The Value-Based Purchasing program now includes 25% of its value in patient experience based on patient perspective as gathered via the Healthcare Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS). Hospitals are under increased pressure to improve their scores or face substantial financial losses.
Transparent data sharing is critical to the success of any program.
Physician coaching skills are an essential qualification for the physician lead chosen to interact with physicians.
Engagement of medical directors who can reinforce training and review monthly scores on an ongoing basis is imperative.
Scripps Health hospitalists see up to 80% of our in-house patients and, therefore, our leadership team felt that it was imperative to focus on these physicians as a starting point for improving our HCAHPS scores. The physicians were initially targeted based on the results of prior pilot studies at Scripps that revealed success in improving physician-related patient experience results through both group training and individual physician-to-physician coaching. Furthermore, one of our initial pilot studies revealed that staff-related patient experience results improved after the results of physician improvement were shared with them. The importance of physician buy-in to improvement efforts was shown to have a positive effect on frontline staff engagement.
Our goal was to improve our hospitalist percentile rankings for certain HCAHPS scores. As this was a new initiative, we did not impose defined metrics to identify what success looked like. Voluntary medical director buy-in was also an important goal.
We have five hospital facilities with six separate hospitalist groups. The medical directors of each of the groups were contacted and asked to be actively involved in the change management process. The importance of physician-to-physician communication was recognized by our system Chief Executive Officer, Chris Van Gorder, and senior leadership team. I was selected to serve as the physician lead for these improvement efforts, in part because of my experience as an emergency medicine physician and in physician coaching. Emergency physicians interact with all specialties and, therefore, have a unique skill set in interacting with various personality types and data needs.
Having been in clinical practice for more than 20 years and being on the academic track on a national level, the clinical credibility was in place, so we had no resistance to training initiatives. The typical physician response to data not having statistical significance was quickly quelled with face-to-face meetings. We designed the physician lead role as a 0.8 FTE position with responsibility for staff training, strategic planning, monthly data distribution to our various physician specialists, physician communication, and to serve as liaison to the board of trustees.
At Scripps, we designed the program so that I, as the physician lead, would first meet with the medical directors, and we also gave the directors the option of inviting me to their monthly hospitalist staff meetings for group training sessions. Five of our six hospitalist groups decided to invite me to their department meetings to roll out the training initiative. One of the five hospitalist groups had such low scores that they asked for 1:1 physician-to-physician coaching on rounds in addition to the group training sessions.
Monthly hospitalist department scores were sent to all of the medical directors to share with their physicians, outlining not only the roll-up score of all the Physician Communication questions, but also the scores on the following questions, which constitute the physician overall communication score:
- How often did doctors explain in a way you could understand?
- How often did doctors treat you with courtesy and respect?
- How often did doctors listen carefully to you?
The scoring scale: never, sometimes, usually, and always. Our organization prides itself on transparency and, therefore, in addition to providing the medical directors with this information, we began to share the scores of all hospitalist groups with each other on a monthly basis. This not only helped to show differences in the scores and physician engagement, but it also created opportunities for open communication between groups about best practices.
Teaching sessions focused on three initial behavioral initiatives: Knock, Sit, Ask. Knocking on the door or curtain showed that our team respected the patient’s privacy. Sitting at the bedside was not just a sign that our physicians were listening carefully and not rushed; studies have shown that patients actually overestimate time spent at the bedside if the clinician is sitting. Asking the patient what their greatest concern for the day was also focused the physician’s attention on the patient’s needs and not on our medical agendas. I developed this Knock, Sit, Ask approach as an easy way for physicians to focus on some achievable yet critical behaviors that we had shown through previous pilot studies to be sustainable and impactful in improving patient experience scores.
Utilization of some key words and phrases — an important element of hospitalist-patient communication — was also reinforced. This included avoiding medical jargon to keep the patients informed about their tests and plan for the day. This benefits not only the hospitalists, but the other physician consultants caring for the patient, as well.
In speaking directly with our patients after rounding, the physician lead can discover common areas of concern. For example, we found that patients often did not know who was coordinating their care, particularly when multiple physicians were involved. We asked our hospitalists to let our patients know about the purpose of the hospitalist service, starting with the emergency department admitting hospitalist and continuing with other hospitalists to provide care when the patient is admitted to the floor.
