Peggy Greco, PhD, Assistant Vice President and Chief Experience Officer at Nemours Children’s Health, joins us to discuss patient experience, including the Speak Up program, which empowers families to share feedback that improves children’s health and safety. She also explores how AI enhances patient care.
Guest:
Peggy Greco, PhD, Assistant Vice President and Chief Experience Officer, Nemours Children’s Health
Host/Producer: Carol Vassar
TRANSCRIPT
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Welcome to Well Beyond Medicine, the world’s top-ranked children’s health podcast produced by Nemours Children’s Health. Subscribe on any platform at nemourswellbeyond.org or find us on YouTube.
Carol Vassar, podcast host/producer:
Each week we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar. And now that you’re here, let’s go.
Stepping up to the mic in our virtual studio right now is clinical psychologist, Dr. Peggy Greco. She serves as Nemours Assistant Vice President and Chief Patient Experience Officer. Dr. Greco, welcome to the Well Beyond Medicine Podcast.
Dr. Peggy Greco, Nemours Children’s Health:
Thank you, Carol. Very glad to be here.
Carol Vassar, podcast host/producer:
Now we know there are so many aspects of patient experience. They are all essential. They include quality, safety, outcomes, cost, satisfaction. The list is almost endless. So we’re having you on here today to bring us up-to-date on how Nemours is moving the needle to create a positive patient experience all the way around for all of our patients and all of our families. And one of the first things I’d love to talk about is the Speak Up campaign.
Now, this is an initiative with the Joint Commission. For those who don’t know the Joint Commission, they are the folks who provide very rigorous accreditation that is so vital to healthcare quality and safety in the US. So Dr. Greco, tell us what is the Speak Up campaign, what are its goals, and how have we incorporated it here at Nemours?
Dr. Peggy Greco, Nemours Children’s Health:
Well, thank you, Carol, for that opportunity to share more about what we’re doing at Nemours. And you listed some aspects of the patient experience, and I think it’s interesting that you almost listed them in order of importance because quality, safety, and outcomes came first. And that’s what we also consider to be most important. And so Speak Up is an enterprise-wide initiative that really helps to improve and impact in a positive way, quality, safety, and health outcomes. And you mentioned it’s from the Joint Commission.
The Joint Commission created a Speak Up program actually aimed toward adult patients, but had very few pediatric materials, only one video, and one handout. So basically what we’ve done is to expand that portfolio and develop a lot of other materials, and not just materials, but also training, because to really have patients and families be engaged, we have to take the responsibility to create a safe environment and a culture that encourages engagement.
Carol Vassar, podcast host/producer:
And this really puts some emphasis on listening to patients and families, what they’re seeing, what they’re experiencing. Talk a little bit about that.
Dr. Peggy Greco, Nemours Children’s Health:
So often, when you think about the things we say and do, we can say and do things differently so that we really encourage more of that speaking, so that we can listen. And you mentioned listening. The more we listen, the more our patients and families will talk. And just to give you a quick example of what I mean by doing things differently. If you ask a yes-no question, do you have any questions to a patient or family, it’s just too easy to say no, shrug your shoulders. But if you ask what are the questions and concerns you have right now? You’ve asked an open-ended, you’ve indicated, “I’m ready to listen.”
And then if you pair that with non-verbal, sitting down, making eye contact rather than hand on the door on the way out, you’re also reinforcing that message with nonverbal signals that, “I want you to tell me what’s on your mind.” And we also encourage persistent questioning because sometimes families aren’t quite sure if we really mean what we say. And so we have follow-up questions that we suggest, such as, what’s the biggest concern on your mind right now? Or what’s the question you’ve been wanting to ask, but you’ve been holding back? So again, we’re using a lot of different really specific strategies to encourage that speaking up and listening is a key part of it. The more we listen, then families are going to speak up even more.
Carol Vassar, podcast host/producer:
I’m curious, the Joint Commission really initiated this in the adult healthcare setting. Nemours is bringing this into the pediatric healthcare setting. Are you working with other hospital systems, other organizations to bring it nationwide?
