. Hospital telephone.
3. Regular meeting.
4. Hospital maintains and promotes positive relationships with community
and provides patient-centered care and services through the departmental
agreement.
Communication with other departments

Patient experience in
adult NHS services

• Statement 1. Patients are treated with dignity, kindness, compassion, courtesy, respect,
understanding and honesty.
• Statement 2. Patients experience effective interactions with staff who have demonstrated
competency in relevant communication skills.
• Statement 3. Patients are introduced to all healthcare professionals involved in their care,
and are made aware of the roles and responsibilities of the members of the healthcare
team.
• Statement 4. Patients have opportunities to discuss their health beliefs, concerns and
preferences to inform their individualized care.
• Statement 5. Patients are supported by healthcare professionals to understand relevant
treatment options, including benefits, risks and potential consequences.
Standards to improve patient experience

• Statement 6. Patients are actively involved in shared decision making and supported by
healthcare professionals to make fully informed choices about investigations, treatment and
care that reflect what is important to them.
• Statement 7. Patients are made aware that they have the right to choose, accept or decline
treatment and these decisions are respected and supported.
• Statement 8. Patients are made aware that they can ask for a second opinion.
• Statement 9. Patients experience care that is tailored to their needs and personal preferences,
taking into account their circumstances, their ability to access services and their coexisting
conditions.
• Statement 10. Patients have their physical and psychological needs regularly assessed and
addressed, including nutrition, hydration, pain relief, personal hygiene and anxiety.

• Statement 11. Patients experience continuity of care delivered, whenever possible, by the same
healthcare professional or team throughout a single episode of care.
• Statement 12. Patients experience coordinated care with clear and accurate information
exchange between relevant health and social care professionals.
• Statement 13. Patients' preferences for sharing information with their partner, family members
and/or carers are established, respected and reviewed throughout their care.
• Statement 14. Patients are made aware of who to contact, how to contact them and when to
make contact about their ongoing healthcare needs.

• Quality Statement:“Respect for the patient”.
Patients are treated with dignity, kindness, compassion, courtesy, respect,
• Quality measure
 Structure: Evidence of local arrangements to provide guidance to staff on how
to treat patients with dignity, kindness, compassion, courtesy, respect,
 Outcome: Evidence from patient experience surveys and feedback that
patients feel they have been treated with dignity, kindness, compassion,
courtesy, respect, understanding and honesty.
Quality statement 1: Respect for the patient

• What the quality statement means for each audience
Service providers: ensure that systems are in place giving guidance to all staff
on treating patients with dignity, kindness, compassion, courtesy, respect,
Health and social care professionals: treat patients with dignity, kindness,
compassion, courtesy, respect, understanding and honesty.
Commissioners: ensure they commission services that have guidance that enables
staff to treat patients with dignity, kindness, compassion, courtesy, respect,
Patients: are treated with dignity, kindness, compassion, courtesy, respect,
Quality statement 1: Respect for the patient

Quality statement 2: Demonstrated competency in
communication skills
• Quality statement:
Patients experience effective interactions with staff who have demonstrated competency in relevant communication
skills.
• Quality measure:
Structure:
a) Evidence of local arrangements to ensure that annual appraisals or performance assessments of staff
include mentoring for and evaluating compliance with the NICE guidance on patient experience.
b) Proportion of staff involved in providing NHS services who have compliance with the NICE guidance on
patient experience examined at their annual appraisal or performance assessment.
Numerator – the number of staff in the denominator who have compliance with the NICE guidance on
patient experience examined at their annual appraisal or performance assessment.
Denominator – the number of staff involved in providing NHS services.
Outcome: Evidence from patient experience surveys and feedback that patients feel staff communicated with
them in a clear and understandable way.

