Published in the December 2008 issue of Today’s Hospitalist
It’s a scenario that’s all too familiar to hospitalists: A patient is admitted after languishing in the ED for hours, and he and his family are in a foul mood. While you do your best to turn the situation around, the patient still gives the hospital a negative rating on his patient satisfaction form. And because you’re the physician of record, the patient’s bad score falls squarely on your shoulders.
As health care payers everywhere turn to satisfaction scores as a proxy of quality, hospitalists are feeling stuck between a rock and a hard place. Published data show that satisfaction scores from patients who arrive at the hospital through the emergency room average 20% lower than for patients who come in electively, according to Amanda Wilson, MD, medical director of Mercy Internal Medicine Service, a hospitalist group that serves Mercy Medical Center in Springfield, Mass.
Those types of problems are attracting attention from the leaders of the specialty. In a white paper on the topic released this summer, The Phoenix Group concluded that the tools to measure hospitalists’ role in patient satisfaction are “far less than adequate.” The group, which calls itself an “action-oriented think tank” and includes representatives from most of the largest hospitalist groups in the country, also concluded that survey results can lead to “inferences or accusations of unacceptable performance, leaving the hospitalist feeling prodded, defensive and disenfranchised.”
While hospitalists may feel like there’s a disconnect between satisfaction scores and actual performance, experts say it’s no time for physicians to sit on the sidelines and pout. That’s because as imperfect as patient satisfaction scoring may be, it’s a measurement “and potential marketing tool “that hospitals are taking very seriously.
Going public
Medicare is a good example of the clout that payers are giving patient satisfaction scores. Since March 2008, hospitals that have been reporting their scores on a standardized patient satisfaction survey to the Centers for Medicare and Medicaid Services (CMS) have seen those data published online on the Hospital Compare Web site. Hospitals that don’t voluntarily participate in the public reporting initiative don’t receive their full Medicare reimbursement.
Perhaps even more hospital administrators are scrutinizing those scores to see how they stack up against their competition. And they’re increasingly passing along their concerns to physicians.
IN Compass Health, a national hospitalist management company based in Alpharetta, Ga., has seen a growing number of hospitals include patient satisfaction targets that hospitalists must hit. If the physicians don’t meet those goals, explains Robert Harrington Jr., MD, vice president of medical affairs for IN Compass, they risk losing a portion of the financial support that the hospital provides.
IN Compass is far from alone. Roughly half of the hospitalists interviewed for this article say some portion of their bonus is being linked to patient satisfaction scores.
“A lot of pressure is coming from hospital boards, which in many cases are made up of lay people,” Dr. Harrington says. “They don’t always understand the Joint Commission core measures, but they sure understand what customer service is because that’s how they’ve been successful in business.”
What improves scores?
What can hospitalists do to improve their patient satisfaction scores “and their ranking with hospital executives? Physicians say that sometimes, improving satisfaction can be as simple as helping patients understand what a hospitalist is and attaching a name to a face.
With all of the people entering a patient’s room, it can be easy to mix up doctors, nurses and other caregivers when surveys are being filled out after discharge. And one bad interaction can taint an entire survey. Mike Hawkins, MD, regional medical director for the Southeast region of Cogent Healthcare, a national hospitalist company based in Brentwood, Tenn., says his group’s physicians take the tried and true approach of distributing pamphlets to explain the hospitalist model of care to patients and their families. The pamphlets include photos of hospitalists so patients can more easily identify the doctors they’ve seen.
Communication and active listening are vital to a good patient experience (and a good score), experts say. “If you spend five minutes with a patient and you’re standing in the doorway backing up while talking, your patient satisfaction is going to be in the gutter,” Dr. Hawkins says. “If you spend that same five minutes sitting, nodding and actively listening, although you really didn’t spend any more time, their perception is that you did. Your satisfaction rates are going to be higher.”
A “showroom” approach
The same factors that make up a meaningful patient encounter will also benefit satisfaction scores, Dr. Hawkins adds. He suggests that hospitalists prepare for a patient visit by familiarizing themselves with lab results and X-rays; communicate in laypersons’ terms that the patient can understand; appear presentable and sit down with the patient during every visit; focus on relationships with the patient, family members and other hospital staff; and manage patient expectations, which can sometimes be unrealistic.
At IN Compass, Dr. Harrington says, the company suggests that its physicians use a pre-written explanation for patients who might not be familiar with the hospitalist concept. He has also developed a mnemonic device physicians can use to remind themselves of the key elements of a successful patient encounter, “PCARE,” which stands for preparation, communication, appearance, relationship and expectations.
And he encourages doctors to use what he calls the “automobile showroom” approach to satisfaction surveys. Before a patient is discharged, says Dr. Harrington, the doctor should explain that the patient may be asked to fill out a satisfaction survey.
Doctors should not be afraid to come right out and ask for an excellent score if the patient was satisfied, he says. If a patient expresses dissatisfaction, the doctor should ask whether there’s anything that would help improve the experience and remedy the situation if possible.
