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Giving HCAHPS its due

November 2014
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Published in the November 2014 issue of Today’s Hospitalist

IF THE Hospital Consumer Assessment of Healthcare Providers and Systems ” HCAHPS “went away tomorrow, I don’t think many hospitals, doctors or nurses would complain.

We’ve all heard the arguments against HCAHPS. All sorts of hospital variables can affect our scores, even when those variables are completely out of our control. Our scores as attendings, for instance, can go south if patients have a bad experience with a consultant during a hospital stay “or a coughing roommate, an unresponsive nurse or a 10-hour wait in the ED.

Then there are all the problems with attribution. When patients see two hospitalists during their hospital stay, who are they actually rating on their surveys?

How about patients who are unhappy if we don’t liberally prescribe pain meds? And if we prescribe opioids to relieve psychological distress, can we blame patients for wanting to turn around and come back to the hospital?

As a study in the March 12, 2012, Archives of Internal Medicine titled “The cost of satisfaction” stated, “patients often request discretionary services that are of little or no medical benefit, and physicians frequently accede to these requests, which is associated with higher patient satisfaction.” We are fully aware that unnecessary tests “as well as unneeded medications and inappropriate interventions “increase costs and the risk of patient harm.

The case for HCAHPS
Providers are understandably frustrated when their patient-experience scores don’t portray the entire picture of their encounters. Many people in health care think that only patient outcomes “not patient experience “should define quality.

But low scores may have much bigger consequences than just lost income under value-based purchasing. We know, for instance, that an inability to explain treatments clearly can affect not only patient satisfaction but quality of care.

Patients are less likely to adhere to a treatment plan when physicians do a poor job conveying information. And while some patient expectations may be unrealistic or even harmful, addressing expectations is an important component of the clinical experience.

How should we respond to this complex issue? If we are going to use the term “care” in medicine, it seems wrong to totally ignore the patient experience. Clearly, the answer is not frivolous orders. But I believe that if we as a profession were communicating more effectively, most of these arguments would subside. And many of us acknowledge that we have a lot of opportunity to improve.

A better experience
Once we accept that patient experience is important, the next step is improving it. There are plenty of skills we can learn to boost communication and satisfaction scores. Here are specific recommendations that we give doctors to enhance patients’ impression that physicians listen and care:

1. Knock before you enter a room. Ask if it is all right to come in.

2. Introduce yourself, and leave a card with the patient. A card with your picture helps patients connect a name with a face.

3. Explain what your role will be in their care.

4. Acknowledge visitors in the room. Ask who they are after you introduce yourself.

5. Sit down whenever possible. Standing does not save time, and it gives people the impression that you are in a hurry.

6. Use language that patients can easily understand. Medical jargon creates barriers to understanding.

7. Always explain what new medications and tests you are ordering.

8. Manage patients’ expectations: “In a few days, you will be healthy enough to leave the hospital, but you will probably feel fatigued for several weeks.”

9. After explaining the plan, always ask if there are any questions.

Check yourself
In addition to learning better communication skills, doctors may need to work on their own expectations.

Try tapping, for instance, into your own perceptions of when patients are being good vs. difficult. Do those differences have to do with whether or not patients and families agree with you? Do you perceive those who ask frequent questions as being high maintenance?

What other businesses push back on the voice of the customer? Here’s what the author of an opinion piece in the Aug. 29, 2013, New England Journal of Medicine had to say: “Culturally, we could benefit from a lens shift toward seeing more-vocal patients and families as actively engaged in their health care, presenting new, potentially important information, and expressing unmet care needs. At the systems level, we need to both count (using specially designated sections of the medical record) and reward (through diagnostic and billing codes) the time that providers spend talking to patients and families.”

A role for incentives
That last comment points to another problem: the time pressures we are under that limit communication.

Ordering is faster than conversation and, unfortunately, the system mostly rewards the fast, “productive” physician, not those who take extra time. At our hospital, we realized providers didn’t have skin in the game when it came to HCAHPS. We decided that all new and renewing physician contracts would have an HCAHPS incentive.

Just about all of us agree that health care needs further innovation to help grade the patient experience. While we are all waiting for that evolution to take place, being responsive to patients today is still a priority that won’t go away.

HCAHPS scores may influence outcomes. Hospitals and providers with top HCAHPS scores ultimately decrease their liability. And when patients trust and like you, they will follow your advice and be more compliant with medications and other treatments.

Gil Porat, MD, is chief medical officer for Penrose Hospital and St. Francis Medical Center in Colorado Springs, Colo. He ‘s also a practicing hospitalist. You can listen to Dr. Porat’s free “Hospital Medicine” podcast on iTunes.