Dr. Peggy Greco, Nemours Children’s Health:
So that is a great question. We have circled back, we love pediatrics as a whole, and Nemours, in particular, is very collaborative with other organizations. So we reached back out to Joint Commission and they’re putting together a web article that will have links to all of our materials so that that way they can spread the word and have also a centralized resource for other organizations. We’re also speaking on this topic at conferences, and right now we’re working on having a website presence that summarizes what Speak Up is all about and has all the materials available.
Carol Vassar, podcast host/producer:
And this is very empowering for patients and families. And that is really a key piece of that. Expand on what you’ve said about the empowerment piece.
Dr. Peggy Greco, Nemours Children’s Health:
So when you look at tying back that empowerment to the why. Why speak up? Why are we working on engagement? Why do we want our patients and families to be empowered? That there’s research out there that shows that there’s a decrease in potential safety issues and also improved health outcomes when we have engaged patients and families, and they’re really an underused source of data about errors. So we really want to empower them to be active. And patients and families want to, they want to be active. Why aren’t they? We have to take a hard look at what are we doing in our culture, our hospital culture, our outpatient culture to encourage that speaking up, that activation, and how much are we aware of the barriers that are sometimes present for patients and families, and addressing those barriers.
So for example, language barriers. Are we using preferred language? Are we always using interpreters? Are we maybe providing a list of commonly asked questions to help with the language barrier? So that activation really requires a cultural approach in terms of making sure that we’re sending that message consistently in a lot of different ways to patients and families that we want to hear your voice. And when we hear their voice, when they’re engaged, their health outcomes are better.
Carol Vassar, podcast host/producer:
What are the different ways that families can speak up? You talked about listening and looking people straight in the eye and having them engaged and telling you what’s going on. Does this also happen through maybe surveys that are taken online of patients after they’ve had an experience at Nemours?
Dr. Peggy Greco, Nemours Children’s Health:
Yes. So when you think about the patient-family voice more broadly, there’s lots of different ways in which we are eliciting, encouraging that patient-family voice. And that includes the surveys you’ve mentioned, which are provided after every visit, after every hospital stay. It also includes our family advisory councils. We’re moving to more specialty-based family advisory councils where families are giving input in a specific area or in a specific language. We also have a quite large virtual family advisory council that gives input in that way as well.
So lots of different ways to hear the patient and family voice. And most of the ones I just mentioned are after visit or after inpatient stay input. And Speak Up is really in the moment input because we know that we have an opportunity to prevent confusion and clarify in the moment when patients and families are with us interacting. So Speak Up is really focusing on that type of engagement.
Carol Vassar, podcast host/producer:
So there are many ways that people can speak up, if you will.
Dr. Peggy Greco, Nemours Children’s Health:
Absolutely.
Carol Vassar, podcast host/producer:
So after people have spoken up, there’s action that needs to be taken oftentimes either clarification or maybe a change in policy. Is there a specific example of a patient, a family member speaking up that resulted in change at Nemours?
Dr. Peggy Greco, Nemours Children’s Health:
Another great question, and I want to go back to what you said about listening because the follow-up actions for speaking up are key. And really the first follow-up action has to be listening, and that’s during the feedback. The second has to be, thank you. We are really re-emphasizing that feedback is a gift, and we want to show gratitude for that gift. It’s not always a well-packaged gift, and that’s okay because there’s a lot of anxiety and stress, very understandably so. But to know that no matter how it’s delivered, that feedback is a gift. So, thank you for that. Having that information allows us to improve and do something differently. I would say thus far, because where Speak Up is focused on the interaction between the family and their individual care provider or their care team.
And most of the things they’ve spoken up about in those environments have been about their own care. So it’s provided opportunities to clarify medication instructions, to clarify what their diagnosis is about, and to sometimes clarify for kids information that they may have heard differently or obviously had interpreted or processed in an age-appropriate manner, but would benefit from further explanation. So Speak Up really lends to being able to improve that interactive care. I would say the patient and family voice in other realms, the surveys, the family advisory councils really allow us to get feedback more broadly about our system and to be able to make changes based on that feedback.
Carol Vassar, podcast host/producer:
And you’re listening to the kids as well as the families, aren’t you?
