Many organizations try to help physicians improve their patients’ experience through feedback delivered by non-physician personnel. At Scripps, we wanted to evaluate the impact of physician-to-physician feedback, because we believed that peer pressure could lead to greater receptiveness—particularly in a system with both employed and affiliate physicians such as ours.
Several competing factors have prompted hospitals, physician groups, and physicians to focus on improving their patient experience scores: the desire to at least maintain market share, the Centers for Medicare and Medicaid Services’ (CMS) Value-Based Purchasing program, quality recognition programs such as Leapfrog and Truven, and online star ratings of individual physicians, including patients’ public reporting of their experiences.
The CMS Value-Based Purchasing program earmarks 25% of metrics toward HCAPHS, forcing improvement in patient experience to the forefront of our efforts in order to mitigate substantial financial losses. At Scripps Health, we realized that for this fiscal year, which is based on data from 2 years ago, we left approximately $1.8 million on the table in the patient experience arena alone. With this recognition, I led our organization in launching several pilot studies to rapidly assess which strategies would sustain improvement in individual physician experience scores.
We recognized early in our initiatives that the value of physician-to-physician communication cannot be overemphasized. In particular, we found that conversations regarding statistical significance of the survey results, and the sometimes inherent resistance to change that is often encountered with new initiative rollout, were mitigated by having a physician meet directly with key physician group stakeholders. There is inherent credibility in a trusted physician colleague who has proven clinical strength.
We hypothesized that by focusing on simple, actionable tips and techniques, the physician coach could best address the challenge of motivating physicians to change their bedside practice. Our challenges included a mixed physician model—only 1,000 are foundation physicians, while 2,000 are independent — which brings inherent difficulties due to the inability to influence the independent physicians via metric-driven incentives. In addition, we encountered typical obstacles as those faced across the United States when discussing patient experience— resistance to accepting the data, often coupled with arguments such as clinical significance, flawed survey tools, and that their patients are more ill than those of their peers. However, given that a physician led this initiative, we were able to quickly address these concerns and move on to the actual work of improving individual and group MD patient experience scores.
We structured our intervention as follows: first and foremost, the implementation of individual MD-specific reports for our key service lines that would impact HCAHPS—general surgery, women’s health, orthopedics, cardiac surgery, and neurosurgery. Because our emergency departments and urgent care centers have high hospital admission rates, we also developed customized reports for these departments. Physicians have an inherent drive to be successful, so not surprisingly, once they saw their scores, many “self-corrected” and have come to the median with minimal changes in their practice patterns.
We focused on three easy actions to implement at the patient’s bedside—Knock, Sit, Ask:
- Knock on the patient’s door or curtain as a way to show respect for his or her privacy.
- Sit at the patient’s bedside. Research indicates that patients overestimate the time a physician spends with them by 15% if the physician sits, versus underestimating the time spent by 8% for the same conversation held in a standing position.
- Ask the question: What is your greatest concern? This serves to address the patient’s inner uncertainties that he or she may not otherwise express to the clinician. It demonstrates that the physician is indeed listening to the patient, considering that a patient’s concerns are often different than those of the treating physician.
Secondly, we implemented 1:1 physician coaching. We have found that physicians who reach out personally to ask for assistance have a markedly higher rate of improvement than those who undergo “forced coaching.” In the latter group, the division director informed poorly performing physicians that the physician coach would be contacting them for a shadowing visit. These physicians were not required to contact the physician coach directly, and the visit was entirely scheduled by the physician coach. As we recently reported, the physicians who had to purposefully ask for help have improved by an average of 56 percentile. However, two physicians in the “forced coaching” group actually dropped their scores, and the group itself only increased by an average of 7.6 percentile. It was evident from the first coaching encounter that these providers were not truly on board with the suggested changes in bedside approach—they did not immediately incorporate the tips reviewed with them prior to seeing patients.
In another pilot, we held entire staff sessions for an urgent care center struggling with patient experience scores in the 25th percentile. During these sessions, we shared key phrases to highlight the care delivered as well as patient population demographics. This included the percentage of patients who scored specific clinical questions along the Poor to Very Good spectrum. The urgent care team then reviewed their scores on a monthly basis and continued to utilize the key phrases taught to them during the interactive sessions. The next calendar year, the entire urgent care score increased to the 53rd percentile. Also, their physician scores improved from the 70th to the 90th percentile during the same time. This proves that team training is imperative to move department scores—focusing on only one group, such as nurses or physicians, at a time does not improve the rate of change rapidly enough.
We continue to build upon our success at Scripps by expanding the group training and individualized 1:1 coaching with our hospitalists, but we know that we have much more to accomplish. We learned how important it is for the clinician leading the initiatives to gain credibility of staff across all levels—at Scripps, having this clinically recognized physician has been vital to physician and staff buy-in. The best approach to improving personal physician scores involves engaging the weaker performers as much as the most motivated; there is always room for improvement, even among top performers. Because it is not scalable to have one physician do all coaching, the next step is to build upon the model we currently have in place by expanding it to involve other physicians who have improved their personal scores through this program. These physicians would then train to serve as individual physician coaches at their respective sites.
Special thanks to Chris Van Gorder, CEO and President of Scripps Health, and the Scripps Patient Experience Team: Vic Buzachero, Cara Williams, Stacie Calvin-Ryer, Joanna Harlan, and Sarah Cho.