We conducted a prospective cohort study of 450 patients new to an HIV clinic in Houston, TX, to examine the roles of life stressors and initial care experiences in predicting being lost to follow-up in the first year of care. Patients completed a self-administered survey following their initial provider visit. In logistic regression models, patients who reported better experiences with the HIV provider at the first visit were less likely to be lost to follow-up at 6 months (aOR = 0.866, p = 0.038) and 12 months (aOR = 0.825, p = 0.008). Patients with a higher burden of stressful life events were more likely to be lost to follow-up at 6 months (aOR = 1.232, p = 0.037) and 12 months (aOR = 1.263, p = 0.029). Assessments of patient experience and life stressors at the initial visit have potential to predict patients at risk of dropping out of care.

Background Despite a growing call to train clinicians in interpersonal communication skills, communication training is either not offered or is minimally effective, if at all. A critical need exists to develop new ways of teaching communication skills that are effective and mindful of clinician time pressures. We propose a program that includes real-time observation and video-based coaching to teach clinician communication skills. In this study, we assess acceptability and feasibility of the program using clinician interviews and surveys. Methods The video-based coaching intervention targets five patient-centered communication behaviors. It uses trained communication coaches and live feed technology to provide coaching that is brief (less than 15 min), timely (same day) and theory-informed. Two coaches were trained to set up webcams and observe live video feeds of clinician visits in rooms nearby. As coaches watched and recorded the visit, they time stamped illustrative clips in real time. Video clips were a critical element of the program. During feedback sessions, coaches used video clips to promote discussion and self-reflection. They also used role play and guided practice techniques to enforce new tips. Clinicians included residents ( n = 15), fellows ( n = 4), attending physicians ( n = 3), and a nurse practitioner ( n = 1) at two primary care clinics in Houston, Texas. We administered surveys to clinicians participating in the program. The survey included questions on quality and delivery of feedback, and credibility of the coaches. We also interviewed clinicians following the intervention. We used rapid analysis to identify themes within the interviews. Results Survey measures showed high feasibility and acceptability ratings from clinicians, with mean item scores ranging from 6.4 to 6.8 out of 7 points. Qualitative analysis revealed that clinicians found that 1) coaches were credible and supportive, 2) feedback was useful, 3) video-clips allowed for self-reflection, 4) getting feedback on the same day was useful, and 5) use of real patients preferred over standardized patients. Conclusions Video-based coaching can help clinicians learn new communication skills in a way that is clinician-centered, brief and timely. Our study demonstrates that real-time coaching using live feed and video technology is an acceptable and feasible way of teaching communication skills.

Background Despite a growing call to train providers in interpersonal communication skills, communication training is either not offered or is minimally effective, if at all. A critical need exists to develop new ways of teaching communication skills that are effective and mindful of provider time pressures. We propose a program that includes real-time observation and video-based coaching to teach provider communication skills. In this study, we assess acceptability and feasibility of the program using provider interviews and surveys. Methods The coaching intervention involved training providers to use five patient-centered communication behaviors. Two coaches were trained to observe and record live video feeds of provider visits. As coaches observed provider visits, they prepared feedback, which they delivered to the provider. During coaching sessions, coaches gave feedback while showing clips from the visit in which patient-centered communication behaviors could be included. Coaches practiced communication skills with providers using role-plays during coaching sessions. Providers included residents (n=15), fellows (n=3), attending physicians (n=3), and a nurse practitioner (n=1) from a VA clinic and county clinic specializing in care for patients with HIV. We report descriptive results from a survey taken by providers participating in the program. The survey was adapted from validated items used in I/O psychology to assess the feedback environment, including questions about the intervention’s feasibility and acceptability. A qualitative analysis was also conducted on transcripts of provider interviews following the intervention. We used rapid analysis to identify themes within the interviews. Results Survey measures on showed high feasibility and acceptability ratings from providers, with mean item scores ranging from 6.2 to 6.8 on a 7-point scale. Qualitative analysis revealed that providers found that 1) coaches were credible and supportive, 2) feedback was useful, 3) video-clips allowed for self-reflection, 4) getting feedback on the same day was useful, and 5) use of real patients preferred over standardized patients. Conclusions Video-based coaching can help providers learn new communication skills in a way that is provider-centered, brief and timely. Our study demonstrates that real-time coaching using live feed and video technology is an acceptable and feasible way of teaching communication skills.

