UNC Department of Emergency
Medicine Relies on Bivarus for
Patient-Centered Analytics to
Transform Care Delivery and
Improve Patient Safety
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BACKGROUND
The University of North Carolina (UNC) Department of Emergency Medicine consists of 26
clinical faculty, 5 research faculty, and multiple adjunct faculty involved in the teaching,
administration, research, and clinical care missions of the department. The department sees
approximately 75,000 adults and pediatric patients yearly. As one of the largest referral centers
in North Carolina, UNC’s ED sees some of the highest acuity patients in the state, with an admit
rate near 30%. The department is a certified Level I Trauma Center, American Burn Association
(ABA) Burn Center, accredited Chest Pain Center (CPC) and a certified Joint Commission on
Accreditation of Healthcare Organizations (JCHAO) Comprehensive Stroke Center.
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CHALLENGE
In an effort to monitor patient experiences, the UNC ED previously
experience. Physicians and administrators were interested in a
used a paper-based survey platform from provider Press Ganey to
platform that provided timely data they could act upon—granular
survey patients who were admitted from the ER, but only after
enough that it could be tied back to an actual encounter and
discharge from the hospital. These data were provided on a
specific providers. Finally, a solution that also allowed patients to
quarterly, then monthly, basis. The department’s initial response
provide free-text comments that would be more descriptive of
rate was dismal. Although the department successfully improved
each patient’s overall experience.
their Press Ganey ranking from the 15th to 65th percentile, there
was concern that the low response rate did not capture the true
patient experience. Physicians and administrators were only able
CHA LLENGES
to access data months after patient discharge, and the data were
too high level for their needs and not tied to individual patient
visits. Moreover, the time spent in the ED represented only a
portion of the total inpatient experience, and specific ED
information was difficult to delineate from the survey results.
Low response rates
Non-actionable, high-level data
Data not tied to individual patient visits
The UNC ED required a solution that would complement their
existing safety reporting processes, more accurately match their
adult patient population, and reduce the latency between the
patient’s actual encounter and the measurement of that
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SOLUTION
Following a pilot test, UNC’s ED implemented the Bivarus platform
New Science in Patient Experience Measurement
to capture and measure near real-time experience data. The
The Bivarus measurement system uses a sophisticated sampling
Bivarus platform focuses on capturing the patient voice and arming
algorithm to determine which set of 10 measures are dynamically
physicians, nurses, and administrators with actionable data for
presented within each survey to a single patient. This system takes
meaningful, patient-centered interventions to improve care
into account both the relative importance given to measures
delivery and service operations.
(configurable by customers, see Figure 1) and the reliability of prior
observations.
SOLUTION
Therefore, more important measures are asked more frequently,
and question occurrence is adjusted as new observations are
Customized, dynamic surveys
obtained. This unique methodology guarantees that the obtained
mean response is not due to chance.
Simple, effective interface
Near real-time data to monitor interventions
So, even though the typical item bank contains 50-100 measures, a
patient NEVER has to answer more than 10 measures.
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Unique to Bivarus, the item bank is fully customizable, using existing measures within 10
categories, or by creating new measures specific to the organization’s informational needs
(Figure 1).
Figure 1. Category customization through the Bivarus portal
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Simple, effective patient interface
From the patient perspective, survey interactions are very simple
and easy to use. Typically taking less than 2 minutes to complete,
the surveys place little burden on the patient.
The surveys, which always consist of 10 measures, are
delivered to adult patients via their preferred method (email or
text message) within 24-48 hours after a health care
experience. Patients answer using a 5-point scale for each
measure, and free-text comments are also possible (Figure 2).
Figure 2. Sample patient survey
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Near real-time data to identify and monitor interventions
Data are updated every 6 hours and available 24/7 through the web-based portal, providing granular feedback about every aspect of the patient
experience. The UNC ED values this ability to review the data on a daily basis, and trends in quantitative and qualitative feedback help identify
opportunities for interventions and service recovery, which are then monitored through the same portal (Figure 3).
In the UNC ED, approximately 50% of responding patients provide free-text comments, which have been particularly useful for identification of
issues and development of specific and immediate interventions, which can also be monitored through the Bivarus portal.
Figure 3. Overview of category scores within the Bivarus portal
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RESULTS
With the implementation of the Bivarus platform in the UNC ED,
the following results were achieved:

Improved response rates

Improved care delivery and service operations

Increased patient safety

Actionable feedback for providers/practitioners

Perceived value by management
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Improved response rates
Response rates in the UNC ED using Bivarus improved to 3 times that over the previous Press
Ganey survey, owing to the ease of use and lack of response fatigue (Figure 4).
30
27.8%
25
Percent
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15
10
8.8%
5
0
Press Ganey
Bivarus
Figure 4. Response rates to surveys during January 2013
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Since its adoption, the annual response rates with Bivarus have continued to remain at
approximately 28% (Figure 5).
Figure 5. Response rates in the UNC ED, 2013 and 2014
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Despite the use of technology to solicit feedback (either via text or email), all age groups are
well represented with the Bivarus survey (Figure 6). Not only do older patients respond well
using this platform, but younger patients also complete the survey.
60
53.7%
50
44.2%
40
30.1%
30
25.6%
24.9%
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10
23.6%
22.7%
24.4%
16.1%
7.2%
3.9%
6.6%
0
0-17
18-34
35-49
50-64
Press Ganey
65-79
Bivarus
80+
Figure 6. Survey response by age group in January 2013
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Furthermore, patients providing data using the Bivarus platform more closely mirror the UNC
ED patient population, compared with the Press Ganey survey, which over-represented patients
aged 50–64 years and under-represented patients aged 18–34 years (Figure 7).
30
28.5%
28.1%
26.1%
25
22%
20
20%
19.5%
19.4%
17.1%
16.3%
18.4%
16.4%
13.8%
15
13.8%
10.4%
10.2%
10
8.1%
6.1% 5.9%
5
0
0-17
18-34
35-49
Press Ganey
50-64
Bivarus
65-79
80+
All ED Patients
Figure 7. Survey demographics, compared with the UNC ED population in January 2013
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Improved care delivery and service operations
The Bivarus platform is unique regarding how the data are used in interventions and improved
provider performance.
For example, the UNC ED identifies and focuses on interventions through a daily data review,
and a 90-day action plan is developed for each intervention. Compared with the high-level data
from previous surveys, Bivarus data can be tied to an individual patient visit. The discussions
are no longer centered on the accuracy of the data, but rather how the department and/or
providers can best act on the data. This philosophical change has facilitated improvements in
care delivery and service operations.
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Service operations example: Bathroom cleanliness
Because of the volume of patients in the ED, it can be challenging to maintain the cleanliness of
the bathrooms, which can change within a short period. In the UNC ED, an average score of 3.9
(out of a possible 5) was observed for bathroom cleanliness, and an upward trend in patient
complaints for this issue was observed in the Bivarus portal.
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As in any busy workplace, interventions can work in the short-term; however, as other priorities
surface, longer-standing interventions can receive less focus. The power of the Bivarus system
is the ability to continuously monitor the outcomes of interventions. In this case, there was a
decrease in the score for bathroom cleanliness again in October 2013 (Figure 8). At this time,
the Director of Environmental Services was granted access to the Bivarus portal for direct
monitoring, and the scores improved with reinforcement of the intervention.
Figure 8. The intervention for bathroom cleanliness in July 2013 resulted in better scores, and
the intervention required reinforcement in October 2013
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Anecdotal patient feedback
Patients have noticed subsequent changes in the service
reviewed monthly by the ED’s patient advisory board, which
received and now provide positive feedback regarding their
consists of 4 patients that meet with clinical leadership to review
experience.
Bivarus data, and identify and monitor interventions.
“Best experience yet in ER; it is improving! Thank you!!!
Over a 12-month period starting in Summer 2012, the UNC ED
Two hour visit including ultrasound for leg swelling after
safety team was able to identify 242 safety related comments
breast surgery!! .”
within the free-text comments submitted via the Bivarus platform:
“Emergency room care certainly improved over my last
visit...Facility more comfortable; valet parking very
helpful. Assistance using wheelchair, getting into bed, etc.
very helpful also.”
Departmental monitoring of safety
Of the 2,800 comments in the Bivarus system for UNC ED in 2013,
roughly 9% were safety-related issues, including serious adverse
events and preventable near-misses.