 Service providers ensure that systems are in place to train and assess staff competency in
relevant communication skills.
 Health and social care professionals ensure that they receive training in relevant
communication skills and can demonstrate this competency.
 Commissioners ensure they commission services that have arrangements for competency-
based training and assessment of relevant communication skills.
 Patients are cared for by staff who can communicate with them in a clear and
understandable way.
Quality statement 2: Demonstrated competency in
communication skills

Quality statement 3: Patient awareness of names,
roles and responsibilities of healthcare professionals
• Quality statement
Patients are introduced to all healthcare professionals involved in their care, and are made
aware of the roles and responsibilities of the members of the healthcare team.
• Quality measure
 Structure: Evidence of local arrangements to ensure that patients are introduced to all
healthcare professionals involved in their care, and are made aware of the roles and
responsibilities of the members of the healthcare team.
 Outcome: Evidence from patient experience surveys and feedback that patients were
introduced to all healthcare professionals involved in their care, and were made aware of
the roles and responsibilities of the members of the healthcare team.

 Service providers ensure that local policies are in place to make sure that patients are
introduced to all healthcare professionals involved in their care, and are made aware of
the roles and responsibilities of the members of the healthcare team.
 Health and social care professionals ensure that they introduce themselves to patients and
give a clear explanation of their role and responsibilities.
 Commissioners ensure they commission services that have local policies in place requiring
that all healthcare professionals introduce themselves to patients and give a clear
explanation of their role and responsibilities.
 Patients are introduced to all healthcare professionals involved in their care, and are made
aware of the roles and responsibilities of the members of the healthcare team.
Quality statement 3: Patient awareness of names,
roles and responsibilities of healthcare professionals

Quality statement 4: Giving patients opportunities to
discuss their health beliefs, concerns and preferences
Patients have opportunities to discuss their health beliefs, concerns and preferences to inform their
individualized care.
• Quality measure
Structure: Evidence of local arrangements to ensure that patients have opportunities to discuss their health
beliefs, concerns and preferences, and these inform their individualized care.
Process: Proportion of patients given the opportunity to discuss their health beliefs, concerns and
preferences.
Numerator – the number of patients in the denominator who were given the opportunity to discuss their
health beliefs, concerns and preferences.
Denominator – the number of patients accessing NHS services.
Outcome: Evidence from patient experience surveys and feedback that patients feel they had opportunities
to discuss their health beliefs, concerns and preferences, and these informed their individualized care.

 Service providers ensure that systems are in place to provide opportunities to establish
patients' health beliefs, concerns and preferences and use them to inform individualized
care.
 Health and social care professionals establish the patient's health beliefs, concerns and
preferences and use them to inform individualized care.
 Commissioners ensure they commission services in which the patient's health beliefs,
concerns and preferences are established and used to individualize care.
 Patients have opportunities to discuss their health beliefs, concerns and preferences, and
these are taken into account when making decisions about their care.
Quality statement 4: Giving patients opportunities to
discuss their health beliefs, concerns and preferences

Quality statement 5: Understanding treatment
options
Patients are supported by healthcare professionals to understand relevant treatment options,
including benefits, risks and potential consequences.
• Quality measure
 Structure: Evidence of local arrangements to ensure that healthcare professionals support
patients to understand relevant treatment options, including benefits, risks and potential
consequences.
 Outcome: Evidence from patient experience surveys and feedback that patients were
supported by healthcare professionals to understand relevant treatment options, including
benefits, risks and potential consequences.

 Service providers ensure that systems are in place to support patients to understand
relevant treatment options, including benefits, risks and potential consequences.
 Health and social care professionals support patients to understand relevant treatment
options, including benefits, risks and potential consequences.
 Commissioners ensure they commission services in which patients are supported to
understand relevant treatment options, including benefits, risks and potential consequences.
 Patients are helped by healthcare professionals to understand relevant treatment options,
including benefits, risks and potential consequences of care.
Quality statement 5: Understanding treatment
options

Quality statement 6: Shared decision making
Patients are actively involved in shared decision making and supported by healthcare professionals to
make fully informed choices about investigations, treatment and care that reflect what is important to
them.
• Structure:
a) Evidence of local arrangements to ensure that patients are actively involved in shared decision making,
including using the most effective way of communicating to maximize the patient's participation in
decisions.
b) Evidence of local arrangements to ensure that patients are supported to make informed choices using
risk communication and decision support, such as patient decision aids.
c) Evidence of local arrangements to ensure that information provided to facilitate shared decision
making is evidence-based, understandable and clearly communicated.