Wait time, defined as time spent in the waiting and exam rooms waiting to see a provider, is a key quality metric in a number of national patient experience surveys. However, the literature on wait time does not show a consistent correlation between long waits and worse overall patient care experiences. Herein, we examine contextual factors that can shape the manner in which patients may respond to different wait times. We also identify actions providers and clinics can take to promote positive wait experiences and mitigate negative ones. We conducted over 130 h of semi-structured interviews with patients new to two HIV primary care clinics in Houston, Texas. We interviewed patients before the first provider visit, again within two weeks of the first visit, and again at 6–12 months. We analyzed the interviews using directed and conventional content analysis. Our study showed that patients’ “willingness to wait” is the product of the actual wait time, individual factors, such as the perceived value of the visit and cost of a long wait, and clinic and provider factors. Analyses revealed key steps providers and clinics can take to improve the wait time experience. These include: 1) proactively informing patients of delays, 2) explicitly apologizing for delays, and 3) providing opportunities for diversion. Patients noted the importance of these steps in curtailing frustrations that may result from a long wait. Our study highlights key steps cited by patients as having the potential to improve the wait time experience. These steps are practical and of particular interest to clinics, where waits are oftentimes inevitable.

Objectives: This study 1) defines patient involvement from the perspective of patients new to a provider, 2) describes provider communication that patients perceive as promoting involvement, and 3) examines changes in patient definitions of involvement over time. Methods: We enrolled 56 patients at two HIV clinics in Houston, Texas, from August 2013 until March 2015. We interviewed patients three times during the first year of care and analyzed interviews using content analysis. Results: The mean age was 45 years; 54% were men. Patient definitions of involvement ranged from adherence- to decision-oriented. Analysis revealed three provider communication behaviors that patients perceive as promoting involvement: 1) soliciting patient feedback, 2) discussing treatment options and trade-offs, 3) narrating the decision-making process. Definitions of involvement can change over time as providers reframe the patient's illness as manageable and through perceived partnerships with the provider. Conclusion: Provider communication plays a critical role in shaping new patients' perception of involvement and can make patients feel involved even when patients do not actively make medical decisions. Practical implications: Finding strategies to make patients feel involved in their care is important, particularly for new patients, even if those strategies do not necessarily promote more talk from the patient. Published by Elsevier B.V.

Background: New patients are a particularly vulnerable population because they are at high risk of missing a subsequent visit or dropping out of care completely. However, few data exist on what new patients value in the beginning of a relationship with a new provider. Persons with HIV infection may be an ideal population to study the drivers of a positive initial patient-provider relationship, as it is a chronic and serious condition that requires a reliable, ongoing relationship with a provider. Informed by patients' real experiences, this study aims to identify what patients see as the most critical elements for building trust and rapport from the outset.Methods: We conducted longitudinal, in-person interviews with 21 patients new to the HIV clinic at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, from August 2013 to March 2015. Patients were interviewed across three time points: once before their first provider visit, a second time within two weeks after the first visit, and a third time at 6 to 12 months after the first provider visit.Results: We conducted 61 h of patient interviews. The mean age was 53 years; 52% were non-Hispanic white, 23% were non-Hispanic black and 19% were Hispanic. Patients described significant anxiety and vulnerability not just from HIV itself, but also in starting a relationship as a new patient to a new provider. Our analysis of these experiences revealed five actions providers can take to reduce their patients' anxiety and build trust early in the first visit: 1) provide reassurance to patients, 2) tell patients it's okay to ask questions, 3) show patients their lab results and explain what they mean, 4) avoid language and behaviors that are judgmental of patients, and 5) ask patients what they want [i.e., treatment goals and preferences].Conclusions: Our study incorporates direct input from patients and highlights the unique psychological challenges that patients face in seeking care from a new provider. The actionable opportunities cited by patients have the potential to mitigate patients' feelings of anxiety and vulnerability, and thereby improve their overall health care experience.

