Title
Chapter 02: The Patient Experience at MD Anderson
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Description
In this chapter, Elizabeth Garcia provides insight into the different roles she has held while at MD Anderson Cancer Center. She describes her start as Clinical Administartive Director in the GYN Oncology Center and her eventual transition to the Office of Performance Improvement. Garcia notes her action-oriented strengths in these positions, detailing how the different intiatives she has been a part of strive to be anchored in service and patient care. In particular, she notes how expanding the Ask MD Anderson Call Center, Service Excellence Program, and trasnparency intitative have all helped shift the insitution’s culture to be more patient oriented than physician oriented.
Garcia also highlights mentors and collegues who have been influential throughout her time at MD Anderson. She ends by reflecting on the effects of the COVID-19 pandemic in relation to patient experiences and how the institution might have handled issues differently.
Transcript
Nina Nevill
So to what you have at the forefront of your memory right now, at least, I know these things can seem like such a far ways away, but can you walk me through what positions you have held and what your different roles and jobs have been at MD Anderson since you started?
Elizabeth Garcia, BSN,MPA,RN
Sure. I was hired as a Clinical Administrative Director in the GYN Center and so that’s leading the care across the continuum of care for patients coming in with GYN Oncology Cancer. And I tried to redefine the position and made it more a service line leader of GYN Oncology. For example, I helped develop, along with the medical director at the time Dr. Charles Levenback, develop a format of retreats for the physicians in GYN oncology. We developed it about 10 years ago, and it’s still being used today. And what it does is bring all the physicians together once a quarter to sit down and talk about standardizing care based on evidence. And standardizing care based on the evidence means you’re a safer, higher quality, better experience for patients. And they literally sit in a room and discuss certain treatments or certain processes or whatever it is, and all agree that they will all do the same thing based on what the evidence shows, so you don’t have any outliers then. And they all promise to do it. And if they don’t follow that, they actually do regular reviews of the records. And if they don’t follow that, the Chair will actually sit down with them and say you committed to doing this standardized treatment or standardized process or whatever it is, and you don’t seem to be doing that, to keep everyone accountable.
And GYN has been held up as one of the—well, this morning I was on a call that Dr. Tereffe, our chief medical executive, said the highest performing department in quality and safety in the institution and a lot of that is because they regularly sit down and make sure that they’re standardizing care based on evidence. So they’ve been able—and they have a lot of excellent physician leaders in that department that are very interested in quality and safety, which helps a lot. So that helped push things forward in redefining the role as more of a service line leader and also collaborating with inpatient so patients go back and forth between ambulatory and inpatient and making sure inpatient and ambulatory were marching to the same drummer, had the same philosophies about patient experience, and we’re helping each other make sure the patients got all the information that they needed, etcetera. And I also did a lot of ad interim during that time, during the nine years. I did ad interim assignments for up to two years in Brain and Spine Center, in Genital Urinary Center, in Cancer Prevention. And I’m sure there was another one and now I can’t remember.
And then about nine years in, I had an opportunity to move to the Office of Performance Improvement. And I have a background in performance improvement science. I’m certified in medical quality. And I was very involved in many projects, such as the one I was talking about in GYN to do process improvement and quality improvement. So I became the Director of Process Improvement for the Office of Performance Improvement, and I was hired with the knowledge that the Director of Patient Experience was leaving because I was qualified to take that position as well. So three months in, I got that position. And we did a lot of changes during that time. I was there. For example, we started incorporating our patient and family advisors into more things in the institution was a big one. So they had started a patient and family advisory council, and it was about 30 patients and they had monthly meetings where they would give feedback on different things. But we actually doubled the size of the patient and family advisory council, unpaid employees who are there to give us feedback and participate in process improvement—and my son just sent me a text. It was funny. Sorry.
Nina Nevill
No, that’s okay.