• Process:
a) Proportion of patients who were asked about any issues that may prevent them being actively involved in decisions
about their care.
 Numerator – the number of patients in the denominator who were asked about any issues that may prevent them
being actively involved in decisions about their care.
 Denominator – the number of patients accessing NHS services.
b) Proportion of patients supported to use an evidence-based patient decision aid.
 Numerator – the number of patients in the denominator supported to use an evidence-based patient decision aid.
 Denominator – the number of patients accessing NHS services for whom there is a relevant evidence-based decision
aid.
• Outcome:
a) Evidence from patient experience surveys and feedback that patients found that the information provided to facilitate
shared decision making was understandable and clearly communicated.
b) Evidence from patient experience surveys and feedback that patients feel able to make decisions that reflect what is
important to them.

 Service providers ensure that systems are in place to actively involve patients in shared decision
making and to support patients to make fully informed choices about investigations, treatment and
 Health and social care professionals actively involve patients in shared decision making and support
patients to make fully informed choices about investigations, treatment and care that reflect what
is important to them
 Commissioners ensure they commission services in which patients are actively involved in shared
decision making and supported to make fully informed choices about investigations, treatment and
 Patients are actively involved in shared decision making and supported to make fully informed
choices about investigations, treatment and care that reflect what is important to them.

Quality statement 7: Supporting patient choice
Patients are made aware that they have the right to choose, accept or decline treatment and these
decisions are respected and supported.
 Structure: Evidence of local arrangements to ensure that patients are made aware of their right to
choose, accept or decline treatment and that these decisions are respected and supported.
 Process: Proportion of patients made aware of their right to choose, accept or decline treatment.
 Numerator – the number of patients in the denominator made aware of their right to choose,
accept or decline treatment.
 Outcome: Evidence from patient experience surveys and feedback that patients know about their
right to choose, accept or decline treatment and feel that their decisions were respected and
supported.

 Service providers ensure that systems are in place to make patients aware of their right to
choose, accept or decline treatment, and to make sure that healthcare professionals respect
and support these decisions.
 Health and social care professionals ensure that they make patients aware of their right to
choose, accept or decline treatment, and respect and support these decisions.
 Commissioners ensure they commission services in which patients are made aware of their
right to choose, accept or decline treatment and these decisions are respected and
supported.
 Patients have their choices respected and supported when deciding whether to accept or
decline treatment, and when choosing between treatments.
Quality statement 7: Supporting patient choice

Quality statement 8: Asking for a second opinion
Patients are made aware that they can ask for a second opinion.
• Quality measure
 Structure: Evidence of local arrangements to ensure that patients are made aware that
they can ask for a second opinion.
 Process: Proportion of patients made aware that they can ask for a second opinion.
 Numerator – the number of patients in the denominator made aware that they can ask
for a second opinion.
 Outcome: Evidence from patient experience surveys and feedback that patients know that

 Service providers ensure that systems are in place to make patients aware that they can
ask for a second opinion.
 Health and social care professionals ensure that patients are made aware that they can
ask for a second opinion.
 Commissioners ensure they commission services in which patients are made aware that
 Patients are made aware that they can ask for a second opinion.
Quality statement 8: Asking for a second opinion

Quality statement 9: Tailoring healthcare services to the
individual
Patients experience care that is tailored to their needs and personal preferences, taking into account their circumstances,
their ability to access services and their coexisting conditions.
• Quality measure
 Structure: Evidence of local arrangements to ensure that care is tailored to patients' needs and personal preferences,
taking into account their circumstances, their ability to access services and their coexisting conditions.
 Process: The proportion of patients with care tailored to their needs and preferences, taking into account their
circumstances, their ability to access services and their coexisting conditions.
 Numerator – the number of patients in the denominator who have care tailored to their needs and preferences,
taking into account their circumstances, their ability to access services and their coexisting conditions
 Outcome: Evidence from patient experience surveys and feedback that care was tailored to the patient's needs and
personal preferences, taking into account their circumstances, their ability to access services and their coexisting
conditions.

