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Listening, Acting, and Learning Together to Build a Better Model of Care

Judd, Marie FACHE

Frontiers of Health Services Management: Fall 2019 - Volume 36 - Issue 1 - p 14–24
doi: 10.1097/HAP.0000000000000063
Feature Articles

SUMMARY As a large, nationally integrated, mission-driven healthcare system, Ascension recognizes the need for a multifaceted approach to communication—one that facilitates both national alignment and local action while advancing the Quadruple Aim of enhancing the person/patient experience, improving population health, reducing costs, and improving the work life of healthcare providers.

The Ascension Person and Family Experience Model provides a framework to support a comprehensive communications strategy that encompasses our care teams, leaders, and communities. The model, which comprises a feedback loop with three steps—listen, take action, and learn together—guides both personal interactions and organizational change. It gives direction to our human-to-human connections and enables us to listen as an organization to our voice-of-the- customer data. In living the model, we take meaningful action both by developing just-in-time solutions to problems close to the person/patient and by launching systematic actions on the macro level. We also find ways to learn and innovate together through both local huddles and national conversations.

The model has been operationalized across the system with the support of a cross-discipline, cross-continuum national structure. It owes its success to a persistent focus at all levels of the organization on what matters most to those we serve and to those who serve beside us.

Marie Judd, FACHE, CPXP, SPHR, is national vice president of patient and care team experience for Ascension based in St. Louis, Missouri.

The author declares no conflicts of interest.

The heart of healthcare is service to individuals in need through compassionate, personalized care. Foundational to this premise at Ascension is effective, efficient, and empathic communication—communication that conveys who we are; what is important to us; and how we collaborate, serve, learn, and connect with each other on a human level.

Ascension is a nonprofit Catholic healthcare system with more than 156,000 associates and 34,000 affiliated providers serving at more than 2,400 sites in 21 states and the District of Columbia. We seek to deliver compassionate, personalized care to all, especially to those who are poor and vulnerable. This work is guided by the organization’s values of reverence, integrity, wisdom, creativity, dedication, and service to the poor. These values shape how we strive to communicate in encounters every day nationwide:

  • Reverence. We engage with the person in front of us to truly understand what matters most, forming a person-to- person connection.
  • Integrity. We engage in transparent discussions and information sharing as a team, making us better collectively.
  • Wisdom. We lead with curiosity to ask questions and lead with humility to seek out the guidance of those closest to the work, driving engagement and high reliability.
  • Creativity. When confronted with difficult decisions and potential roadblocks, we pull together for open dialogue, catalyzing innovation and avoiding false choices and stagnant thinking.
  • Dedication. We embrace servant leadership by listening to those we serve, taking meaningful action in response, and ensuring closed-loop feedback to foster a more engaged workforce.
  • Service to the poor. We try to understand barriers that hinder healing and the well-being of persons/patients in need.
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The Many Forms of Communication

Communication in healthcare takes many forms. Essentially, it is the glue that holds complex systems and structures together and facilitates the human-to-human connections that define how we deliver care. In mapping the communication landscape at Ascension, we have identified five different perspectives:

  • As care teams (clinical and nonclinical), we communicate with those we serve and those who serve beside us to promote safe, compassionate, and personalized care.
  • As servant leaders, we communicate with our associates, providers, and peers as an engaged and inspired workforce.
  • As a large, integrated system, we communicate to foster both national alignment and locally led action in accordance with our shared mission and values.
  • As a learning organization, we communicate to accelerate cycles of improvement and operational agility.
  • As a transformative system, we communicate to meet the needs of consumers and our communities proactively and effectively as we develop the care continuum of the future.
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National Alignment, Local Action: A “Both/And” Approach

As an integrated health system, Ascension needed a model to operationalize how we communicate and collaborate for both national alignment and locally led action. The underlying objective of this “both/and” approach is to advance the Quadruple Aim of enhancing the patient experience, improving population health, reducing costs, and improving the work life of healthcare providers (Bodenheimer and Sinsky 2014). We needed to design structures and systems to support the cascading of experience goals, build learning communities, scale best practices, and drive meaningful improvement both nationally and locally.