Elizabeth Garcia, BSN,MPA,RN
To process improvement and we started bringing in them more to use storytelling to be able to illustrate how important patient experience is, which is in an evidence-based way to really improve the patient experience. So, for example, in our clinical safety and effectiveness course, that it was part of my responsibility there, that is a very well-known course at MD Anderson and throughout the UT System to train people how to do process improvement, science-based process improvement, we started opening every class with a patient story, that a patient would come in and tell their story of getting care at MD Anderson. And the idea is to refocus everyone on why we’re there. We’re there for the patients. The patients should be at the center of everything we do. So we did a lot of changes in the CS&E course to make it more effective for the institution, rather than people working on their own personal projects that they would have to be projects that did a lot of good for a lot of people. And we did a lot with elevating process and quality improvement in the institution, such as growing the QIAB, which is the Quality Improvement Assessment Board, which is like the research board only for quality improvement, so that people have to register their quality improvement projects in order to publish them so that we make sure they’re using science and that patients are protected and all that.
And then when Karen Lu, who was the chair in GYN and still is, was named at—when the chief medical executive or the chief medical officer left, Dr. Lu was made the ad interim medical executive. And, of course, we worked together in GYN. So one of the first things she did was pull me into operations, reporting directly to her, instead of in the office of performance improvement, and gave me other areas in operations and made me the Associate Vice President of Patient Experience. So, at that point, I got the call center, Ask MD Anderson, and patient advocacy and patient relations. No. I didn’t get patient education ‘til later, but some other operational things. And then I was in operations. So I was able to influence operations because the whole idea is that patient experience is all about your culture, and your culture is your operations. So very shortly after that—well, Harvey hit very shortly after that. And I was made ad interim over new patient access at the time as well, which was a very big job to take on.
And then, let’s see, so I was running all these areas, etcetera. And then the institution started the operational priorities, so we picked certain things that were operational priorities based on a retreat we held. And patient experience was one of the operational priorities. So Dr. Webber, who was made my partner around that time as the Chief Patient Experience Officer, and I paired up to do a very—and this was a pivotal action that we took that really drove us forward, is we held a retreat. We did a lot of research all around the country about how we would have a strategy to improve our patient experience, what things did they do at the Cleveland Clinic and the Mayo Clinic and at the Ritz Hotel, and at Disney, that really improved the experience. And so we came up with a strategy. And there were four major initiatives that we presented in the leadership retreat one Friday morning. And we were amazed at the attendance we got. But we used a very specific process to present things in that retreat. We didn’t discuss what should the strategy be. We presented what the strategy should be according to our research, and then let people give feedback, but it was very actionable items. It was this is what we’re going to do. You can talk to us about how you want it done, but this is what we’re going to do.
And some of the initiatives in that was that, first of all, expanding our Ask MD Anderson call center to have a clinical component to help patients with clinical issues, symptoms, after hours when their centers are closed ,weekends and holidays, but also to follow-up on discharges. Because at discharge time, the patient is very vulnerable because they’re going through a very difficult transition. And so we wanted a component of the call center to be clinical. We also wanted to—at the time, our call center was open Monday through Friday, 8:00 to 5:00, which makes no sense at all because people need to get—after hours, they can get in touch with departments all day and so to expand our hours, to weekends, holidays, and evenings, and have 24/7 clinical support. Then another initiative we proposed that day was our service standards and the service excellence program. So every single organization we looked at had specific service standards. They had core values too, but service standards are the core values in action. It’s like you can say caring, integrity, discovery, safety. What’s our fifth one? It’s about money. And now the name escapes me. Sorry. But the service standards actually tells you the behaviors that match those core values, and the service standards were—so Courtney Holladay and I were paired up to say, okay, now, you’re going to come up with an institutional service standard and an education program for those service standards. And then Monica Johnson was in diagnostic imaging and had developed a service standards program and the service excellence program for diagnostic imaging, so we pulled her in with us. And Courtney and I developed, sponsored, and they were developed—the service excellence program was developed. And it went live institutionally right around the time Dr. Pisters came. Three modules.
And on the Thanksgiving before—Dr. Pisters started December 1st. On the Thanksgiving before he came, he tweeted that he had gone online and done the first class for service excellence and how important service excellence was to the institution and that was like a rocket took off. Then the day after Thanksgiving, which we were closed, but I had like 15 emails, 25 emails from people saying, how can I get signed up for service excellence? So that was huge that Dr. Pisters’ is a supporter. And that was launched institutionally in September of that year. So what year did Dr. Pisters start? 2018?
Nina Nevill
Oh, I’m not sure. I think so.
