Published in the July 2016 issue of Today’s Hospitalist
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IN 2014, THE HOSPITALISTS at Chicago’s Northwestern Memorial Hospital implemented the latest in a string of interventions, all designed to promote patient-centered care and improve patient satisfaction.
The hospitalists had used geographic rounding for years, along with daily interdisciplinary rounds held in a conference room. Their latest intervention was daily bedside rounds, with nurses rounding at the bedside with a hospitalist physician or advanced practice provider. The goal, as stated in a study published online last December in BMJ Quality & Safety, was “to engage, activate and improve patient satisfaction and experience.”
Except that it didn’t. According to patient interviews and surveys, both those done in-house as well as HCAHPS surveys completed post-discharge, patients in units with bedside rounds were no more likely to recommend the hospital or give it a top-box overall rating than the patients in a control group.
~ David J. Yu, MD, MBA Presbyterian Hospital
“We expected a positive result, which is why we studied this so rigorously,” says lead author Kevin J. O’Leary, MD, MS, chief of Northwestern Memorial’s hospital medicine division. “But no matter how we analyzed it, we just didn’t see much of an impact on patients.” The hospitalists have since gone back to a conference room to hold their interdisciplinary rounds.
The bedside rounds abandoned at Northwestern Memorial are a reminder of what hospitalists across the country have learned over the past several years: Improving patient satisfaction is hard to do. While hospitals scramble to remedy the parking problems and cold food that damage patient experience, clinicians are trying to re-tool something more amorphous: how they interact and communicate.
Some doctors grumble that all the training and role-playing they’re going through to improve their communication have nothing to do with quality of care. But proponents argue that better patient satisfaction is not only in patients’ best interests, but in the best interest of physicians as well.
Since satisfaction scores were first factored into Medicare reimbursement in 2012, some physicians have complained that the whole push behind patient satisfaction is just to “keep patients happy.” They argue that low scores may reflect physicians’ refusal to prescribe inappropriate medications or their raising uncomfortable topics like smoking or substance abuse.
Some doctors also rail against having nurses or clerical staff interview hospitalized patients about physicians’ performance, saying such practices can confuse patients. And they balk at using scripts or checklists during patient encounters, worried they’ll come across as more “Stepford” than genuine.
“Every patient is related to your neighbor, your nurse or your technician. We’re in the ideal setting to do this well.”
But some data suggest that doctors with better patient satisfaction scores also report higher professional satisfaction. And a growing body of evidence supports the use of satisfaction scores as a quality indicator. A study published in the June issue of JAMA Internal Medicine, for instance, found that higher CMS star ratings for hospitals were associated with fewer readmissions and lower mortality. Another study published in March in the Journal of Patient Experience linked higher star ratings to lower rates of some in-hospital complications.
As for concerns about using scripts or communication checklists, “I think scripting gives the impression that it’s robotic and uncaring, and it certainly could be,” says Jeffrey Petry, MD, MMM, system vice president and chief hospitalist officer at Premier Health in Dayton, Ohio, who oversees 90 doctors in four programs across five hospitals.
Despite those potential downsides, Premier Health hospitalists are trained to use the AIDET script (a communication framework that stands for Acknowledge, Introduce, Duration, Explanation and Thank you) in each patient encounter. As Dr. Petry sees it, relying on that format is not all that different from another standardized approach used by physicians everywhere: the history and physical.
“That’s a standardized script that every physician across the world does, and we spend hours understanding it,” Dr. Petry says. “This is a different script in which patients don’t remember necessarily what you said, but they’ll remember how you made them feel.”
This spring, St. Tammany Parish Hospital in Covington, La., received an outstanding patient experience award from HealthGrades, given to those hospitals that garnered the 15% highest overall patient experience scores. That’s no accident, says Patrick Torcson, MD, MMM, the medical director of the hospital medicine department, citing the hospital’s top-down commitment to patient experience.
Having a good doctor with excellent communication skills, is better than an excellent clinician with mediocre ones.”
~ Rachel Lovins, MD, Middlesex Hospital
Dr. Torcson also notes that it’s much easier to produce satisfied patients in community hospitals than in academic centers or urban safety net hospitals. He adds that working in Louisiana gives community hospitals there another edge.
“Everybody here is related, which I guess is a south Louisiana thing,” says Dr. Torcson, who’s on the board of directors of the Society of Hospital Medicine. “Every patient is related to your neighbor, your nurse or your technician. We’re in the ideal setting to do this well.”
Another fact of life in terms of medical care in Louisiana: Patients typically bring their entire families with them when they’re hospitalized. Like Dr. Petry’s group, Dr. Torcson and his colleagues rely on AIDET to frame their communication with patients, learning to acknowledge and introduce themselves to everyone in the room.