In building the model, we wanted to avoid the pitfalls that can occur when a large organization does not take a balanced approach to integrating a diverse group of local and regional health systems into a national system. An organization that relies too heavily on “mandates from national” risks losing operational agility and the ability to tailor interventions to the needs of local communities. At the same time, an organization that does not prioritize the alignment and integration of key priorities, processes, and standards risks creating duplicative efforts, process gaps, additional costs, and overall inefficiency.

Ascension sought to create a structure that would improve the person and family experience (PFE). Our solution was to engage a team of committed, engaged, and forward-thinking leaders to cocreate balanced systems and structures for communication and scale. These systems and structures took a “both/and” approach of national alignment and locally led action.

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Purpose of the Experience Structure

We envisioned a structure to support PFE that would enable leaders at the national and local levels to do the following:

  • Cocreate national strategies and tactics to deliver compassionate, personalized care by seeking the guidance of those closest to the work in our local communities
  • Share information across the system to achieve faster cycles of improvement
  • Foster a learning community to establish best practices for collecting, reviewing, and acting on large amounts of voice- of-the-customer (VOC) feedback—qualitative and quantitative—to drive effective, efficient, and meaningful improvements locally and nationally
  • Scale local best practices and resources to eliminate work that does not add value
  • Align goals to advance all dimensions of the Quadruple Aim across the system

Given these parameters, the complexity of communication in a large organization, and the need for a unified approach to delivering compassionate, personalized care, we set up a national communication structure consisting of three interactive groups:

  • PFE steering committee. This diagonal slice of the organization across the continuum encompasses both clinical and consumer-facing roles; includes representation from person/patient and family advisers and local markets; and has national support team partners in information technology, mission integration, human resources, marketing and communications, strategy, revenue cycle, and environment of care. The PFE steering committee guides the horizontal alignment of national goals, strategies, and prioritization.
  • National PFE team. These internal consultants and advisers connect and build learning communities, such as the PFE operating council (described next), to advance our national priorities and achieve the Quadruple Aim as an integrated system.
  • PFE operating council. C-suite executives and PFE representatives from each market meet as a national team twice per month. They review and draw insights from VOC outcome and process measures related to national and local targets, and they share local actions in processes, best practices, and integration with other teams and work streams for efficiency. They also work together to build competencies for VOC integration for targeted insights, effective action planning, key stakeholder engagement, communication plans, and validation measures; reach consensus on local actions and communication plans to improve as an integrated system; and lead improvement locally using the Ascension Model for PFE (described next) and best practices identified by the national learning community.

In 2017, the PFE steering committee crafted the following tenets to develop and deploy the Ascension Model to shape how we interact, share information, cocreate strategies, and deliver results together:

  • We, as a system, move beyond patient experience.
  • We take a holistic approach to care: We are all persons before we are patients.
  • We take an integrated approach to the Quadruple Aim, grounded in our mission.
  • We focus on healthy workplace cultures and the engagement of associates and providers as our foundation.
  • We take a broad view of PFE across the continuum, including pre- and post-care, to include all consumer-facing needs.
  • We engage in intentional partnerships and collaboration across Ascension, remembering that PFE is a team sport and avoiding silos.
  • We learn as a system by listening to our local facilities and stakeholders, working through pilot tests of change, and reviewing best practices.
  • We drive market-led cocreation and adoption of our national model to operationalize how we deliver care as a system.
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Ascension’s Experience Model: Listen, Act, and Learn Together

The Ascension Model for PFE (Exhibit 1) provides a framework for our organization to meet our experience goals nationally and locally. The model, founded on evidence- based best practices and innovations developed in our local facilities, is the outcome of input from stakeholders across Ascension’s care continuum. It takes the form of a feedback loop with three components: listen, take action, and learn together.