Cross-sectional studies have shown an association between better patient experiences and health outcomes. However, the direction of causality remains unclear. Our prospective study seeks to determine whether better initial patient experiences predict subsequent retention in HIV care. We enrolled patients new to an HIV clinic in Houston, Texas, from August 26, 2013 to November 18, 2013. The patients' overall experience with the HIV provider was based on six items; overall experience with the HIV clinic was based on five items. We measured subsequent retention over the first 6 months and entire first year of HIV care. Analyses included 140 patients. Sixty-one percent were non-Hispanic black, 41 % were diagnosed with HIV within the last 3 months, and 36 % had a CD4 cell count < 200. Thirty three percent were totally satisfied with their initial HIV provider experience and 32 % were totally satisfied with their initial HIV clinic experience. Retention was 68 % over the first 6 months and 51 % over the first year. Satisfaction with the HIV provider at the initial visit significantly predicted 6-month retention in care (aOR = 3.56, p = 0.006). Similar results were found for satisfaction with the HIV clinic (aOR = 4.67, p = 0.002). Neither of the patient experience measures at the initial visit predicted 12-month retention. Patients with better initial care experiences have significantly greater retention in HIV care. The effect of better initial care experiences was limited in duration. Consistently improving patient care experiences, not only at baseline but also on subsequent visits, may be a way to increase retention in HIV care.

The Satisfaction Profit Chain (SPC) is a theoretical framework that helps link attribute-level perceptions, overall customer satisfaction, customer intentions/behaviors, and financial outcomes. This chapter reviews existing empirical research in this area and provides guidance and recommendations for future research. It is intended to be helpful to managers and academics who are interested in understanding how customer satisfaction -- a focal construct -- is embedded in the context of its antecedents and consequences.

INTRODUCTION:Analogous to the business model of customer satisfaction and retention, patient satisfaction could serve as an innovative, patient-centered focus for increasing retention in HIV care and adherence to HAART, and ultimately HIV suppression.OBJECTIVE:To test, through structural equation modeling (SEM), a model of HIV suppression in which patient satisfaction influences HIV suppression indirectly through retention in HIV care and adherence to HAART.METHODS:We conducted a cross-sectional study of adults receiving HIV care at two clinics in Texas. Patient satisfaction was based on two validated items, one adapted from the Consumer Assessment of Healthcare Providers and Systems survey ("Would you recommend this clinic to other patients with HIV?) and one adapted from the Delighted-Terrible Scale, ("Overall, how do you feel about the care you got at this clinic in the last 12 months?"). A validated, single-item question measured adherence to HAART over the past 4 weeks. Retention in HIV care was based on visit constancy in the year prior to the survey. HIV suppression was defined as plasma HIV RNA <48 copies/mL at the time of the survey. We used SEM to test hypothesized relationships.RESULTS:The analyses included 489 patients (94% of eligible patients). The patient satisfaction score had a mean of 8.5 (median 9.2) on a 0- to 10- point scale. A total of 46% reported "excellent" adherence, 76% had adequate retention, and 70% had HIV suppression. In SEM analyses, patient satisfaction with care influences retention in HIV care and adherence to HAART, which in turn serve as key determinants of HIV suppression (all p<.0001).CONCLUSIONS:Patient satisfaction may have direct effects on retention in HIV care and adherence to HAART. Interventions to improve the care experience, without necessarily targeting objective clinical performance measures, could serve as an innovative method for optimizing HIV outcomes.

OBJECTIVE:This study seeks to understand the drivers of overall patient satisfaction in a predominantly low-income, ethnic-minority population of HIV primary care patients. The study's primary aims were to determine 1) the component experiences which contribute to patients' evaluations of their overall satisfaction with care received, and 2) the relative contribution of each component experience in explaining patients' evaluation of overall satisfaction.METHODS:We conducted a cross-sectional study of 489 adult patients receiving HIV primary care at two clinics in Houston, Texas, from January 13-April 21, 2011. The participation rate among eligible patients was 94%. The survey included 15 questions about various components of the care experience, 4 questions about the provider experience and 3 questions about overall care. To ensure that the survey was appropriately tailored to our clinic population and the list of component experiences reflected all aspects of the care experience salient to patients, we conducted in-depth interviews with key providers and clinic staff and pre-tested the survey instrument with patients.RESULTS:Patients' evaluation of their provider correlated the strongest with their overall satisfaction (standardized β = 0.445, p<0.001) and accounted for almost half of the explained variance. Access and availability, like clinic hours and ease of calling the clinic, also correlated with overall satisfaction, but less strongly. Wait time and parking, despite receiving low patient ratings, did not correlate with overall satisfaction.CONCLUSIONS:The patient-provider relationship far exceeds other component experiences of care in its association with overall satisfaction. Our study suggests that interventions to improve overall patient satisfaction should focus on improving patients' evaluation of their provider.