Dr. Peggy Greco, Nemours Children’s Health:
Absolutely. So, kids have a lot to tell us, and not just teens. Sometimes we think that if you’re below a certain age, you shouldn’t be actively engaged. And so Speak Up is really actively aimed towards kids. In fact, the Joint Commission has produced a great video. It’s really short, called Kid Power: Speak Up, and it’s about… It’s a cartoon. It’s two little characters, one encouraging the other. You have the power to speak up. No question is a dumb question. Anything you think about or worry about is worth speaking up about. So we have that video, we auto-assign it to all of our inpatients. And there’s other specific ways. We have stickers that go along with the video, just to remind kids you have the power to speak up.
And again, just like with patients, with parents and families to reach out and elicit child discussion really results in hearing something from the voice of the child. So for example, to say, “Maria, now it’s your turn. What are you worried about?” And it may be, “Can I play on the playground?” But that’s a valid worry. Or maybe they heard something, often kids hear something that they worry about that wasn’t quite correct. So it gives that opportunity to be able to correct that and really minimize a lot of worry. Even if they’re tiny ones, to be able to talk to them, to engage them, they may want to just show you their bunny that they brought, but again, it’s a lifelong relationship that we’re building.
We’re building an environment of trust and we want to establish that relationship as early as we can.
Carol Vassar, podcast host/producer:
I’m going to circle back to the question about any specific examples where change has been implemented based on the feedback you’ve gotten through Speak Up.
Dr. Peggy Greco, Nemours Children’s Health:
So, there’s a couple of different ways in which we’re tracking the impact, and that’s really important so that we can refine a program depending upon that impact. And one way is looking at the specific instances that you’re talking about. We’ve also done some measures of comfort and confidence of our associates to encourage patients and families to speak up. And we’ll be doing some post evaluations to see if we’re seeing a positive impact. The other is we’re looking at whether patients and families are speaking up more about safety concerns. And so a lot of our educational materials are geared towards safety. So we’ve produced now… Our team has done great. I want to highlight Caitlin Danzig.
She’s done a tremendous job in working with clinical teams to put together handouts that inform patients and families about the condition and about the questions they can ask. Some of these handouts are general in terms of being able to take medication safely. Some of them are more specific, like speaking up for your child’s tracheostomy. And through this specific material, families then are better informed as to what they can speak up and ask questions about. And one of the ways we’re tracking that is to look at event reporting. How often families speak up and say, “I’m worried about this,” or “I noticed redness around here like you outlined in your handout. I wanted to make sure you took a look at that.”
So we’re just starting to track that and I’ll be excited to come back and let you know about the impact we’re seeing in terms of parent initiated safety concerns.
Carol Vassar, podcast host/producer:
Looking forward to it. I want to turn our attention now to an aspect of inclusion and equity that also falls into what you do and that’s the patient equity index. What is that and what does it measure?
Dr. Peggy Greco, Nemours Children’s Health:
So the patient experience health equity index is one of the many ways in which Nemours focuses on health equity. And we know that experiences are different for different patients and families, and we want to be able to look at that. So for our post-survey questions, we look at the experience reports from our patients and families by race, ethnicity, and language. So we’re able to identify disparities and to make sure we’re addressing those. We’ve taken the five that are most disparate, or where there’s the most difference between groups on those survey items, and put them together into an index so that we can track improvement over time, and looked at it by race, ethnicity, and language.
So, to give you a really specific example, one of the survey items in that index is “Did you know what to do if you had questions after your visit?” And we noticed that families who identified as Black, Hispanic, spoke Spanish, were much lower on that item than other groups. And so part of our three-year focus on making sure families know what to do if they had questions was to specifically ensure that all families knew because we were able to show that when they didn’t know there was a risk of readmission to the ED after 24 hours and that risk was higher for those identifying as Black or Hispanic. So that initiative is focused on how can we have improvement?
And we ended up not only having improvement across the board for all patients and families, but narrowing that disparity as well when we had a number of different methods and processes for ensuring comprehension before families left our care.
Carol Vassar, podcast host/producer:
It sounds like you’re collecting the information and turning it into actionable, measurable change. You’ve given us a great example there. Are there other examples?