Elizabeth Garcia, BSN,MPA,RN
Yeah, I think it was—
Nina Nevill
2018, that sounds right.
Elizabeth Garcia, BSN,MPA,RN
Harvey was 2017, so he started December 2017. So September 2017 is when the service excellence started. Okay. So we had the call center, service excellence. Then a third very important initiative that we proposed that day was transparency. So transparency has been used for improvement of quality and safety indicators in surgery for a long time. Well, not a long time, but for like 25 years. So surgeons are famous for publishing their rates to each other and for themselves, rates of surgical site infections, or urinary tract infections after surgery, or successful outcomes, or whatever it is that they publish this data. They actually put their names on a list and say this person is number one for this, this person is number two for this, and using that to improve their practices to show what is evidence-based by practice and who should they be emulating and whatever.
So we learned from other institutions, specifically Huntsman Cancer Center in Salt Lake City. We went and visited them and we became friends with their patient experience leaders. And they had a star rating program. They were one of the first in the country where out on the internet and inside, they actually publish star ratings for each of their doctors based on their communication and the willingness to recommend of patient surveys. And they did this for many different reasons. One of which is that it takes control of the information on the internet because people who are upset about their care are more likely to go figure out how to put a Yelp review or a Healthgrades review, and usually end up with a very low score, if you just go search Google search. And our doctors were suffering from that because we had no information out on the web ourselves, controlling the information, so they suffered from low scores.
The other thing is that when they get their personal score, and they see the average in the institution is higher than their personal score, they get really interested in improving that score. We also started putting out comments to them about all the patient comments, positive or negative. And so we started a star rating transparency program. And this past October after three years of working on this, we actually published it on the internet publicly. So there are comments, positive and negative, out there. The doctors, we have a process for them to appeal, whether they’ll be posted if there’s extenuating circumstances, but we certainly post negative comments. And they all have a star rating out there on the internet. And when you Google, that’s the first thing that comes up for our physicians. So that was a big deal for bringing in new patients, especially newly diagnosed new patients in the Houston area.
Nina Nevill
That’s huge.
Elizabeth Garcia, BSN,MPA,RN
It’s huge.
Nina Nevill
Absolutely. I can’t imagine. It seems like in every career field or in every realm, people are much more likely to go to the internet when they have something overwhelmingly negative than overwhelmingly positive. And just from a patient point of view being able to have access to that data, I’m sure could make a huge difference in knowing who to go to. We always say from outside of the medical—outside of healthcare, it’s so hard to know kind of what provider to go to. And there’s so much out there that it’s hard to weed through and even know what that process would look like. And it can be really overwhelming on folks. So it’s neat that you guys were able to put together something like this that seemed like it would incentivize providers, but also help patients. It’s like a win-win kind of situation.
Elizabeth Garcia, BSN,MPA,RN
Yes, yes, it was. And we have a graph that shows once we started publishing the star ratings, just to the individual providers, we didn’t even send them out to the institution yet, or on the internet yet—when we put them out to the providers, we have a graph that shows the communication scores went up and how important is communication to a cancer patient from their provider. And we did all this based on evidence, so we didn’t make any of this up from our back pockets or decide this is what we want to do. We researched it and had a strategy based on what’s worked in other institutions. And I really believe that’s why every single one of the initiatives we planned has come to fruition much more even than we imagined it would. But transparency had other things involved in it. So if you go to any of the units right now or the centers, they have a fully transparent board showing all our patient experience scores, all our patient satisfaction scores, and exactly what that unit is working on. And that’s transparent for the individual staff, the patients, the caregivers, the providers, everyone. It’s totally transparent to them up on the board. And just doing that—and then we publish a report every quarter that shows how the institution is doing regarding scores and we benchmark it. We have a red, yellow, green report to show where we are because our goal is to be the 80th percentile peer rank. And so we show each individual unit and center and what their scores are in each of the domains right next to each other, so it’s like a competition next to each other.
And if you’re all green, you win an award and we do a lot of recognition. So quarterly, we do recognition if you hit your benchmarks for the quarter. Then yearly, we do recognition if you hit your benchmark for the year, big celebration with Dr. Pisters and a guest speaker and lots of things. When we were able to do it in person for a couple of years, it was like a big party. We did do it online and that turned out pretty well too. And then, also, we celebrate all our providers who are in the top one percentile of the nation for communication scores. And we have about 150 a year, which is pretty impressive.