A modern business is a knowledge business. What it can do depends on what it knows, the preponderance of which resides in the skills of employees, their experiences, insights and intuitions, and their relationships. Knowledge management has therefore increasingly recognized workers as important contributors to the intellectual capital of businesses. Customers, too, can add to what companies know, but to learn from them, businesses must listen attentively to what they have to say. Unfortunately, an increasing reliance on technology impedes conversations between companies and those they serve to the detriment of both. By expanding the scope of its knowledge management effort to include its customers, however, a company can gain new knowledge to bolster its service, improve its operation, and accelerate its innovation. Much of what has been learned about gathering knowledge in the workplace can facilitate this undertaking.

A large business generally knows its customers through quantitative analyses and summary reports, which are staples of market research and corporate reporting. Too often, the voices of individual customers are muffled by a torrent of numbers, and the stories they would tell are garbled. Few managers and even fewer executives hear customers speak, in their own words and ways, about the company's products and services. Yet, as we discuss, these stories may suggest enhanced customer service, better products, and organizational innovation; indeed, a number of companies have shown that the value of attentiveness to customer stories can be great. Herein, we describe a controlled, exploratory approach a company might take to develop its own engagement with customer storytelling—one that encompasses not only its interactions with customers along the front line, but also conversations ongoing in social media. Our proposal demands sustained commitment from senior management. We counsel senior executives to lead by example, to listen to customer stories, to learn from them, and to share them with others in the executive suite. By truly caring about storytelling, business leaders can better serve their customers and their companies.

Information technology is reshaping relationships between companies and customers, often bringing benefits to both. The unfettered use of technology, however, can erode customer care. For a company to care for customers, its managers and front-line employees must listen empathetically to what they have to say. But a rash of ‘innovations’ aimed primarily at reducing costs has made many companies opaque to their customers, who are—as a consequence—inadequately served and increasingly frustrated. Equally damaging is the resulting estrangement of employees from customers, a separation that dampens the empathy upon which true care for customers depends. As a number of innovative companies have shown, though, technology need not necessarily sour relations between businesses and those they serve. Indeed, technology can actually enrich them if senior managers (1) affirm their commitment to active, empathetic involvement with customers; (2) understand the ways in which current procedures and systems mediate interactions with customers; and (3) promote the deployment of social networks and other technologies to help customers tell their stories, and to enable workers and managers alike to hear them. Only when employees can step into their customers’ shoes can companies add authenticity to the claim: “We care for you.”

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Service businesses today make extensive use of post-service experience surveys to obtain feedback from customers on service quality, satisfaction, and future repurchase behavior. Recent research has found that such surveys have the potential to evoke question-behavior effects (QBE) on participating customers and moreover suggests its impact on firm revenues is positive. However, our findings indicate that the effects may not always be beneficial. The research the authors report is set in the automotive quick lube industry and comprises two field experiments and a lab experiment. The authors find that customers participating in firm-sponsored surveys delay immediate service repurchases, thus reducing cash flows, but also accelerate subsequent ones in the following periods. Our results are explained by the inferences that customers make as they participate in such surveys, which affect customer behavior in a complex manner, and provide an additional mechanism to understand the operation of QBEs. One important caution emerging from this finding is that service firms conducting satisfaction surveys for tracking purposes on an ongoing basis should be careful not to survey customers too often.

In major organizations today, senior management is increasingly apprehensive about the threats to company reputation from Internet criticism and rumor rapidly spreading through online communities. We believe the source of the threat lies in the emerging culture of the Internet, which has been largely ignored by practitioners and academics alike. In particular, the Internet has fundamentally altered the notion of authority. Where it once vested in the few, authority has now become the claim of many, who are empowered and emboldened by the Internet. Managing damage to company reputation, however, requires more than adapting traditional media relations to the Internet. In addition, we believe it requires business leaders to re-invigorate their connections with customers and encourage their employees to speak to customers directly and forthrightly about their own work, plans and aspirations related to company's products and services.