Dr. Peggy Greco, Nemours Children’s Health:
Exactly. So you hit on something really important in terms of the why. Why do we collect this information? Why is the patient and family voice so important? And then you can tell this is something I’m passionate about. It is because they know they are experts, we have to respect that expertise. They’ve experienced our care, we have to know what it’s like from their perspective,. And we have to know because we have to always improve. I know we have that mindset of continuous improvement at Nemours, and this is a good example of that.
We actively utilize that information so that we can improve, we can change things, we can understand what patients and families need that might be a little different than what we’re providing. So that’s really key. It’s really for purposes of improvement that we’re paying attention and trying to find more and more ways to hear that patient and family voice.
Carol Vassar, podcast host/producer:
How do you see changes moving forward, being incorporated into how Nemours associates work with patients from the information collected from this index?
Dr. Peggy Greco, Nemours Children’s Health:
So great question. I think one of the ways in which what we’ve talked about with Speak Up and engagement and the health equity index overlap is in understanding that there are sometimes cultural and language barriers, racial and ethnic barriers to speaking up, that the experience is different for different patients and families. And we have to be aware of what some of those barriers are, whether because there’s a different relationship in a healthcare provider and patient from the original country the patient came from, or whether there’s implicit bias in the interaction that is discouraging engagement.
We have to address those barriers. And so we’re taking a deeper look at how can you identify, be aware, so that then we have some strategies to really reduce the impact of those barriers so that we are getting all of our families, again, across the board equitably that we’re hearing from all of our patient family voices.
Carol Vassar, podcast host/producer:
And one of those issues that I’m sure you’re running up against is language, which can create a barrier of provision to healthcare services. We all know that, we’re all working on that. I’m curious, with the advent of AI and the incorporation of things like care AI at Nemours hospitals, is there a way to expand translation capabilities to ensure the closure of some of those language gaps, especially for the growing Spanish-speaking communities we serve?
Dr. Peggy Greco, Nemours Children’s Health:
I think so. There’s a number of ways in which AI is improving patient experience. And I’ll give an example that also ties into the improvement with the provision of care in different languages, as you’re talking about. One is the use of virtual nurses. So virtual nurses are… Well, this is more an example of technology than AI, but we have nurses that are Nemours nurses, they know the units well. They’re in a centralized, quiet location, minimized with distractions and providing some of the more lengthy parts of care, such as admission and discharge, and tracking the patient experience scores has shown that the patient experience improves, communication improves, and improves more for those families who are Spanish speaking.
And part of that is because the virtual nurse is able to get an interpreter online immediately and throughout the whole interaction, it’s not pieced together, it’s not having to find that interpreter for each smaller interaction. Instead, it’s a seamless way of interacting. One other quick example, and this one is of AI, some of our physicians now use an AI-enabled dictation tool that has ambient listening. So basically an app that’s listening, it’s private, it’s controlled, it’s HIPAA privacy related, but it’s listening and it produces a draft note. And so what AI technology does is it allows the physician to pay full attention to the patient and family.
Face to face contact, good eye contact, really engage, feel connected, not having to look at the computer, not having to write notes. And we’ve seen huge jumps in patient experience scores in terms of physician communication and overall experience. And again, seeing that improvement for our speakers of other languages as well. We did just move to a new vendor, and I think they do have, as far as language services, and they will have some technology advantages that our former vendor didn’t. And so we’re excited to start to use those as well.
Carol Vassar, podcast host/producer:
Well, it sounds like AI is being used for good in so many areas, including overcoming those language barriers. Speaking of language and Spanish-speaking families, I understand that there’s a Spanish-speaking families advisory council either established or in the works. Tell us about that.
Dr. Peggy Greco, Nemours Children’s Health:
Yes, information. So as you know, we’ve got many different catchment areas across the eastern United States and especially in our Florida areas. We have a high percentage of our families that are Spanish speaking and we have representation on our family advisory councils. But it’s different to be able to speak in your preferred language in that environment. And so we want to have that comfort level and really hear directly what are the ways in which we can improve, and to get that input and to partner together from the start for our Spanish-speaking families. And so we’re really excited to have that up and going, but I’ll come back and tell you more about that as well.