Nina Nevill
Wow, that’s very impressive.
Elizabeth Garcia, BSN,MPA,RN
They have to be in the 99th percentile compared with everyone in the nation. And we have more people in the top 10 percentile, so we celebrate the top 1 percent. And then we celebrate everyone in the top 10 percentile too. And, believe me, I get tons of email—around that time when we publish the list and invite them to the celebration, we get tons of emails saying, why aren’t I on this list? And I’m like, look at your scores. You got a report every month. So there’s a lot of—
Nina Nevill
That’s funny.
Elizabeth Garcia, BSN,MPA,RN
Yes. Doctors are very competitive. You have to use it to your advantage. And they really like the recognition. They really do. The list gets published on our—and then the different services put the list out on social media. They’re very proud of it, which they should be. And we have among the highest average score for our institution in the entire nation. And we’re very proud of that as well. So, yeah, a lot of recognition that was part of our strategy as well, that we learned from Huntsman Cancer Center, really. So the units and the centers get awards yearly too and there’s a big celebration for them. And they’re all invited, and we take pictures, and put them out on Twitter, and recognize the units for getting there as well. And then, quarterly, we actually go visit the units or the centers that get their award and bring them cookies and balloons. And we take pictures and post it on social media. And on the units, inpatient, we actually do rounds at night too and bring them cookies and whatever. So we do a lot of recognition.
Nina Nevill
Yeah, that recognition is so important. I think regardless of what level you’re at or where you are in your career path, it’s huge. It makes a huge difference, so it’s nice to hear that both are being done. You have to be—the accountability has to be there, but the recognition also has to be there. And I think that’s when things tend to work well is when you have both.
Elizabeth Garcia, BSN,MPA,RN
And your accountability models are so much easier when you have recognition. We focus on the recognition, not on the negativity. Now, a lot of people—what started happening when we did recognition and when we did the star ratings, we started getting calls from people saying, help us improve, so that we didn’t have to beg them to do something. They reached out to us, so they’re motivated. They’re ready to go. And then they can see when they do something that something actually improved, so the recognition is extremely important. And we’re looking forward to getting back to doing it in person because, of course, we’ve had to do it remotely, thus far.
Nina Nevill
Well, in terms of the—oh, I’m sorry, go ahead.
Elizabeth Garcia, BSN,MPA,RN
No, you go ahead.
Nina Nevill
I was just going to say we will absolutely get to kind of the pandemic and this past year just in a moment here. But before we move on, again, we’re kind of going back a little bit in time, you mentioned that Dr. Pisters has been very supportive it sounds like. But I’d like to know, I guess, earlier on even in your time at MD Anderson, who some of the key people were for you in terms of mentoring, or just ally, or people who kind of helped you along the way?
Elizabeth Garcia, BSN,MPA,RN
So my clinical administrative director peers in ambulatory were incredibly supportive and important and mentoring because MD Anderson is a huge organization and coming in as a new person, as a director, you really need those people to help guide you how to get things done, who’s important to know, all that stuff, what the expectations are. They’ve just been—and there’s so many to name and a lot of them have retired and left me behind. But, for example, even now, like, Judy Moore, who’s the Executive Director of Ambulatory Services, and she’s been here many, many years. And she was one of my peer [CADS?] later in my years in—I mean, she’s just—and we work together all the time now. She’s just so smart, so hardworking, so dedicated to the institution, and she knows so much. She’s just been incredible.
Let’s see. There were several people who retired, Gwen Tate. She was here many, many years, maybe 33 years before she retired. And she was the CAD in brain and spine. And she actually came after me when I was at intra membrane and spine. She was a tremendous asset to the institution and continues to work as a nursing administrator contributing. I have to say probably the biggest supporters and influence in my career and my ability to move forward and get things done were my physician partners along the way. MD Anderson has dyad partners. And in the centers, we have dyad partners long ago before we had dyad partners at my level now. So I was hired by Dr. Charles Levenback, who retired about three months ago. And he was the Medical Director of the GYN Center. And we did a lot of things together. We got a lot done. And we were very, very productive. And it’s because we trusted each other, and we really worked as partners. No one was better than the other. No one’s voice counted, other than I would never tell him how to do medical care and he would never tell me how to do administration. But, together, we did a lot together. And that was fun when he was retiring how everything we had accomplished together was highlighted, which was really fun. And then, he was my partner actually when I was in Office of Performance Improvement for that short time because, at the time, he was the Chief Quality Officer.