 Service providers ensure that systems are in place to tailor care to patients' needs and personal
preferences, taking into account their circumstances, their ability to access services and their
coexisting conditions.
 Health and social care professionals ensure that they tailor care to patients' needs and personal
preferences, taking into account their circumstances, their ability to access services and their
coexisting conditions.
 Commissioners ensure they commission services in which care is tailored to patients' needs and
personal preferences, taking into account their circumstances, their ability to access services and
their coexisting conditions.
 Patients experience care that is tailored to their needs and personal preferences, taking into
account their circumstances, how easy it is for them to use the services they need, and any other
health problems they have.
Quality statement 9: Tailoring healthcare services to the
individual

Quality statement 10: Physical and psychological needs
Patients have their physical and psychological needs regularly assessed and addressed, including
nutrition, hydration, pain relief, personal hygiene and anxiety.
• Quality measure
 Structure: Evidence of local arrangements to ensure that patients have their physical and
psychological needs regularly assessed and addressed.
 Process: Proportion of patients who have their physical and psychological needs regularly assessed
and addressed.
 Numerator – the number of patients in the denominator who have their physical and
psychological needs regularly assessed and addressed.
 Outcome: Evidence from patient experience surveys and feedback that patients feel their physical
and psychological needs were regularly assessed and addressed.

 Service providers ensure that systems are in place to regularly assess and address patients'
physical and psychological needs.
 Health and social care professionals regularly assess and address patients' physical and
psychological needs.
 Commissioners ensure they commission services in which patients' physical and
psychological needs are regularly assessed and addressed.
 Patients are regularly checked and asked whether they need any extra support, for
example with eating and drinking, pain relief, continence problems or anxieties.
Quality statement 10: Physical and psychological needs

Quality statement 11: Continuity of care
Patients experience continuity of care delivered, whenever possible, by the same healthcare professional
or team throughout a single episode of care.
 Structure: Evidence of local arrangements to ensure continuity of care and that, whenever possible,
patients see the same healthcare professional or team throughout a single episode of care.
 Process: Proportion of patients seeing the same healthcare professional or team throughout a
single episode of care.
 Numerator – the number of patients in the denominator seeing the same healthcare professional
or team throughout a single episode of care.
 Outcome: Evidence from patient experience surveys and feedback that, whenever possible, patients
saw the same healthcare professional or team throughout a single episode of care.

 Service providers ensure that systems are in place for care to be delivered, whenever
possible, by the same healthcare professional or team throughout a single episode of care.
 Healthcare professionals ensure that, whenever possible, the patient sees the same
healthcare professional or team throughout a single episode of care.
 Commissioners ensure they commission services in which, whenever possible, patients see
the same healthcare professional or team throughout a single episode of care.
 Patients see the same healthcare professional or healthcare team throughout a course of
treatment whenever this is possible.
Quality statement 11: Continuity of care

Quality statement 12: Coordinated care through the exchange
of patient information
Patients experience coordinated care with clear and accurate information exchange between
relevant health and social care professionals.
• Quality measure
• Structure: Evidence of local arrangements to support coordinated care through clear and
accurate information exchange between relevant health and social care professionals.
• Outcome: Evidence from patient experience surveys and feedback that patients feel that
information about their care was shared clearly and accurately between relevant health and
social care professionals.