12 adverse events

40 near misses
•
31 preventable, approximately half serious

23 medical errors with minimal risk of harm

167 general safety related issues

Other issues relating to sanitation, hand hygiene, care
transitions, medication administration
Of the 52 adverse events/near misses, only 5 (10%) were also
found in the existing UNC safety event reporting system that relied
on provider self-reporting. Using Bivarus, the Clinical Leadership
The Patient Measures of Safety survey category includes 10
Group can create a more complete reporting system that
measures focusing on safety issues. These data are collected and
incorporates the patient’s unique perspective and is better able to
presented monthly to the Clinical Leadership Group. They are also
strengthen their safety culture.
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Care delivery example: Safety at the operational level
A trend in contrast dye exposure in allergic patients was detected using free-text comments by
patients in Bivarus surveys, and actions are currently underway to address the underlying issues
to improve patient safety.
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Provider/practitioner benefits
Bivarus provides scientifically precise provider-specific reports, which are being used to derive
provider scorecards for physicians and residents in the UNC ED for continuous improvement
and mentoring purposes (Figure 9). These report cards are also making their way into resident’s
CVs as they begin looking for full-time attending positions.
Figure 9. Detailed provider reporting in the Bivarus portal
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A mentoring program was recently implemented to match mentors
Perceived value by management
with residents with the aim of improving their skills and ratings.
There is also perceived value by the management team in the
The pairing is based on mentors’ strengths (higher scores) and
reporting mechanisms of the platform, providing the ability to
areas in which residents need to show improvement (lower
immediately address and monitor patient safety and satisfaction.
scores). To date, a mentor has been identified for each of the 3
domains: Communication, Patient Centered Care, and Provider
Expertise and Interpersonal Skills.
“I learned more from 10 minutes reviewing this report
once than I have in 10 years of [reviewing reports from the
Press Ganey system]. Very nice.”
Providers appreciate the shift from a punitive system to one that
—ED Medical Director
offers the ability to directly receive patient feedback, identify areas
for improvement, and monitor their performance.
“This powerful and novel approach to assessing patient
satisfaction is a game-changer; it will fundamentally
As a result, physicians and administrators at UNC have become
more engaged with the data and no longer question its accuracy.
change how we manage the service experience for our
patients—here and nationally.”
In addition, physicians are requesting and using the Bivarus data
for credentialing and recertification purposes.
—Chairman, Department of Emergency Medicine
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SUMMARY
The Bivarus platform differs from other offerings in its ability to provide representative and
event-specific data that are actionable, thereby improving care delivery and provider
performance using patient-reported perspectives on the delivery of care and provision of
service.
The resultant improvements in quality, safety, outcomes, operations, and cost can be realized
at all operational levels, including the provider level. Patients are increasingly informed
consumers of health care, necessitating greater efforts for patient engagement.
With observable changes in care, services, and environment that clearly reflect their feedback,
patients are more likely to feel valued and remain loyal.
The use of the Press Ganey survey has been phased out in the UNC ED, and focus is shifting to
more sophisticated use of the Bivarus data to inform and monitor interventions.
Bivarus is also being adopted in other hospital departments, and a more holistic view of the
patient’s perspectives on their care at UNC may be available in the future.
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