We encouraged improvement of the handoff process by (1) having the signing-off hospitalist tell the patient who the oncoming physician was and reassure the patient that they would be in great hands, and (2) having the oncoming physician acknowledge the signing-off physician by name and reassure the patient that a discussion had taken place and that the new hospitalist would take good care of them.
The medical directors of hospitalist Groups A, B, and D regularly reviewed their HCAHPS scores at department meetings and reinforced the training tips. Hospitalist Group C asked for 1:1 physician-to-physician training in April 2017 as they started in the 3rd percentile and wanted to rapidly try to improve their scores. In addition, as physician lead, I attend department meetings on an every-other-month basis to review the data and reinforce the training tips and areas of improvement.
While Hospitalist Group F did hold one group training session, patient experience scores were not reviewed on an ongoing basis and I did not attend any ongoing meetings or email additional training tips. Hospitalist Group E asked for monthly scores of individual physicians based on the discharging physician but did not ask for an in-person meeting with the physician lead. However, training tips were shared via email as well as the monthly reports. Results were tracked over a 1-year period beginning in October 2016.
The team consisted of myself as the physician lead and individual physician coach, plus the individual hospitalist group medical directors. Ultimately, the team expanded to the hospitalists within each group, including approximately 16 to 20 physicians per group.
The different hospitalist groups saw varying results, and while group training was the same, it was the level of engagement of the group’s medical director that made a significant difference in results. This engagement was evident in the approach to the patient experience data sent to the medical directors on a monthly basis. This involved reviewing the data with the group either at the monthly department meetings or at minimum distributing the scores electronically, and a review of the teaching tips on an ongoing basis. As there is no current metric for tracking individual hospitalist physician improvement data, the level of engagement was gauged by the success of the entire group.
The figure above shows the starting point of our groups and the results after 1 year. Of note, the hospitalist groups with the most medical director–level engagement and passion for patient experience had the best results. Measuring the aggregate group hospitalist HCAHPS survey scores, we found that Hospitalist Group A went from the 31st percentile to the 70th percentile; Group B improved from 21st to 63th percentile; and Group D went from 15th to 31st percentile, despite significant physician turnover during the year. Group C began its training later than the others but improved from 3rd percentile to 25th percentile in just 6 months.
However, since we have started reporting this data on a monthly basis, groups E and F have asked for additional training support and for data based on the discharging physician so that they can try to improve on their scores. Scores for Group E, which did not engage the physician lead by inviting me to an in-person training session, remained in the bottom quartile during the study period, increasing only from the 15th percentile to the 18th.
Where to Start
- Identify a physician lead who has clinical credibility with physicians.
- Hardwire a monthly data reporting system.
- Identify medical directors who are interested in increasing their group HCAHPS scores to help drive and reinforce behavioral changes.
This study highlights the importance of ongoing and focused attention to data as well as the role of direct physician lead support and buy-in from hospitalist medical directors. The provision of practical and easy-to-implement tips as well as a focus on monthly individual physician-specific feedback reinforced that small behavioral changes can dramatically improve percentile rank. Indeed, after the 1-year study period covered here, Group E contacted the physician lead seeking engagement and training and has since improved their overall physician-related HCAHPS communication scores by 11 percentile units.
To sustain our improvement results, with the implementation of our new electronic medical record system we are able to identify our discharging hospitalists so that we can provide physician-specific data on a monthly basis. This attribution is important because the hospitalist who discharges patients represents the last opportunity for service recovery and to address any questions or concerns before the patient leaves the hospital. We are continuing with the monthly distribution data, as well, to continue to reinforce our organizational focus on patient experience.
The administrator who oversees all individual hospitalist groups has implemented an incentive program with 25% of the potential incentive based on patient experience scores. We hope that while money is not the key driver for physicians, the percent allocation of incentives focused on patient experience will highlight our ongoing commitment to further improvement in our physician communication.
Acknowledgements: The author would like to thank Chris Van Gorder, President and CEO of Scripps Health, San Diego, Richard Sheridan, and Jeff Batres for their incredible support and dedication.