Care Redesign
Relentless Reinvention

How We Improved Hospitalist-Patient Communication

Case Study · February 5, 2017

Low HCAHPS scores triggered changes in how hospitalists at Rush University Medical Center communicate with patients. Interventions — including physician “facecards,” a checklist, targeted feedback, and financial incentives — have improved scores and can be adopted by other hospitalist programs. The hospitalists’ rate of improvement in patient communication exceeded that of other physicians at Rush.

Key Takeaways

  1. Tools to improve doctor-patient communication — checklists, physician “facecards,” white boards — are most useful when they are part of a concerted and sustained improvement effort.

  2. Physicians value targeted individual feedback based on in-person observation and patient interviews as a measure of patient-centered care more than they value HCAHPS scores.

  3. Prioritizing improved communication and using department-wide incentives makes it possible to create a culture that values patient communication.

The Challenge

Hospitalists, who take care of the bulk of hospitalized patients across the country, face unique challenges in rapidly establishing trust and rapport with acutely ill patients. Many of these patients arrive via the emergency department and are confused by the numerous medical personnel they encounter — a problem that may be amplified in academic settings by the presence of trainees. This confusion may be one reason for hospitalists’ relatively low patient experience scores on the Hospital Consumer Assessment of Health­care Providers and Systems (HCAHPS) survey, which is a focal point now that hospitals may face financial penalties for low scores.

In 2008, HCAHPS communication scores for our hospitalists hovered around the seventh national percentile. We were frustrated by low scores for what we believed was good care at our hospital. There was a growing awareness among our hospitalists that satisfied patients are more likely to adhere to treatment, and a desire to provide patient-centered care drove an effort to improve hospitalist-patient communication.

The Goal

Our goal was to create processes that would engender and sustain a hospitalist culture that prioritizes the patient perspective and experience. We hypothesized that improving hospitalist-patient communication would have a strong impact on patients’ overall evaluation of care provided. To that end, we introduced several innovations to improve patient and team communication.

The Execution

Efforts to improve hospitalist-patient communication began in 2007. This laid the groundwork for a more focused initiative in 2013 when leadership of the Division of Hospital Medicine made communication a group priority. Key initiatives included:

  • Hospitalist “facecards”: We created two-sided, 4”x 6” business cards for each hospitalist, which included a photograph, description of the hospitalist role, and contact information. These were to be handed to each patient to initiate conversation about the hospitalist’s role and his or her responsibility around care coordination.
  • Best practices checklist: A checklist (see table below), based on existing literature, was created in 2008 and updated in 2013. Various iterations — from full-length to much abbreviated forms — have been distributed to hospitalists. Even the shortest checklists mandate use of facecards, in-room white boards for two-way communication, and daily afternoon rounds to update patients on care plans and results.
  • Feedback on communication style: At first, hospitalists were observed in simulated settings and received feedback. This has been replaced by observation in clinical settings by psychologists who provide private one-on-one feedback to the hospitalists. Checklist use initially was monitored by medical student observers who were assigned to shadow hospitalists. We have since sought feedback via bedside interviews, in which patients are asked (by health systems management and medical students) whether they know the name of their physician and recall receiving a facecard, how they would rate their care from their physician, and how their physician could improve. This direct patient input is routed back to the individual hospitalist. These interventions allow feedback that is more targeted and robust than possible with quarterly HCAHPS provider reports.
  • A culture of transparency and collaboration: Within the hospitalist group, individual HCAHPS scores, bedside interview feedback, and checklist utilization were shared and reviewed monthly at division meetings.
  • Incentives: Starting in 2013, a percentage of the group’s incentive bonus was dedicated to achieving a group HCAHPS metric.
  • Education: The hospitalist group participated in annual educational sessions that focused on effective communication, introduction of our best practices checklist, and information regarding the HCAHPS survey. Residents attended similar sessions. We worked with one of our well-respected, highly proficient hospitalists to create a brief video to share her patient communication practices with other physicians. Other consistently high-performing providers offered educational seminars and input about practices they felt made them successful.
  • Benchmarking: To put our group’s performance in context, we began collecting data from other academic hospitalist programs to create a hospitalist-specific database of HCAHPS scores.
Rush University Medical Center's Best Practices Checklist for Hospitalists

Rush Best Practices Checklist for Hospitalists. Click To Enlarge.

While many of these interventions are well-known as best practices within hospital medicine, the repeated efforts and updating over time reinforced support among our hospitalists. Physicians may be skeptical of HCAHPS data, but we found that direct observation and data about individual physician performance fostered a desire to improve.

The Team

Division of Hospital Medicine leadership; clinical psychologists who specialize in physician communication; senior director of marketing research, specializing in patient survey analysis; medical and health system management students.

Metrics

Our Doctor Communication scores for hospitalists demonstrated an improvement of 59 national percentile points (seventh to 66th national CMS percentile) since 2008 (see figure). Improvements over time have also been seen in the hospitalist patients’ overall rating of the hospital (from 67.8% patients who would “rate the hospital a 9 or 10” in 2008 to 76.9% in 2015).