And then after Dr. Levenback was Dr. Pamela Soliman, who’s still in GYN Oncology, and she was my partner. And Dr. Karen Lu, who was the Chair of GYN, and then she was ad interim Chief Medical Officer, and we did a lot. We got through Harvey together. We rescheduled I think it was something like 900 new patient appointments.
Nina Nevill
Oh my goodness.
Elizabeth Garcia, BSN,MPA,RN
It was unbelievable. Yes. And thousands of regular appointments, but it was unbelievable. But, anyways, so she was my partner for that time and continues to be a mentor. And then, now my current partner is Dr. Randall Weber, who’s the Chief Patient Experience Officer. Never was there such a gentleman. He’s a Southern gentleman. He was an officer in the Marines, and he’s a world-renowned head and neck surgeon, and a brilliant administrator on top of it. And we’ve also gotten a lot done.
Nina Nevill
That’s wonderful. It sounds like an incredibly supportive community throughout the years. And it’s always wonderful to hear people have such nice things to say about the people that they work with and how much community is fundamental in getting to where you are and to where you want to be.
Elizabeth Garcia, BSN,MPA,RN
Yes, yes. And then I have to mention Dr. Carol Porter, who’s the Chief Nursing Officer. So she and I work very, very closely together all the time and have for the whole time she’s worked here, but she was actually my boss in New York City 20 years ago. Now, more than 20 years ago, 25 years ago. Yeah. And she ended up here about five years ago. And we work great together. We just have such a good understanding, so she’s been a great, great mentor as well. And nursing and patient experience are tied together so tightly and that’s what we needed. And many, many other leaders, just very, very strong leadership competency in our organization.
Nina Nevill
That’s always good to hear. Now, before we kind of switch gears to talking about the events of this past year a little bit, I have, I think, one more question. We might have to come back at some point, but one question for now at least. And this is kind of what I say is like the fun question or it’s a fun question, more than being too serious. But the question is, if you had to confidently say that you are better than roughly 10,000 people or a large group of random people at one thing, what would that one thing be? That’s a tough question to
Elizabeth Garcia, BSN,MPA,RN
Well, people have said to me that I’m the best at getting stuff done, closing the loop.
Nina Nevill
That’s important.
Elizabeth Garcia, BSN,MPA,RN
I’m a action oriented. I don’t like to discuss for a long time. I’m like, just make a decision and do something. And I think that’s helped drive forward our initiatives in that we didn’t take a lot of time to discuss and let a million people weigh in and veto whatever. We said, we researched very thoroughly. We got feedback from many, many different constituents. We put a plan together, we put a deadline in place, and we did it. We did not let anything delay us. We did not let—so I think that being action oriented is incredibly important to get things done.
Nina Nevill
Oh, absolutely. Yeah, the conversational aspect, while important, can sometimes take away with—they say too many cooks in the kitchen or it’s very easy to want to keep discussing something and keep mulling over something, keep improving and tweaking and adding perspectives, and that’s wonderful, it’s part of the process, but to be able to say that you’re somebody who can just get things done and action oriented, not everyone can say that. So it’s got to feel pretty good to have that.
Elizabeth Garcia, BSN,MPA,RN
And I think that one of the things we didn’t cover that I want to make sure we cover is that the whole idea behind our initiatives and behind what Dr. Weber and I were trying to do is that we were trying to shift the culture, which is one of the most hard things you can possibly do. So our goal when we set out in our retreat and then in over time is to become a patient centered, value driven organization. And I think that Dr. Weber would tell you, and I’m allowed to say this because he would tell you this, is that for many, many years, we were very physician centered. We made decisions based on what was most convenient, what was best for the physicians. The physicians drove the decision making without patients weighing in.
