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Listen to the Patient

From: The Hospitalist, July 2008

It should matter to hospitalists what those in their care think

by Larry Wellikson, MD, FHM

Larry Wellikson, MD

As the healthcare system struggles with the definition of quality and the implementation of patient-centered care, renewed attention is being given to patient satisfaction.

Now, this performance measure has moved from the hospital’s marketing department into the C-suite, where senior administrators at some hospitals have patient satisfaction scores tied to their compensation.

Pressure is being applied to nudge key hospital care providers, including hospitalists, to keep their patients happy while giving them the care they deserve.

With the recent publishing of the Hospital Consumer Assessment of Healthcare providers and Systems (HCAHPS) scorecards for each hospital on the Hospital Compare Web site (www.hospitalcompare.hhs.gov), patients can see and compare local hospitals.

Because hospitalists are managing an ever-increasing portion of the hospital census, we can count on being right in the middle of all this. Coupled with the fact that 40% of hospitalists are directly employed by their hospital and a significant portion of other hospitalist groups have contracts with hospitals tied to quality improvement, we can expect a lot of pressure to not only improve patient satisfaction, but to make the “numbers” look better.

More often than not, hospitalists admit patients who are acutely ill, presenting through the ED. It is well known that patients admitted electively are more satisfied than those with an acute illness who come through the ED.

What Survey Measures

An important starting point for hospitalists and especially their leaders, who will be engaged in conversations with the C-suite about patient satisfaction data, is to better understand what the data indicate.

First, you need to know that the patient questionnaires were designed by several large vendors, the largest being Press Ganey.

While it is possible to segment the patients by those treated by a hospitalist and those not, the questions were not meant to describe, define, or compare the performance of different physicians. Remember, non-hospitalists for this purpose includes not only internists, but also surgeons, obstetricians, and other specialists.

Some questions on the survey about physicians include:

  • During this hospital stay, how often did doctors treat you with respect? (never, sometimes, usually, always);
  • During this hospital stay, how often did doctors explain things in a way you could understand? and
  • During this hospital stay, how often did doctors listen carefully to you?

Other questions that might pertain to care directed by hospitalists but also relate to the entire care team include:

  • How often was your pain controlled?
  • Before giving you a new medicine, how often did staff tell you what it was for? and
  • Before giving you a new medicine, how often did staff describe possible side effects in a way you could understand?

While you might aggregate all the replies specifically about the doctors’ performance and grade all the doctors separately, the all-important questions to the C-suite are the last two sections:

  • How do patients rate the hospital? and
  • Would patients recommend the hospital to friends and family?

Patients Are Different

It is important to understand the unique characteristics of the patients admitted and managed by hospitalists and to understand how these patients may respond differently to the standard patient satisfaction surveys than others in the patient population.

More often than not, hospitalists admit patients who are acutely ill, presenting through the emergency department (ED) with medical problems. Some studies have estimated that more than 70% of hospitalists’ patients come through the ED, while for the rest of the staff it is closer to 30% to 40%.

It is well known that patients admitted electively are more satisfied than those with an acute illness who come through the ED. In addition, patients admitted for medical problems have lower satisfaction ratings than those admitted for general surgery, subspecialty surgery, or obstetrics.

Therefore, if your hospital administration has pulled together statistics that purport to compare patient satisfaction for your hospitalist group versus all other admissions, you need to make sure that comparisons are made to a similar population, i.e., acutely ill patients admitted through the ED with medical diagnoses. The survey companies should be able to produce just such a comparison.

It is equally as important to make sure you focus on the total experience at the hospital and not just the questions specifically concerning only the doctors. Since hospitalists not only do front-line, face-to-face patient care, but also work with the team and attempt to improve the system to provide better overall quality, make sure to focus on questions like “How do patients rate the hospital?” and “Would patients recommend the hospital to friends and family?”

The other consideration is to understand how close the top quartile is to the bottom quartile, when comparisons are made with this data. In many of these surveys the patients are giving ratings on a scale of one to four, with many of the responses at three or four. Therefore, the top score might be a 3.6 and the bottom score average 3.2. It is important to understand if you are just minor adjustments away from being in a good range or if you are either so far above or below the standard of care that a real situation exists.

HM’s Role

Does the hospitalist model lead to better patient satisfaction? Like most things in hospital medicine, the answer is yes, no, and maybe. There are certain aspects of hospital medicine that should lead to happier patients:

  • Present and easily available;
  • Expert in hospital care;
  • Improved coordination of care by specialists;
  • Availability for multiple visits if patient condition changes;
  • Availability to visit with loved-ones at their convenience; and
  • Rapid response to nurse’s concerns.

There are aspects of getting your care from a hospitalist that may initially make the patient more concerned:

  • They may be unfamiliar with the hospitalist and the hospitalist model;
  • The hospitalist may demonstrate little or no knowledge of the patient’s history;
  • The referring physician may not introduce the patient to the hospitalist; and
  • The hospitalist may not explain the relationship with the referring physician.

How to Be Proactive

With all we have to do every day (and the list seems to get longer by the minute), it is easy to get perplexed by having to be responsible for the patients’ satisfaction with their hospital experience. That being said, hospitalists perform well when we step up to the plate and take action in these ways:

  • Proactively meet with the person in the C-suite who oversees the patient satisfaction survey process or relates to the hospitalist group (e.g., vice president of medical affairs or chief medical officer) to better understand the survey results;
  • Make sure if the data are being used to compare hospitalist care with non-hospitalist care that the comparison group of patients is equivalent (i.e., acutely ill medical patients admitted through the ED, not surgical or obstetrical patients);
  • Make sure to focus not only on the “doctor-related” questions, but on patients’ overall satisfaction with the hospital; and
  • Offer to help the C-suite improve patient satisfaction, but don’t attempt to “own” this performance measure for the entire hospital. Hospitalists can be helpful, but this is broader than any one group of physicians.

Further, make improving patient satisfaction a core goal for your group. Some strategies that may work include:

  • Have a script for each patient encounter (“Hi, I’m Dr. Smith, I take care of Dr. Jones’ patients in the hospital. The way we communicate about your care is … The advantages to our partnership are …”);
  • Hand out a brochure with your group’s hospitalists’ pictures, answers to frequently asked questions, and how to contact the hospitalist; and
  • Sit down and shut up (i.e., patients will perceive you are taking time with them and listening if you are seated and let them speak without interruption).

Hospitals have been doing patient surveys for some time now. The Centers for Medicare and Medicaid Services and other payers are placing more emphasis on this quality measure. Now that the results easily are available to the public, major newspapers and broadcast media are calling attention to patient perspectives on their hospital care.

Once hospitalist groups understand the data, there is an opportunity to partner with their hospitals to better understand how our patients see their hospital care and allow for hospitalists to have an appropriate role in working with the other health professionals to improve patients’ experience with their care. TH

Dr. Wellikson is the CEO of SHM.

Note to readers: I would like to acknowledge SHM co-founder Win Whitcomb, MD, and SHM Senior Vice President Joe Miller for their assistance with this column.


This copy is for your personal, noncommercial use only. No part of this article can be reproduced without the written permission of the publisher. Order presentation-ready copies for distribution to your colleagues, clients, or customers by contacting our reprints department at reprints@wiley.com. Copyright © 2009 Society of Hospital Medicine, administered by John Wiley & Sons Inc.

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