The core of the model is a focus on what matters most to all persons in our ministries, from the patients and families we serve to our caregivers and other associates whose engagement is vital to our success. We learn what matters most by growing our ability to listen with empathy and attention and by gathering national quantitative and qualitative data. We take action on what we learn using process improvement methodologies with a strong orientation toward results. Finally, we share our learning to drive systematic improvement locally across the nation and the care continuum.

A balanced approach to listening and taking action allows us to better understand those we serve so that we can make meaningful improvements. We are not necessarily trying to gather more information but rather to put different pieces of the story together. This approach involves the effective use of feedback for insights and action that avoid the data-rich, information-poor (DRIP) trap noted by Peters and Waterman (1982).

Listening and action go hand in hand. They are not mutually exclusive but rather provide a means to manage in a continuous circle. Listening without action erodes trust and produces organizational stagnation. Action without listening leads to capricious interventions and the inefficiencies of throwing darts with the hope that something will stick. When listening and action are balanced, we see greater organizational agility, greater efficiency, and improved outcomes because we can prioritize and address what matters most to those we serve.

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Step 1: Listen

To drive action and improvement based on the voice of those we serve at Ascension, we build organizational competencies to listen in the following ways:

  • We listen with empathy to make a human- to-human connection in all encounters with persons/patients, family members, associates, providers, and volunteers so that we can understand what is important to each unique person and provide the best care for body, mind, and spirit.
  • We listen as a national organization to the large quantitative and qualitative VOC data sets that come in every day from across the continuum so that we can understand those we serve in our local communities and align our goals and actions with consumer needs.
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Make Human-to-Human Connections

Connecting with the person/patient whom one is serving—whether in a clinical or a nonclinical role—requires strong communication skills, including the following:

  • Listening with empathy
  • Using active listening methods, including teach-back, to ensure effective information transfer
  • Providing interpreters and translated documents for persons/patients with limited English proficiency
  • Using plain language, free of jargon and confusing acronyms, to improve healthcare literacy
  • Remaining inclusive through culturally competent language and actions that honor all persons/patients and respect their dignity
  • Engaging persons/patients and families in discussions, handoffs, and decisions to ensure they are at the center of all we do
  • Providing psychologically safe environments for our care teams and those we care for to foster trust and transparency

When we listen and seek to understand one another, we expand our capacity to exceed expectations in experience and engagement by reducing the guesswork. This approach also creates an environment in which we can better deliver on the Quadruple Aim.

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Form the Foundation with Associates and Providers

A key principle of any improvement model includes seeking feedback from those closest to the work and closest to the issue. Unfortunately, these experts—the patients, their families, and frontline caregivers and providers—frequently are not consulted by leaders because doing so may present challenges in complexity, scope, and time. We, as leaders, must be intentional about deference to expertise by soliciting input and acting accordingly. At Ascension, this engagement is the foundational element of any Quadruple Aim improvement.

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Ask What Matters Most

Compassionate, personalized care starts by asking “What matters most to you?” and then listening attentively to the response. This respectful listening applies to everyone at Ascension. It fosters engaged and inspired team members who can live their calling in healthcare. When our teams feel they are valued, as demonstrated via listening, action, and closed-loop feedback, we see the following:

  • Higher associate and provider engagement
  • Improved productivity, teamwork, and efficiency as a result of greater discretionary effort
  • Improved quality and safety outcomes
  • Better PFE and overall consumer loyalty

The concept of “what matters” is an essential element of the Age-Friendly Health System initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association of the United States. The goal of this initiative is to ensure that the care of older adults incorporates essential evidence-based practices, causes no harm, and is consistent with what matters to older adults and their families (Institute for Healthcare Improvement, 2019). As one of five pioneer health systems in the initiative, Ascension has worked to share ways we have operationalized this approach in our organization. After all, it is one thing to say ‘This is what we would like to do’; it is another to deliver on that promise across a large system.

We operationalize the “what matters” concept by incorporating the question “What matters most to you?” into daily encounters. Associates and providers pose the question to persons/patients and families to personalize the care experience and design care plans. At facilities across our system, a laminated poster or a section of the communication board in patient rooms captures the information in a way that can be shared quickly and easily with any member of the care team, ensuring that we take a team approach to improving PFE.