A focus on hospitalists helped Rush’s physicians overall to achieve a domain score for Doctor Communication above the 50th national percentile in recent years, which enabled the hospital to avoid a penalty in the CMS Hospital Value-Based Purchasing program. The ongoing improvement of hospitalists helps bolster the overall hospital performance in this domain, adding to payments.

Improvement in Doctor-Patient Communication: HCAHPS Scores for Rush Hospitalists and Non-Hospitalists

HCAHPS Scores for Rush Hospitalists and Non-Hospitalists. Click To Enlarge.

The rate of improvement in Doctor Communication for Rush hospitalists has improved faster than for non-hospitalists. Between July 2008 and June 2014, the rate of increase in the Doctor Communication domains score rose 14.0% for the hospitalist (71.9 to 82.0 “always”) compared to an increase of 7.3% for non-hospitalists (79.1 to 84.9 “always”).

Of the five academic institutions that shared hospitalist HCAHPS data (all of which showed higher satisfaction among patients of non-hospitalists than hospitalists), our program performed well relative to the other four sites.

HCAHPS hospitalist scores for communication dropped dramatically for a few months in 2014. This was concurrent with unprecedented 100% occupancy. Scores in 2015 rebounded and exceeded prior levels. We are assessing how a high census may affect doctor-patient communication.

Where to Start 

  1. Report your institution’s current patient survey results (for hospitalists and non-hospitalists) to hospitalists in a relevant, timely, and transparent format.
  2. Prioritize patient communication as a goal for the hospitalist group. Consider including group performance in incentive metrics. Offer regular education and feedback.
  3. Develop internally validated best practices for hospitalists (including use of facecards, whiteboards, and rounding protocols) to enhance communication and provide timely and transparent feedback about compliance.

Next Steps

Future directions include: 1) using and expanding the hospitalist-specific HCAHPS database to create a more robust benchmarking tool for academic hospitalist programs; 2) standardizing a joint physician-nurse bedside rounding protocol; and 3) conducting a Lean process improvement study to better identify drivers for variations in scores over time.

This ongoing effort is one of continuous improvement, until the performance gap between hospitalists and non-hospitalist colleagues closes completely.

 

Thanks to Irwin Press, PhD; Amir Jaffer, MD; Jisu Kim, MD; Margaret McLaughlin, MD; Jamie Cvengros, PhD, CBSM; Kathryn Bogey; Phil Shaw; Lindsey Manning; Sarah Jouras; Catherine Johnson; Anne Burgeson; Alita Tucker; and Xiang Liu.

This case study originally appeared in NEJM Catalyst on April 6, 2016.

New Call for Submissions ­to NEJM Catalyst

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Relentless Reinvention

Coverage Expansion and Delivery System Reform in the Safety Net: Two Sides of the Same Coin

Safety-net health system transformation is threatened by recent health reform proposals that erode coverage gains.

Relentless Reinvention

Building Baltimore’s Accountable Health Community

The Baltimore City Health Department is tackling health disparities by taking a city-wide approach to addressing patients’ social needs.

Relentless Reinvention

Leading Quality in Changing Times

Leaders prove their worth during times of uncertainty.

Relentless Reinvention

Adopting Innovations in Care Delivery — The Case of Shared Medical Appointments

Given the effectiveness of group interventions, why aren’t doctors routinely using them to treat physical and mental conditions?

Relentless Reinvention

“Being the Best at Getting Better” — Creating a Culture of Change

How Cincinnati Children’s Hospital Medical Center built a culture focused on broad-based change that is transformational for children and their families.

Relentless Reinvention

Rural Health Care: Thirty Miles at Sea — Providing Consistent Care in an Inconsistent Environment

How one of the smallest hospitals in Massachusetts addresses the needs of its unique population.

Relentless Reinvention

Lessons from Oregon in Embracing Complexity in End-of-Life Care

Persons with chronic progressive medical illness require more care in the ICU and more hospitalizations, and often receive late or no referrals to hospice care. These utilization patterns are strikingly different in Oregon.

Relentless Reinvention

The Move to Value-Based Care in Navy Medicine

Achieving the mission of Navy Medicine to “keep the Navy and Marine Corps family ready, healthy, and on the job” requires rethinking current health care delivery models.

Relentless Reinvention

Improving Access to Specialist Expertise via eConsult in a Safety-Net Health System

Electronic referral system supports communication between primary care and specialty providers.

Relentless Reinvention

Redesigning the Delivery of Specialty Care Within Newly Formed Hospital Networks

As the trend toward hospital mergers and consolidations continues, how can newly formed health care networks optimize their delivery of specialty care? They will need to consider a redesign of service lines that includes both centralizing and decentralizing strategies.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Care Integration

50 Articles

The Danger and Opportunity of Leading…

Rising from department chair to Dean, President, and CEO: lessons from Jeff Balser.

Primary Care

109 Articles

Reading List: Rushika Fernandopulle

NEJM Catalyst Thought Leader Rushika Fernandopulle weighs in on the most influential and inspiring texts…

Treating Low-Income Individuals Is Our Obligation

The CEO of NewYork-Presbyterian discusses the policies, interventions, and perspectives required for making sure low-income…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now