Published in the May 2014 issue of Today’s Hospitalist
IT’S THE ACHILLES’ HEEL of hospital medicine: the prevalence of handoffs and the potential to omit key patient information. That threat is particularly acute as hospitalists end a block of service and transfer their patients to another physician just coming on.
“The first day of service is always the hardest,” points out Robert Bessler, MD, president and CEO of the Tacoma, Wash.-based Sound Physicians, a national hospitalist organization with more than 1,000 hospitalists and post-acute care providers.
“That’s because you’re learning the patients and having to develop the relationships, so you want your partner to have managed you up well.” There’s something else that often goes missing, according to Dr. Bessler: good feedback loops. “The health care industry is plagued by a lack of feedback mechanisms,” he says. He adds that many doctors have not received any feedback on their performance since they got grades in medical school.
~ Robert Bessler, MD
To improve handoffs and the quality of physician communication around them, Sound Physicians has built exactly that kind of feedback mechanism in the form of a handoff evaluation survey. The electronic tool “which is part of each practice’s SoundConnect software platform “has been rolled out to all of the company’s hospitalist groups.”To get reproducible performance, you need more than just good docs,” Dr. Bessler notes. “You need early, clear feedback so you know if you’re letting other team members down.”
Handoff surveys asking about the performance of individual physicians are completed not by chiefs or senior partners, but by the hospitalists who receive handoffs from those physicians.
“We don’t want doctors to be evaluated just by themselves and their chiefs,” says Dr. Bessler. “We also want peers to be giving feedback. That’s how we raise the bar for everybody.”
Some large Sound Physician practices use the survey tool for all team members if they sense that the quality of their signoffs may be slipping. But the handoff evaluation tool is particularly useful for new doctors just coming on board, particularly in larger practices. That’s according to Scott Sears, MD, the company’s chief clinical officer and the chief medical officer for Sound Physicians’ Northwest region.
“We tend to use the tool for a focused period of time and have colleagues evaluate a new physician after several service rotations so we can get a variety of feedback,” Dr. Sears says. While the survey tool is typically used to evaluate service handoffs, it can also be used to gauge the quality of handoff communication between night and day shifts, and vice versa.
On the survey form, hospitalists are asked to rate colleagues on the handoff they just received, using a 1-to-10 scale in eight different domains. Rated factors include the following:
- signout was complete and helpful;
- signout was communicated directly, either face-to-face or over the phone;
- notes were legible;
- problem lists were complete;
- there had been good communication with the family;
- the primary care physician was called;
- a complete discharge summary or off-service note was dictated, if appropriate; and
- the patient’s medical care was appropriate.When doctors give a colleague less than 8 in that last category, they are instructed to list specific examples.The advantage of using peer rankings, Dr. Bessler points out, is that the data produced are not anecdotal.”It’s not the chief having a review and saying, ‘Hey, I hear from your peers that your notes aren’t always legible,'” he says. “Instead, if the chief points out that you scored 7 out of 10 in one category and the group average in that category is 8.5, you know that’s an area for you to raise your game.”
Setting group standards
Physicians also take reviews done by their peers much more seriously, Dr. Bessler adds, than survey scores on physician communication reported by external vendors such as Press Ganey. With outside surveys, he explains, it’s very easy for doctors to question the quality of the data and push back on poor scores because it’s impossible to drill down and examine individual performance.
That’s not the case with the handoff evaluations. “This really helps point out people’s blind spots,” says Dr. Bessler. “It’s not seen or used as punishment, but to help build a better practice.” In Dr. Sears’ experience, new physicians typically fall short because they don’t regularly have face-to-face or phone conversations during handoffs.
“Often, doctors are coming from practices where that isn’t the standard,” says Dr. Sears. “Instead, the standard was, ‘I just leave really good notes in the EMR and I expect my partner to read them.’ But that doesn’t communicate all the nuances about the family or other factors that come across in a brief conversation in person or by phone.”
All new doctors have a formal evaluation after 120 days. If patterns of communication problems crop up via handoff surveys before then, the physician may meet earlier with the practice chief or senior partner to discuss those issues.
Typically, Dr. Sears says, doctors need no remedial training even when a problem is identified. “It’s a way to convey the communication expectations of our team, and people very quickly fall in line,” he explains. The chief or senior partner may offer tips or action items to help hospitalists better communicate during handoffs. And either the chief or senior partner may monitor the doctor’s signouts for a few more rotations to make sure the goals were accomplished.
“Once you know that people are providing feedback,” Dr. Sears explains, “you find out very quickly what the team standards are and you modify your behavior. That’s the power of this tool.”
Several feedback loops
The handoff evaluations are just one of several feedback mechanisms employed throughout Sound Physicians’ practices. Doctors do see, for instance, vendor data on patient satisfaction. And each practice surveys 20 nurses in each hospital every year about the performance of individual group members.
Consultants in each hospital also receive annual surveys on hospitalist performance, while partners within each practice are evaluated by partner colleagues.
And to improve patient experience in client hospitals, Sound Physicians now maintains a direct observation program in which every doctor is observed interacting with patients and given feedback. The observer may be a fellow physician, one of the practice nurses or a hospital employee.
“You can’t drive performance,” Dr. Bessler points out, “without people knowing how they’re doing.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.