Leaders also make what matters most a central topic in their rounds with all stakeholders. By listening, leaders learn what is working and what is getting in the way of high-quality experiences. In 2018, we integrated “What matters most to you?” more explicitly into our processes for leader rounding by embedding the question into an electronic solution. The Ascension Rounding Tool, which can be accessed on a computer, tablet, or smartphone, prompts a conversation that allows leaders to make a human connection with the person in front of them—associate, provider, or patient—so that they can take meaningful action on feedback they receive.

A chief nursing officer (CNO) recently shared a story at an Ascension PFE operating council meeting about leading the charge in her market to ensure that listening for what matters is an essential part of every patient stay. During senior leader rounding, the CNO asked a patient, “What matters most to you?” The woman, who was happy to be asked, answered, “Going home, and God.” In further discussion, the CNO learned that no one had asked the patient this simple but important question. The woman also expressed concern about mixed messages related to her discharge from different members of the care team and mentioned that she had not received a visit from the chaplain. The CNO was able to focus on the patient’s needs and take immediate, meaningful action by engaging the care team to reconcile the discharge information and by reaching out to the spiritual care department for a chaplain visit that day. This response made a world of difference to the patient.

The Ascension Rounding Tool supports individual encounters while also enabling real-time organizational listening. It serves as a one-stop shop for rounding processes by gathering and aggregating data to support systematic action. With the tool, leadership can identify themes, trends, and immediate opportunities at the unit, clinic, and department levels, as well as regionally and nationally, to drive both just-in-time and systematic improvement.

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Listen to Drive Improvements

Another strategic and purposeful way leaders at Ascension listen to those we serve is through VOC analysis, a systematic way to understand our current state or, put another way, to “know our business.”

Qualitative and quantitative VOC data incorporate the perspectives of those we serve and ultimately predicts how likely they are to recommend our services to their friends and families. According to research conducted by the Beryl Institute, the top driver for selecting a provider is recommendations from friends and family (Wolf 2018). Our ability to understand how we can improve loyalty by taking meaningful action based on data is imperative to driving growth in our markets.

We frequently conduct organizational listening through review of feedback and large data sets, both qualitative and quantitative. We receive feedback through channels such as Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, loyalty surveys, rounding data, person and family advisory council (PFAC) conversations, town halls, focus groups, community listening sessions, associate engagement surveys, and just-in-time pulse surveys or process measures. These sources of feedback are disparate and can be confusing, but they are useful only if we review them, understand their insights, and apply the information in a way that drives improvement across the Quadruple Aim.

For example, when we review CAHPS data on responsiveness in the inpatient setting, we may find correlations with falls measures or staff time away from the bedside (e.g., to look for supplies). In theory, if we listen and put key data sets together, we can address issues more effectively. In practice, we might improve the processes related to supplies and stocking levels, which can improve associate engagement and allow more time for associates to address patient needs proactively. This, in turn, can reduce the chance of falls for patients who try to walk without assistance when their call light is not answered quickly enough.

Finding the meaning and value in our data is essential if we are to avoid the DRIP trap. We do not want data for the sake of data; rather, we want to use the information we have at our disposal to understand and tell a story. Integrating VOC data enables Ascension leaders and caregivers to take focused action. No system or leader has the time or resources to deploy strategies or tactics that are inefficient, that do not affect the perceptions of those we serve, and that do not play a meaningful role in improving outcomes. An integrated approach to VOC data allows us to prioritize the right efforts.