Now, we’re an entirely different culture. We have our patient advisors, who are actually patients, sitting on top level committees like [QAPI?], weighing in on decisions. Rosanna Morris, who’s a fabulous mentor and my boss now and a wonderful administrator, has put patient advisors on the highest level of executive committees throughout her organizational structure. And you never know what patients need or want until you actually ask them. We think we do, but we really don’t. So it’s all about cultural transformation to patient centered, value driven care. That’s what all our initiatives are based on.
Nina Nevill
That’s a great mission to have. Now, I think I have a good broad understanding of these initiatives and of some of the work that you’ve done, the importance of changing this culture over time. Is there maybe a specific kind of example that you could give of a project or an initiative where you felt like you were able to shift a little bit of that to representing and upholding the needs of the patient and also giving the practitioners and the providers support that they need?
Elizabeth Garcia, BSN,MPA,RN
Oh, so one of the best examples is our clinical services and Ask MD Anderson. So, previously, if a patient had—now, if you’re a cancer patient and you’re just getting your first chemotherapy and you go home, you’re going to have a million questions about what’s going on with your symptoms. Cancer patients just have a lot of questions and needs that may pop up. They don’t know they’re going to have the—they don’t know what they don’t know until it happens. So up until we opened our Ask MD Anderson clinical services in November 2019. Let’s see, this past November. Yeah, in November 2020 is when we opened our Ask MD Anderson clinical services, so just before the pandemic, really.
So, before that opened, if our patients had a question, a clinical symptom after hours, after 5:00 p.m., weekends and holidays, they would call the page operator to call the doctor on call, number one, is one choice. And the second choice is to go to the ACCC, previously known as the emergency room. And many, many, many times, the patient would page the physician who would be on call who might be in the OR, or out having dinner with their family, or taking care of another patient in the emergency room, or whatever. And they may not have access to Epic. They may not know the patient at all. And, oftentimes, they would say, just go to the ER. After November 2020, every single patient that calls to talk to a physician or has a clinical symptom can talk to an advanced practice provider or an RN, an experienced oncology RN or an advanced practice provider. So now, we have cut back the pages to on call physicians by 50 percent. It saves about—I can’t remember the numbers. It’s somewhere about 20,000 pages a year to on call providers. Sometimes we still have to call them. But if we call them, they have the situation already. So then when they talk to the patient, they already have the background. They may not have access to Epic, but they have all the background, etcetera. And just being able to—and we’ve dropped the readmission rate back to the EC—people having to go to the ACCC by like five percent.
I had a slide that I showed when I was trying to convince everyone that they had to invest in this. And I had a slide that I showed that showed the budget. And then it was a slide that I showed that said a cancer patient being able to talk to an experienced clinician 24/7, priceless. And it is priceless. And we are there Christmas, we’re there Thanksgiving, we’re there—and, originally, when we opened in November 2020, we were open from 5:00 p.m. to 11:00 p.m. on the weekdays. And then on the weekends and holidays, we were open 8:00 a.m. to 7:00 p.m. And then all of their times it would go to pages. But when the pandemic hit, our wonderful Executive Director, Janice Finder said, hey, we need to be able to talk to these patients all the time. They have so many questions about, oh, my God, do I have COVID? What should I do? Do I need a test? Our calls went up a lot. And literally overnight, she figured out the staffing using overtime, getting commitment from our wonderful staff, and we opened 24/7. And we have been open 24/7 since then.
Nina Nevill
That’s incredible. That is a huge—
Identifier
GarciaE_20210731_C02
Publication Date
7-13-2021
Publisher
The Historical Resources Center, The Research Medical Library, The University of Texas MD Anderson Cancer Center
City
Houston, Texas
Topics Covered
A: Professional Path;B: Critical Perspectives on MD Anderson;B: Institutional Processes;B: MD Anderson Culture;B: Obstacles, Challenges;B: Care;C: Leadership;
Recommended Citation
Garcia, Elizabeth BSN, MPA, RN and Nevill, Nina, "Chapter 02: The Patient Experience at MD Anderson" (2021). MD Anderson 2020 Interview Project. 20.
https://openworks.mdanderson.org/mda2020_interviewsessions/20
Conditions Governing Access
Open
About the Interview
From the interview:
Elizabeth Garcia, BSN,MPA,RN, Oral History Interview, July 13, 2021