• What the quality statement means for each audience:
 Service providers ensure that systems are in place to support coordinated care through clear and
accurate information exchange between relevant health and social care professionals.
 Health and social care professionals ensure that they support coordinated care through clear and
accurate information exchange.
 Commissioners ensure they commission services in which coordinated care is supported through
clear and accurate information exchange between relevant health and social care professionals.
 Patients can expect information about their care to be exchanged in a clear and accurate way
between relevant health and social care professionals, so that their care is coordinated with the
least possible delay or disruption.
Quality statement 12: Coordinated care
through the exchange of patient information

Quality statement 13: Sharing information with partners,
family members and carers
• Patients' preferences for sharing information with their partner, family members and/or carers are established,
respected and reviewed throughout their care.
• Quality measure
 Structure: Evidence of local arrangements to ensure that patients' preferences for sharing information with
partners, family members and/or carers are established, respected and reviewed throughout their care.
 Process: Proportion of patients whose preferences for sharing information with partners, family members and/or
carers are established, respected and reviewed throughout their care.
oNumerator – the number of patients in the denominator whose preferences for sharing information with
partners, family members and/or carers are established, respected and reviewed throughout their care.
oDenominator – the number of patients accessing NHS services.
 Outcome: Evidence from patient experience surveys and feedback that patients' preferences for sharing
information with partners, family members and/or carers were established, respected and reviewed throughout
their care.

 Service providers ensure that systems are in place to establish, respect and review patients'
preferences for sharing information with partners, family members and/or carers.
 Health and social care professionals establish, respect and review patients' preferences for sharing
information with partners, family members and/or carers.
 Commissioners ensure they commission services in which patients' preferences for sharing
information with partners, family members and/or carers are established, respected and reviewed.
 Patients are asked if they want their partner, family members and/or carers to be given
information about their care, and their preferences are respected and reviewed throughout their
care.
Quality statement 13: Sharing information
with partners, family members and carers

Quality statement 14: Information about
contacting healthcare professionals
Patients are made aware of who to contact, how to contact them and when to make contact about their ongoing
healthcare needs.
• Quality measure
 Structure: Evidence of local arrangements to ensure that patients are made aware of who to contact, how to
contact them and when to make contact about their ongoing healthcare needs.
 Process: Proportion of patients made aware of who to contact, how to contact them and when to make contact
about their ongoing healthcare needs.
 Numerator – the number of patients in the denominator made aware of who to contact, how to contact them
and when to make contact about their ongoing healthcare needs.
 Outcome: Evidence from patient experience surveys and feedback that patients know who to contact, how to
contact them and when to make contact about their ongoing healthcare needs.

 Service providers ensure that systems are in place so that that patients are made aware
of who to contact about their ongoing healthcare needs, and how and when to contact
them.
 Health and social care professionals ensure that patients are made aware of who to
contact about their ongoing healthcare needs, and how and when to contact them.
 Commissioners ensure they commission services in which patients are made aware of who
to contact about their ongoing healthcare needs, and how and when to contact them.
 Patients are given clear advice about who to contact about their healthcare needs, how to
contact them and when to contact them.
Quality statement 14: Information about
contacting healthcare professionals

Cleveland Clinic, USA
approach to improve
patient experience

The following are the component of Cleveland Clinic patient experience department:
a) Association for Patient Experience
The Association for Patient Experience (AfPE) is established to support
healthcare professionals, patients, and their families by improving the patient
experience.
Cleveland Clinic, USA approach to improve patient
experience

b) Best Practices in Patient Experience
 Best practices are used in healthcare to deliver quality care that promotes
optimal outcomes.
 The Best Practices team assists with the identification and development of
best practices throughout the enterprise to enhance the patient experience
initiative. Working closely with other departments, the team focuses on
HCAHPS domains as well as general patient experience improvement at
hospital driving programs such as:
experience

i. Medicine Communication:
Communicating about medications is critical to a positive patient experience. A patient’s
understanding of medications also drives safety and quality. Patients and their families deserve
to know what medication they are being prescribed, why they are taking the medication,
understand side effects that may occur while taking a particular medication and what to do if
a side effect should occur.
ii. Quiet at Night:
Adequate rest is a key element in helping patients heal. An enterprise-wide "Quiet at Night"
improvement team created guidelines, including H.U.S.H. (Help Us Support Healing) protocol, to
reduce nighttime noise in our hospitals. This includes specific interventions to reduce noise and
provide a restful, healing environment for our patients from 9 p.m. - 7 a.m.
experience