Smoothing out transitions
In her role as director of the hospitalist service at Mercy Medical Center, Dr. Wilson has seen patient satisfaction scores take on an increasingly high profile. Mercy is one of 32 hospitals that make up Catholic Health East, a not-for-profit hospital system on the East Coast that ranks its hospitals on satisfaction scores. Within the past six months, Dr. Wilson’s team has seen its scores rise from near the bottom within the system to near the top.
To start, the hospitalists give patients a detailed, photo-filled brochure identifying the physicians in the group. The goal is to help patients recognize which physician is treating them and explain that patients might see another hospitalist on the team during their stay. The group is also strategically placing chairs at every bedside, so physicians can sit down beside the patient. Physicians are also encouraged to honor the patient’s privacy.
“As we draw the curtain or close the door,” Dr. Wilson says, “I’ll say I’m closing the door just so they know I’m honoring their privacy.” She also tells hospitalists to explain everything they are doing to the patient, as well as what they discover during exams.
Other groups are instituting follow-up calls to patients to make sure the transition home is smooth. “We conduct a ‘transition of care’ call to patients following discharge,” says Kristi Frantz, program director for Sound Inpatient Physicians, a hospitalist company that serves 30 hospitals in the western U.S.
Those calls, which are made from Sound Inpatient’s call center, also “provide an opportunity to ask satisfaction questions specific to hospitalists,” Ms. Franz adds. The company passes that feedback on to physicians, which helps improve scores.
Spearheading broader efforts
At some facilities, hospitalists are using their unique position to lead broader hospital efforts to improve satisfaction. At Mercy Medical Center, for instance, Dr. Wilson is collaborating with nursing on a multidisciplinary team to address specific satisfaction problems like pain management and noise levels. If a nurse feels that a patient’s pain is not being controlled within a certain period of time, she can call a designated pain team “which includes a hospitalist “and the team visits the patient to devise a new plan on the spot.
The hospital has also created a noise management team to provide a more restful environment for patients. Signs are placed strategically around nurses’ stations, which change color when the noise volume rises too high. Other signs around the hospital remind visitors to keep noise levels down.
The Mercy hospitalist group is also developing an inpatient and outpatient concierge service. On the outpatient side, the group plans to provide outreach to primary care physicians and outpatient services through monthly lunches. For inpatients, the service will provide a designated person from the hospitalist group to reach out and help them or family members with needs that may fall outside the realm of direct clinical care.
An impact on compensation
As government and commercial insurers seek to link payment to quality indicators, patient satisfaction is also entering the compensation mix. Some hospitalists are seeing a portion of their bonus payments tied directly to their scores.
Many hospitalists find the idea of linking their pay to satisfaction scores troubling because the surveys used by many hospitals don’t ask patients to identify specific physicians.
“I could have a surgeon working with me who is not that personable,” Dr. Wilson says, “but if the patients say they didn’t have the physician explain things to them, it doesn’t say which one.”
Because hospital-wide surveys can produce such fuzzy results, some hospitalist groups have taken a do-it-yourself approach and devised satisfaction surveys that apply only to their doctors.
The 13-physician hospitalist group at Spartanburg Regional Medical Center in Spartanburg, S.C., has created a survey that asks patients to circle the name of the physician who was in charge of their care. It then asks four questions about the physician’s communication, bedside manner, clarity of instructions and the patient’s overall experience. Patients can rate the physician on a scale from excellent to very poor, and there’s room for comments.
Hospitalists’ scores on these surveys, which are tallied up quarterly, account for roughly 14% of their individual bonuses, says Robert Haddad, MD, a hospitalist at Spartanburg. To receive 100% of the bonus related to patient satisfaction, hospitalists must receive an average score of 88% or higher.
Customer satisfaction
Dr. Haddad says he supports the idea of linking bonuses to satisfaction scores, but he acknowledges that doctors sometimes complain that scores can reflect patient confusion more than anything. His response?
“It’s our job to make sure we communicate to the patient who we are and what number of physicians each patient is seeing.”
In the first three quarters of 2008, the satisfaction level for Spartanburg’s hospitalists averaged 88.3%, up from 82.2% in 2006, says Nancy O. Garrett, CPCS, the director of hospital-based physician services at Spartanburg Regional. During the past quarter, five out of 10 hospitalists received 100% of the portion of the bonus that reflected satisfaction, and the rest received 75% of that part of the bonus, she says.
The hospitalists’ experience at Spartanburg may be a glimpse of the specialty’s future. Leaders in the field say that despite flaws in the current survey system, hospitalists need to provide leadership and work with hospital administrators on satisfaction issues.
“We’re going to have to take a more customer-service approach to patient care and realize that it’s not doctors anymore who have patients,” says Cogent’s Dr. Hawkins. “Patients have doctors, and they’re going to vote with their feet.”
Barbara Kirchheimer is a freelance health care writer based in Highland Park, Ill.
What patients have to say about hospitalization
SINCE MARCH OF THIS YEAR, the results of a standardized patient satisfaction survey have been posted on the Hospital Compare Web site. The survey, which consists of 27 questions, asks discharged patients only three questions about their physicians during their hospital stay, giving patients four different ranking options, from “never” to “always.”
Here are the three questions patients are asked:
How often did doctors treat you with courtesy and respect?
How often did doctors explain things in a way that you could understand?
How often did doctors listen carefully to you?
Source: CAHPS Hospital Survey