And to compensate for the fact that hospitalists are at a disadvantage with satisfaction scores because they don’t have long-term relationships with patients, Dr. Torcson says the hospitalists stress during the “Introduce” portion of each encounter their relationship with the physician who referred the patient.
“We’re very scrupulous about making sure we know who the patient’s PCP or specialist is who sent them to the hospital,” Dr. Torcson points out. “We drive all our introduction around that relationship, with ‘I’m here as his or her proxy while you’re in our hospital.’ ” He adds that the AIDET process is one that his group has scripted, role-played and discussed at every monthly meeting.
Talking up your credentials
At Premier Health in Ohio, Dr. Petry notes that his group has coupled peer coaching with its use of AIDET as a communication tool.
The program brought in physicians from the Studer Group, the company that created AIDET, to implement a “train-the-trainer” program. Dr. Petry, along with the site program directors and associate directors, then shadowed hospitalists in their patient encounters and offered feedback and advice.
One mistake too many doctors make, he says: not using the folding chairs at every bedside. “Sitting down really helps break down barriers, and patients feel like you’re taking your time.” But an even bigger problem for hospitalists is what Dr. Petry calls failing to “manage themselves up.”
“We train doctors, as part of their introduction, to say, ‘I’m board certified in family medicine, I’ve been practicing as a hospitalist for 10 years. You have pneumonia and I’ve treated hundreds of pneumonia cases, so you’re in good hands.’ But they struggle going through their personal credentials.”
Why? “They feel like they’re bragging,” Dr. Petry explains. “We tell physicians, ‘I know you’re uncomfortable with it, but the more you do it, the easier it will be.’ And really, it’s not about how uncomfortable the doctor is. What we’re focusing on is making the patient feel comfortable.”
Another layer of communication
At the 101-bed Baylor Scott & White Hospital, Round Rock in Round Rock, Texas, all new physicians and advanced practice providers attend a day-long interactive communication course, says hospitalist Trina Dorrah, MD, MPH, the regional medical director of quality improvement and the patient experience and the author of the book, “Physician’s Guide to Surviving CGCAHPS & HCAHPS.”
“Many hospitals now understand that having strong communication with patients and families is the foundation of a good patient experience,” Dr. Dorrah says.
She and her fellow hospitalists have also focused on key strategies to boost patient satisfaction and enhance communication. One is effectively incorporating the electronic health record into patient encounters.
“All the hospital rooms have a computer,” Dr. Dorrah says. “While we’re in the room, we can pull up X-rays and lab results and enter orders in real time. That really helps facilitate communication.”
The hospitalists have also hired a team nurse who provides an additional layer of communication for patients.
“We realized that one way to improve our patients’ perceptions of doctor communication is to have a consistent representative for our team, both during and following a hospitalization,” says Dr. Dorrah. The team nurse meets with all new hospitalist patients on day 1 or 2 of their hospitalization, giving them her business card and telling them to call her with any questions or concerns after discharge. “The team nurse provides continuity for patients by acting as the group’s point person as doctors rotate off service.
The patients, Dr. Dorrah says, really appreciate that. “They are happy to know that someone is available to help them with any issues after discharge, and complaints have essentially gone to zero.”
Checklists, on-site surveys
At Middlesex Hospital in Middletown, Conn., the hospitalist group is convinced that, “having a good doctor with excellent communication skills,” says Rachel Lovins, MD, section chief of hospital medicine, “is better than an excellent clinician with mediocre ones.”
The group has brought in a national expert to teach patient-interview skills to small groups of clinicians, and they have done their own internal communications training. But the results haven’t been overwhelming.
“It’s not like we haven’t had any success,” Dr. Lovins notes. “We just haven’t had the kind of success we feel we should have.” The hospital’s overall HCAHPS scores remain, she adds, in the mid to upper 80s, but “we want to be in the upper 90s.”
The hospitalist group’s own patient experience committee is now launching the group-wide use of a scripted discharge checklist. “We filmed two of the doctors using the checklist in a sim lab, and we’re going to share that video with the rest of the group,” says Dr. Lovins. The checklist helps physicians lead patients through a discussion of patients’ diagnosis, post-discharge plan and new medications, with teach-back used in each section.
She expects the checklist, which will be mandatory, to initially generate some resistance. “The physicians are worried about the time it will take, but when we did it in the sim lab, it took three minutes,” Dr. Lovins says. “It seems like a long time, but it’s not.”
This summer, the patient experience committee is launching another project: having a volunteer go to the floors and record patients on an iPad, asking them how they feel about their hospital experience and their communication with their provider.
