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.
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.
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.
Prioritizing improved communication and using department-wide incentives makes it possible to create a culture that values patient communication.
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.
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.
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.
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.
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.
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.
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
- Report your institution’s current patient survey results (for hospitalists and non-hospitalists) to hospitalists in a relevant, timely, and transparent format.
- Prioritize patient communication as a goal for the hospitalist group. Consider including group performance in incentive metrics. Offer regular education and feedback.
- 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.
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.