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Chairs and whiteboards

April 2014

Published in the April 2014 issue of Today’s Hospitalist

THINGS WEREN’T GOING SO WELL for my hospital when I last left you in my February column. There was lots of handwringing over our dismal HCAHPS scores for physician communication.

Unfortunately, new data still have us on the wrong side of the bell curve. Apparently, a tincture of time doesn’t heal, at least for this illness.

The HCAHPS survey, as you recall, contains three questions specific to physicians: During this hospital stay, how often did doctors treat you with courtesy and respect, listen carefully to you, and explain things in a way you could understand?

The latest publicly reported data come from patients discharged between April 2012 and March 2013, which in hospital medicine time is several partners ago. Our doctor communication score this time was 78%. We still lag the Minnesota average (83%) and remain at the 25th percentile nationally. Still, 79% of patients indicated they would “definitely recommend” our hospital to others. This exceeds our competitors’ scores and falls somewhere between the 75th and 90th percentile for that category.

Our administration put together a small work group to discuss ways to improve physician communication. Any countermeasure had to be simple, inexpensive and evidence-based.

If you’ve ever done quality improvement work, you’ll recognize that these are remarkable constraints. Evidence-based is a given, but what occurs in hospitals is never simple or inexpensive.

After relatively little deliberation, we staked our future on two countermeasures: chairs and whiteboards.

Take a seat
We have all heard that we should sit down for patient encounters. But is there any evidence that patients see us differently when we sit instead of stand?

Investigators at the University of Kansas put that conventional wisdom to the test. They had two a priori hypotheses, which were outlined in an article in the February 2012 issue of Patient Education & Counseling. The first was that patients would perceive that physicians spent more time with them than they actually did if doctors sat during rounds instead of standing. The second was that physicians sitting down would actually spend more time at the bedside.

For the study, a research nurse randomly directed physicians to either sit or stand before they entered the patient’s room. The nurse stayed in the hallway and timed the duration of the encounter with a stopwatch. After the physician exited, the nurse interviewed patients using a standardized protocol, asking them to estimate how much time the physician had spent with them. Nurses also asked, “What did you think about the interaction with Dr. X?”

Patient encounters, which were performed by surgeons, were crazy quick: Sitting encounters averaged 1 minute and 4 seconds, while standing visits lasted 1 minute and 28 seconds, with no statistical difference between the two. Patients, however, perceived things much differently. They felt that sitting encounters lasted 5 minutes and 14 seconds and that standing visits were 3 minutes and 44 seconds. That difference was statistically significant.

P values count for something, but effect size ” whether the difference is clinically meaningful “is the name of the game. Ninety-five percent of patients in the sitting group gave positive feedback about their physician, with comments like, “The doctor took the time to sit and listen.”

On the flip side, only 61% of patients in the standing group offered positive feedback. Negative comments included, “He was in and out of my room before I even knew what was going on.”

Note that physician behavior didn’t change. (These were surgeons, after all.) Contrary to the authors’ hypothesis, having doctors sit did not lead to objectively longer encounters. But sitting did effectively warp time and shape perceptions. And patients’ perceptions, at least from an HCAHPS standpoint, are reality.

Writing on the wall
Patients find hospitals absolutely bewildering. While many patients are off their cognitive game due to illness and medications, we throw lots of complex information at them (often while standing!). Then we wonder why our communication scores suffer.

Investigators at the Medical College of Wisconsin found a possible solution at OfficeMax. Their work, published in the March/April 2011 issue of the American Journal of Medical Quality, involved installing whiteboards (dry-erase boards) in hospital rooms facing patients’ beds.

Various parts of the board were labeled as follows: physician, goals, testing, questions, top three concerns and home (for discharge date). Clinicians, patients and families were all encouraged to use the boards, and plenty of markers were available on the wards.

Four general medicine wards received whiteboards, the active intervention, while seven surgical wards served as controls. Press Ganey scores served as the study’s outcome measures.

Researchers’ questions focused on doctor communication, nurse communication and shared decision-making, with two unrelated questions “food quality and room temperature “as controls. This design feature was important, as changes in patient satisfaction could have been part of a larger trend not linked to whiteboards.

Patient satisfaction scores increased across the board (pun intended) on the medicine wards. Doctor communication, nurse communication and shared decision-making scores increased by 4, 6.4 and 6.3 points respectively on a 0-to-100 point scale: statistically significant results. Those upward ticks reversed the hospital’s 18-month slide in all three categories.

Scores from the surgical wards without whiteboards remained flat. Ditto for food quality and room temperature.

Changes ranging from 4% to 6% seem pretty small. But remember: Data are transformed into percentiles. My hospital’s HCAHPS doctor communication score lags the national average by only 3%. But this amounts to an entire quartile on a percentile basis.

With these data in hand, our hospital is going to give these measures a whirl. Most rooms already have chairs, which are often in use by family. The trick will be getting providers to sit on the end of the bed or finding some portable seating solution. I’m half-seriously considering a seat cane, which would also come in handy at my kids’ baseball and soccer games.

Whiteboards run about $45 for the three-by-two foot version the investigators in Wisconsin used. That’s just a single 99231 in Medicare money, plus the continuing cost for dry-erase markers.

Like everything else in hospital medicine, the key will be relentless messaging and hardwiring. I’ll let you know how we do.

David Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family and addiction medicine. You can learn more about him and his work at www.davidfrenz.com or via LinkedIn.