Carol Vassar, podcast host/producer:
Excellent. Looking forward to it. I know we’re jumping all over the place, but there’s so much to talk about that you have your fingers in and you’re working on all for the good. There’s an initiative at Nemours that is a doctor-led clinician liaison program. I understand it’s really unique. Tell us about that.
Dr. Peggy Greco, Nemours Children’s Health:
So we’ve made some changes to engage clinicians more in patient experience, and one of those ways is to have four part-time clinicians who are part of the patient experience team. So they see patients for 80% of their time and the other 20% of their time they’re with patient experience. So they provide coaching, shadowing, they meet with every new physician who starts at Nemours to explain how patient experience is different, how it’s there as a support to give you the information you need, what are the ways in which they can use that information for improvement. And so we’ve definitely seen greater engagement with physicians around patient experience because of that clinician engagement.
Carol Vassar, podcast host/producer:
And how long has that been in effect?
Dr. Peggy Greco, Nemours Children’s Health:
That has been in effect since 2018. Yes. When I talk with colleagues at conferences, they’re always excited about and are trying to start at their own organizations as well. It’s a great strategy to engage clinicians.
Carol Vassar, podcast host/producer:
It sounds like it’s something that could be scaled nationally.
Dr. Peggy Greco, Nemours Children’s Health:
Absolutely, yes. And some have in different ways such as having clinician champions. So I would encourage if there’s organizations that don’t, that this is a really powerful way to increase engagement.
Carol Vassar, podcast host/producer:
How have the physicians who are being coached by the physician members of your team reacted to this? What’s been their experience?
Dr. Peggy Greco, Nemours Children’s Health:
It comes very differently from a fellow physician than from someone who is not a clinician. And so I’m a clinician by background. We have the four clinicians that are the clinician liaisons. When you’re receiving coaching and shadowing from someone who’s experienced it, there’s greater trust from the start. There’s the understanding that you know what this is like, you’ve experienced it. And the shadowing and coaching is really from the perspective of how can we help you improve? This is information for you to be able to be more aware of how you’re talking and interacting with some things you can do differently. And it’s a benefit.
And when you think about most in the medical fields, stop receiving any kind of coaching, shadowing past medical school. We’ve had a number of our physicians say to us, “This has really been a benefit to me to have this time to reflect, to get the input, and to have some specific strategies for improving.” And I will say, not everyone’s happy initially. And so it feels strange to have someone watch you, and it can feel judgmental. I would feel the same way, but I think the proof is in the pudding in terms of as the relationship continues and they see there’s an investment in the individual and finding out what works for them, that that leads to more of a positive relationship and outcome with coaching.
Carol Vassar, podcast host/producer:
Anything else on the horizon when it comes to patient experience at Nemours that you’d like to share?
Dr. Peggy Greco, Nemours Children’s Health:
I would love to share that we are focusing on how unique our individual patients and families are. And I’ll tease a little bit in terms of letting you know there’s going to be some specific ways in which we’ll be focusing on treating patients and families uniquely. And that may mean understanding their needs from a language perspective. It may mean knowing things about them outside of their lives, outside of the medical environment, that may impact their care. But that’s going to be a significant emphasis in the coming years, is what are the different ways in which we’re treating patients and families uniquely?
Carol Vassar, podcast host/producer:
Psychologist Dr. Peggy Greco is Assistant Vice President and Chief Patient Experience Officer for Nemours Children’s Health.
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Well beyond medicine.
Carol Vassar, podcast host/producer:
Thanks to Dr. Greco for sharing her time with us. And thanks to you for listening. Now is your chance to speak up about what topics we examine here on the Nemours Well Beyond Medicine podcast. It’s simple. Just visit nemourswellbeyond.org and leave us a voicemail. While you’re there, we encourage you to subscribe to the podcast and leave a review. You can also send podcast topic ideas to [email protected]. If you’re looking for the podcast itself, nemourswellbeyond.org is a great place to start, but it can also be found on your favorite podcast app as well as the Nemours YouTube channel.
Our production team for this episode includes Cheryl Munn, Susan Masucci, and Lauren Teta. Join us next time as we learn about how families can access community services via a unique volunteer program in Florida. I’m Carol Vassar. Until then, remember, we can change children’s health for good, well beyond medicine.
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