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“Listen” to Data to Take Meaningful Action

Ascension augments data analysis with coaching to help leaders at all levels “know their business” as it pertains to VOC feedback and PFE measures. We use a simple, stepwise flow to familiarize leaders with the foundational elements of listening to the VOC data and figuring out what it means and what to do with it:

  • Commit to reviewing your VOC feedback and PFE measures:
    • CAHPS and loyalty survey data (quantitative and qualitative) across the continuum
    • Associate and provider engagement data
    • Real-time rounding data from persons/patients, families, associates, providers, and volunteers
    • Complaints, compliments, and questions received via social media, call centers, and post-visit or post-discharge calls
  • Derive insight from the information by asking the following questions:
    • What do we do well? What could we improve upon? How do we know? What are we hearing?
    • What are the trends? What other information would help us understand the “why” behind these trends and themes?
  • Drill down by asking the following questions:
    • Where do we have clear wins to spread or problem areas to address?
    • Where do we have high-volume, lower-performing areas to address through priority interventions and a deeper dive into both outcome and process measures?
    • Have we improved as a unit, department, or clinic in the last reporting period, in the last quarter, or over the past year?
    • How do we compare with our competitors? What do these numbers actually mean?
  • Review related feedback, key performance indicators, and operational metrics with partners and key stakeholders across the system to inform your root cause analysis and provide integrated insights:
    • Quality and safety measures
    • Access measures and throughput times
    • Turnover and vacancy data
    • Management stability measures
    • Person/patient and family adviser feedback
    • Town halls, listening sessions, and focus groups
    • Pulse survey questions to key stakeholders to drill down to the “why” behind outcomes
    • Point-of-service feedback (e.g., about billing encounters, appointment scheduling)
  • Routinely share this integrated information with your teams (e.g., during huddles, meetings, one-on-one sessions) and engage them for their input:
    • Additional insights
    • Collaborative problem solving
    • Meaningful action planning
  • Set action plans to drive improvement through various means:
    • Key performance indicators
    • Timelines
    • Clear measures of success
    • Validation measures to address the question “Are we doing what we say we want to do?”
  • Start the process again to establish cycles of improvement.
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Give Voice to Advisory Councils

Listening requires the recruitment, engagement, and development of person/ patient and family advisers for discussions of any program or initiative that affects PFE, including facility design, care processes, pre- and post-care processes, initiatives to reduce disparities in care, safety and reliability approaches, person/patient and family education, research recommendations, and care models. Central to this strategy is the development of PFACs.

In addition to local PFACs across our system, Ascension has a national PFAC that meets virtually and provides just-in-time input to guide and inform national strategies. This year, the national PFAC helped shape our work to combat sepsis with a campaign that encourages persons/patients and family members to speak up if they spot any signs of sepsis. Our PFAC also informed our national work in inclusive consumer-facing education, vendor relationships, behavior standards, and community expectations for provider clinics.

An engaged PFAC can help to transform an organization’s culture, leading to improved PFE and safer care. It can also contribute to a revitalized mission for providers and associates as they learn to connect in new ways with those they serve.

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Step 2: Take Action

When I ask local leaders what informed their action plans to improve care, they usually point to a conference session, a keynote speech, a trusted colleague, or the latest business bestseller. Although all are valid ways to foster learning, insights, and improvement, what stakeholders (internal and external) are saying must also be considered. This is where scientific thinking, root cause analysis, and Lean methodology come into play to drive targeted and meaningful actions instead of merely hoping something works.

When actions are not tied to the VOC in a meaningful way, burnout and initiative fatigue result and the needs of those we serve remain unmet. For example, large-scale training on friendliness and courtesy may not be the top priority if you already have high percentile rankings in this area but your access measures for appointment convenience are below the national median. A friendliness and courtesy training program requiring time and money will not address the customer sentiment “I love that facility, but I just can’t seem to get an appointment.”

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Start with Just-in-Time and Systematic Actions

So how can we take action on what we learn by listening? At Ascension, we recommend starting with just-in-time actions to solve problems right away, as close to the person/ patient as possible. Some issues, however, call for team action and a more systematic approach across multiple units, sites, and regions.

The key is to engage those closest to the work by following Lean and high-reliability principles. We engage these stakeholders—associates, providers, and leaders at every level—to understand what matters most to those we serve. In this way, they drive targeted improvement together. The team can work to close the loop on what matters most by planning responsive actions and taking ownership of results.