iii. Purposeful Hourly Rounding:
Patients like to know someone is watching over them. Rounding with a
purpose not only fulfills the routine requests that are usually made when the
call light is used, but also demonstrates nurses’ availability to the patient and
their readiness to anticipate the patient’s needs. Hourly rounding with a
purpose is proactive, allowing nurses to manage patient care and their own
time more efficiently. Rounding is about building relationships and trust as
much as it is about meeting physical needs.
experience

iv. Leadership Rounding:
Occurring monthly at Cleveland Clinic hospitals, leaders are placed on teams
of three and assigned to a particular inpatient or outpatient location for
rounding. Information collected during the rounding session includes issues,
comments, suggestions and needs from patients and caregivers. These items
are addressed immediately or are addressed through an action plan. As
important as a successful leadership rounding session is, a process to address
the learnings from each session is equally, if not, more imperative.
experience

v. Effective Nurse Leader Rounding:
In order to assure every patient’s experience is always met with a nursing team of
caregivers who are responsive to the needs of our patients and families, the Office of
Patient Experience, in partnership with the Nursing Institute, launched Effective Nurse
Leader Rounding at all CCHS hospitals. Effective Nurse Leader Rounding helps manage
patient expectations, provide necessary service recovery, promote quality care, recognize
exceptional caregivers and role model expected behaviors.
vi. No Pass Zones:
Our "No Pass Zone" program empowers all caregivers to not pass by patient call lights
without acknowledging, answering, or resolving the patient's needs.
experience

c) Center for Ethics, Humanities & Spiritual Care:
A collaboration that brings together services that support patients, educate caregivers and assure best
ethical practices, the Center includes the Bioethics, Medical Humanities, NeuroEthics and Spiritual Care
departments.
d) Center for Excellence in Healthcare Communication:
 Ensuring effective clinician-patient communication is the right thing to do for our patients, and critical
to the delivery of safe, high-quality medical care.
 How effectively clinicians communicate with patients has emerged as a very important issue in
healthcare. The Center for Excellence in Healthcare Communication serves as an enterprise hub for
education, training and resources to physicians and advanced clinical care providers around relationship-
centered communication.
experience

e) Communicate with H.E.A.R.T.®
 Communicate with H.E.A.R.T.® is Cleveland Clinic’s
foundational communication model for delivering a culture
of service excellence. The communication model empowers
caregivers to provide outstanding service to patients,
visitors and fellow caregivers, and it includes interactive
activities to support the learning process.
 The Communicate with H.E.A.R.T.® program includes
interactive training sessions and learning activities that
focus on Cleveland Clinic’s Expected Service Behaviors.
Respond with
H.E.A.R.T.
H ear the story
E mpathize
A pologize
R espond
T hank
experience

f) Employee Engagement: Cleveland Clinic Experience:
 The Office of Patient Experience supports several Human Resources initiatives to integrate an
exceptional employee experience with a world class patient experience.
 Research conducted by the Gallup organization has shown a strong correlation between overall
employee engagement and patient satisfaction.
 In the name of empathy, patient satisfaction and employee engagement, Cleveland Clinic
Experience was introduced in 2010 to continue building a strong base of engaged and
committed caregivers who are dedicated to fulfilling Cleveland Clinic’s mission of putting
Patients First.
experience

g) Healing Services
 Healing Services are holistic FREE care experiences that support your well-being and
naturally help you relax and heal during your hospital stay. Healing Services are
provided by the Healing Services Team, which includes holistic nurses, Spiritual Care
chaplains, licensed massage therapists, Reiki and Healing Touch™ practitioners, and
supervised volunteers. The Healing Services Team is a partnership between the Office of
Patient Experience and the Spiritual Care Department.
experience

h) Patient Concerns: Ombudsman Office
 The Ombudsman Office is the liaison between Cleveland
Clinic and the patient in resolving problems that may
arise during the course of treatment. Cleveland Clinic’s
Ombudsman Office was created in 1975 to provide
patients with direct access to administration and to serve
as a centralized complaint center.
 An Ombudsman has the authority to investigate
complaints independent of the departments involved. The
Ombudsmen report to the highest level of Cleveland Clinic
leadership: the Executive Administration.
Resolve a problem or concern
with the department in which
the problem occurred
Contact the department
manager or supervisor
Contact the Ombudsman’s Office
experience

