Integrating patient preferences in the delivery of Emergency Care. Kano analysis predicts change in experience.

Author: Venk Bellamkonda (@VenkBellamkonda)

In our publication in Annals of Emergency Medicine, Pilot Study of Kano “Attractive Quality” Techniques to Identify Change in Emergency Department Patient Experience, we describe our efforts to improve our patient’s perception of receiving concern and sensitivity from their healthcare providers.

The project originated in 2012, when our patients reported lower than expected ratings of receiving compassion by their emergency department (ED) providers. We used point-of-service survey cards to reassess this measure. We distributed 200 cards and received 193 (97% response rate) returned that gave a median rating of 4 out of 5 (IQR 3,5) with a top box percentage of 33% for provider concern and sensitivity.

A team of us began meeting with patients, advisory groups, and reviewing the literature to identify possible strategies for improving the patient experience. Four interventions were considered to close the patient experience gap:

1. Sending a follow-up letter from the healthcare provider to the patient after their departure from the ED
2. Supplying patients and their families with background information on their healthcare providers
3. Increasing shared decision making opportunities between patients and their providers
4. Increasing protocol-based testing from triage with the intent of decreasing throughput time

The next phase of our project involved using Noriaki Kano’s Attractive and Must-Be Quality model to try to predict the impact that each of these interventions would have upon our patients. We again used point-of-service survey cards with both functional and dysfunctional Kano format questions on them; 180 survey cards were distributed and 158 were returned (88% response rate). The responses were  plotted on a bubble graph as well as analyzed with a novel scoring system whereby the shared-decision making intervention scored 120 out of possible 246 and was likely to improve the patient experience to the greatest degree.

To test the prediction, we surveyed the impact that shared decision making had upon our patients. Two research studies were being conducted on shared decision making with patients experiencing chest pain or minor closed head injuries were ongoing. Twenty-six of 30 people receiving standard care (87% response) returned surveys rating median concern and sensitivity as 4 (IQR 3,5) and 19 of 19 (100% response) people receiving the shared decision making intervention returned surveys rating concern and sensitivity as 5 (IQR 5,5) with a difference of medians of 1 (95% CI 0.1 – 1.9). The top box percentages in the intervention group was 79% compared with 35% in the control group with a difference of 44% (95% CI 12-66).

This data suggest that Kano’s model likely does predict patient preferences and may be useful in other healthcare decision making situations. Please let us know on twitter (@VenkBellamkonda) how you would use the Kano model and read our publication in the November Annals of Emergency Medicine for the complete story.