Says group practice manager Alessandra Cornelio, who chairs that hospitalist committee, “Over the summer, we are aiming for about 60 surveys per provider, all done on day 2 of patients’ hospital stay. We’ll be selecting only patients who’ve had the same hospitalist two days in a row.” The goal is to give physicians daily feedback “and then a weekly score to see if they’re improving throughout the summer.”
While hospitalist leaders with Premier Health have coached their colleagues on better AIDET performance, Northwestern Memorial in Chicago has hired a dozen or so communication coaches, says Dr. O’Leary. The coaches began by shadowing a variety of professionals from technicians and environmental services to clinicians. They have since moved into communication coaching, focusing on nurses and techs new to the units.
“The coaches are just beginning to work with physicians, but we’re going to do that very carefully,” he points out. “We anticipate that some physicians are going to be very receptive, but others will be less so.”
In Albuquerque, the hospitalists who work on the Adult Inpatient Medicine Services at Presbyterian Hospital have also started receiving feedback from point-of-care surveys and coaching, and they plan to continue that process indefinitely.
“Problems occur if you send doctors to some kind of one-off ‘manners school’ or a one-day retreat,” says David J. Yu, MD, MBA, the group’s medical director. “You can’t make patient satisfaction a flavor of the month. It has to become part of the group culture.”
To get physician buy-in, he adds, you need to appeal to physicians’ self-interest. “We quoted them evidence-based research, which demonstrates that medical liability is greater when patients are dissatisfied and that clinical outcomes improve with better communication.”
Dr. Yu has also sold receiving feedback from internal patient surveys as part of doctors’ own professional development. “Training in better communication will develop you as a physician, and it’s a marketable skill,” he points out. “We consider it a benefit of working for Presbyterian: We’re giving our physicians tools, resources and skills that they will need in any job.”
To provide what Dr. Yu calls “individual, actionable data,” his group hired a secretary a year ago to survey patients on the floor, using a questionnaire developed by Utah’s Intermountain Healthcare and vetted by the CMS.
“We publish the individual physician data for the group to see,” says Dr. Yu. The group also trained individual coaches who meet with every new hospitalist and with “physicians who consistently score very low in patient surveys.”
Each coach shadows the physician and then offers tips such as sit down, or speak more slowly or don’t use so many technical terms. The twist in the Presbyterian program: The coaches are all hospitalists.
“They’re people who scored very high, so we asked if they’d be interested in coaching,” says Dr. Yu. “Some said yes and some said no.” Are coaches compensated for their time spent coaching? “Absolutely.”
As for results, “We’re still gaining traction” he says. “We told our administration that we’re not so worried about quick, front-end results, and we’re just now getting to the phase where we have enough data. We want to do it so that it’s sustainable.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Aggregate scores, individual doctors
HOW CAN HOSPITALIST programs assess individual doctors’ communication skills in a way that’s relevant?
According to Kevin J. O’Leary, MD, MS, chief of the hospital medicine division of Chicago’s Northwestern Memorial Hospital, his group has decided against attributing HCAHPS scores—good or bad— to individual discharging physicians.
Why? Because discharging doctors account for only one-third of all the physician encounters that hospitalists’ patients have, he points out, and “we’ve always felt like that’s not meaningful feedback.” Instead, his group now has a volunteer administering physician-specific patient satisfaction surveys on hospitalist units. “We’ve administered more than 340 surveys since February and just recently gave performance data back to individual physicians with a blinded comparison to the score distribution among their peers.”
For the 90 hospitalists within Ohio’s Premier Health, who cover five separate hospitals, their program does look at aggregate scores quarter by quarter. But it also breaks HCAHPS data down to the individual level by discharging doctor. That’s according to Jeffrey Petry, MD, MMM, system vice president and chief hospitalist officer.
Attributing scores to individual discharging physicians, Dr. Petry admits, is far from perfect. “Of course, it’s not pure because there are multiple consultants involved in the care of the patient.” And the HCAHPS questions related to doctor communication are framed as plurals: How often did doctors explain things in a way you could understand?
“That’s another argument that these scores are not valid or reliable” in terms of attributing scores to individuals, he says. “But everyone in the U.S. is being measured by this same yardstick, and we have hospitals around the country that are knocking it out of the park. So what are they doing with this perhaps imperfect yardstick that allows them to be successful?”
Premier Health’s quality bonuses for physicians are in part tied to patient satisfaction, but they are given as part of a group bonus based on aggregate scores. Dr. Petry says he supports using that incentive.
“Sometimes, I question whether tying incentives to this particular quality metric is that big of a motivator,” he says. “But data and logic indicate that the patient experience is going to provide better outcomes, better patient adherence to treatment and better standing in the marketplace with this national consumerism that will not go away. It’s really the right thing to do.”