 97% of dissatisfied patients do not register their complaints because they do not know
how or because they don’t think it will do any good.
 The information provided is communicated to top administration and is used to provide
data for the annual review of physicians and departments and to propose changes.
 The Ombudsman Office can help:
 If Patients have a problem with medical service.
 If Patients have concerns about the quality of your care.
 If Patients have a problem with any of our employees.
 If we did not provide satisfactory service during an outpatient visit or hospital stay.
experience

i) Patient Experience: Empathy + Innovation Summit
 Patient experience has emerged as a dynamic issue for healthcare CEOs, physicians, and
industry leaders.
 No provider can afford to offer anything less than the best clinical, physical and
emotional experience to patients and families.
 As patients become savvier, they judge healthcare providers not only on clinical
outcomes, but also on their ability to be compassionate and deliver excellent, patient-
centered care.
 The Patient Experience: Empathy and Innovation Summit is an annual, three-day,
multidisciplinary conference devoted to exploring patient experience as a key
differentiator essential to the future of healthcare delivery.
experience

j) Patient Experience Leaders Forum
 The Patient Experience Leaders Forum employs a distinctively different
approach to conveying our Patient Experience success. Participants can expect
a variety of dynamic presentations delivered in an approach combining small
group activities, facilitated exercises, workshops, guided tours, large group
discussions, reference materials and leadership rounding. Group sizes of
twenty-five or less foster an intimate learning atmosphere and allow us to
offer several formal and informal networking events with peers and Cleveland
Clinic Caregivers.
experience

k) Voice of the Patient Advisory Councils
 Voice of the Patient Advisory Councils (VPACs) meets regularly to discuss and impact a
variety of issues affecting patients and family members. VPACs include employees and
patients and are a great resource to hear directly from the people served.
 This advisory resource empowers patients and families to take an active role in
improving the patient experience at Cleveland Clinic and provides real-time feedback and
creative solutions to specific challenges.
 VPACs have reviewed several hospital policies, including patient visitation and discharge
information, helped to define the expected service behaviors of all employees, renovated
family areas, and developed educational materials for different nursing units.
experience

l) Volunteer Services
 According to many of volunteers, who were called Ambassadors, the
most significant benefit they receive from volunteering is a genuine
sense of satisfaction from helping others. Ambassadors come from
every walk of life and they appreciate the opportunity to help
others, learn new skills and make new friends.
experience

Conclusion
1. Patient Experience is currently the trend of high modern hospitals.
2. There are many strategies in many other different hospitals which we could develop our
own.
3. Patient Experience gives a special reputation to the hospital through being best care
provider and simultaneously better revenue.
4. Patient Experience doesn’t mean only patient satisfaction, it means total high standards OF
care provision from all aspects.
5. As department, it is very integrated with all departments in the hospital in order to achieve
the outcome of patient experience.
6. Patient Experience is every one’s responsibility.
7. Patient Experience is essentially depend on Leadership commitment and support.

Conclusion
• Comfortable.
• Accessibility.
• Cleanliness.
• Safe environment.
• High technology.
Environment
• Values.
• Knowledge.
• Commitment.
• Satisfaction.
• Patients’ involvement.
• Better communication.
• Patients’ preferences.
People • Timeliness.
• Evidence based.
• Continuous improvement.
• Safe process.
• Accessibility.
• Wide range of services.
• Leadership commitment.
System

Patient
Experience
People
Satisfaction
Environment
Excellence
Process
Thank
You

Patient experience Knowledge, Strategies and Operation

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