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Emphasize Closed-Loop Feedback

To address organizational gaps identified by listening, leaders must engage their teams in root cause analysis, identifying barriers to success and possible interventions. Ascension’s national PFE team trains leaders on the importance of closed-loop feedback (e.g., “Here is what I heard you say, here is what I did or didn’t do, and here is why. What do you think?”).

This simple practice of closing the loop is often the missing component in communication in healthcare. We ask customers and our workforce a multitude of questions to gather feedback; however, the feedback only counts if people feel that they are heard and their opinions are valued, even if the result is not what they had hoped. When we seek feedback but then do not take action in response, trust erodes over time and a “why bother?” culture sets in. This is often a precursor to a drop in internal engagement and a subsequent drop in external loyalty from our communities.

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Step 3: Learn Together

The last step of the Ascension Model for PFE calls us to share wins, lessons learned, best practices, and opportunities with our peers throughout the organization to accelerate cycles of improvement in a more systematic way. This practice fosters a learning organization and an aligned approach to achieving our goals, improves care process reliability, and helps us live our mission.

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Hold Local Leadership Huddles

At daily leadership huddles, senior leaders at local sites discuss what they have learned from rounding and other sources about what matters most to persons/patients and families and to associates and providers. Together, the leaders identify themes and problem areas and share learning from their small tests of change.

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Gather the National PFE Operating Council

Twice a month, Ascension gathers PFE leaders from local markets, the national PFE team, and other internal partners (e.g., human resources, information technology, mission integration) to share great-catch stories and to discuss what is or is not working, progress in achieving outcome measures, and any needs for additional support. This learning community is strengthened by transparent data sharing, open dialogue, and a willingness to support one another in achieving goals.

We also share national data, including outcome and process measures, to provide context, insight, and alignment across Ascension’s markets. The deployment of the Ascension Rounding Tool has been the key to getting real-time VOC information into the hands of our leaders, at all levels, with line of sight to other markets for improved collaboration and faster improvements.

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Use Learning Communities and Open Forums

To foster learning, our national PFE team showcases best practices from local markets during monthly “spotlight calls,” when local leaders, providers, and associates share the work they have accomplished, lessons they have learned, and ideas for adoption in other markets. These calls are recorded and made available for on-demand review.

We also host regular skill-building calls (also recorded and available on demand) based on gaps and needs that are identified through analysis of national VOC data. Among the many PFE-related topics are the following:

  • How to understand and find meaning in qualitative feedback
  • New ways to engage PFAC members virtually
  • Effective service recovery
  • Collecting and using real-time feedback for faster cycles of improvement
  • Daily management systems and huddles for Quadruple Aim improvements
  • Effective action planning and change management

The national team listens, acts, and learns together with local markets to help improve service in their communities.

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At Ascension, we envision a widespread transformation of healthcare, including the following advances:

  • Improved support of care teams for engagement, innovation, and high performance
  • Innovative technological experiences to meet consumer expectations for convenience and access
  • A holistic approach to community wellness, with integration to address social determinants of health
  • Rethinking the places and spaces (virtual and actual) where we provide services to support healthy, vibrant communities
  • Ensuring we reduce disparities in care by fostering inclusive environments

To achieve that transformation, we must continue to focus on effective, efficient, and empathic communication—the glue that enables us to hold true to our role as people serving people, particularly those in need. The Ascension Person and Family Experience Model provides a framework for those efforts.

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Bodenheimer T., Sinsky C.. 2014. “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.” Annals of Family Medicine 12 (6): 573–76.
Institute for Healthcare Improvement. 2019. “Age-Friendly Health Systems: What Is an Age-Friendly Health System?”
Peters T. J., Waterman R. H. Jr. 1982. In Search of Excellence: Lessons from America’s Best-Run Companies. New York: Harper & Row.
Wolf J. A.. 2018. “Consumer Perspectives on Patient Experience 2018.” Beryl Institute. Accessed June 6, 2019.
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