Quality

HM@15 - Is Hospital Medicine a Good Bet for Improving Patient Satisfaction?


 

At first glance, the deck might seem hopelessly stacked against hospitalists with regard to patient satisfaction. HM practitioners lack the long-term relationship with patients that many primary-care physicians (PCPs) have established. Unlike surgeons and other specialists, they tend to care for those patients—more complicated, lacking a regular doctor, or admitted through the ED, for example—who are more inclined to rate their hospital stay unfavorably.1 They may not even be accurately remembered by patients who encounter multiple doctors during the course of their hospitalization.2 And hospital information systems can misidentify the treating physician, while the actual surveys used to gauge hospitalists have been imperfect at best.3

And yet, the hospitalist model has evolved substantially on the question of how it can impact patient perceptions of care.

Initially, hospitalist champions adopted a largely defensive posture: The model would not negatively impact patient satisfaction as it delivered on efficiency—and later on quality. The healthcare system, however, is beginning to recognize the hospitalist as part of a care “team” whose patient-centered approach might pay big dividends in the inpatient experience and, eventually, on satisfaction scores.

“I think the next phase, which is a focus on the hospitalist as a team member and team builder, is going to be key,” says William Southern, MD, MPH, SFHM, chief of the division of hospital medicine at Montefiore Medical Center in Bronx, N.Y.

Recent studies suggest that hospitalists are helping to design and test new tools that will not only improve satisfaction, but also more fairly assess the impact of individual doctors. As the maturation process continues, experts say, hospitalists have an opportunity to influence both provider-based interventions and more programmatic decision-making that can have far-reaching effects. Certainly, the hand dealt to hospitalists is looking more favorable even as the ante has been raised with Medicare programs like value-based purchasing, and its pot of money tied to patient perceptions of care.

So how have hospitalists played their cards so far?

A Look at the Evidence

Listen to Diane Sliwka

In its early years, the HM model faced a persistent criticism: Replacing traditional caregivers with these new inpatient providers in the name of efficiency would increase handoffs and, therefore, discontinuities of care delivered by a succession of unfamiliar faces. If patients didn’t see their PCP in the hospital, the thinking went, they might be more disgruntled at being tended to by hospitalists, leading to lower satisfaction scores.4

A particularly heated exchange played out in 1999 in the New England Journal of Medicine. Farris A. Manian, MD, MPH, of Infectious Disease Consultants in St. Louis wrote in one letter, “I am particularly concerned about what impressionable house-staff members will learn from hospitalists who place an inordinate emphasis on cost rather than the quality of patient care or teaching.”5

A few subsequent studies, however, hinted that such concerns might be overstated. A 2000 analysis in the American Journal of Medicine that examined North Mississippi Health Services in Tupelo, for instance, found that care administered by hospitalists led to a shorter length of stay and lower costs than care delivered by internists. Importantly, the study found that patient satisfaction was similar for both models, while quality metrics were likewise equal or even tilted slightly toward hospitalists.6

In their influential 2002 review of a profession that was only a half-decade old, Robert Wachter, MD, MHM, and Lee Goldman, MD, MPH, FACP from the University of California at San Francisco reinforced the message that HM wouldn’t lead to unhappy patients. “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction,” they asserted.7

Among pediatric patients, a 2005 review found that “none of the four studies that evaluated patient satisfaction found statistically significant differences in satisfaction with inpatient care. However, two of the three evaluations that did assess parents’ satisfaction with care provided to their children found that parents were more satisfied with some aspects of care provided by hospitalists.”8

I think it’s really important to say, “I know you don’t know me, but here’s the upside.” And my experience is that patients easily understand that tradeoff and are very positive.

—William Southern, MD, chief, division of hospital medicine, Montefiore Medical Center, Bronx, N.Y.

Similar findings were popping up around the country: Replacing an internal medicine residency program with a physician assistant/hospitalist model at Brooklyn, N.Y.’s Coney Island Hospital did not adversely impact patient satisfaction, while it significantly improved mortality.9 Brigham & Women’s Hospital in Boston likewise reported no change in patient satisfaction in a study comparing a physician assistant/hospitalist service with traditional house staff services.10

The shift toward a more proactive position on patient satisfaction is exemplified within a 2008 white paper, “Hospitalists Meeting the Challenge of Patient Satisfaction,” written by a group of 19 private-practice HM experts known as The Phoenix Group.3 The paper acknowledged the flaws and limitations of existing survey methodologies, including Medicare’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Even so, the authors urged practice groups to adopt a team-oriented approach to communicate to hospital administrations “the belief that hospitalists are in the best position to improve survey scores overall for the facility.”

Listen to Diane Sliwka

click for large version

Carle Foundation Hospital in Urbana, Ill., is now publicly advertising its HM service’s contribution to high patient satisfaction scores on its website, and underscoring the hospitalists’ consistency, accessibility, and communication skills. “The hospital is never without a hospitalist, and our nurses know that they can rely on them,” says Lynn Barnes, vice president of hospital operations. “They’re available, they’re within a few minutes away, and patients’ needs get met very efficiently and rapidly.”

As a result, she says, their presence can lead to higher scores in patients’ perceptions of communication.

Hospitalists also have been central to several safety initiatives at Carle. Napoleon Knight, MD, medical director of hospital medicine and associate vice president for quality, says the HM team has helped address undiagnosed sleep apnea and implement rapid responses, such as “Code Speed.” Caregivers or family members can use the code to immediately call for help if they detect a downturn in a patient’s condition.

The ongoing initiatives, Dr. Knight and Barnes say, are helping the hospital improve how patients and their loved ones perceive care as Carle adapts to a rapidly shifting healthcare landscape. “With all of the changes that seem to be coming from the external environment weekly, we want to work collaboratively to make sure we’re connected and aligned and communicating in an ongoing fashion so we can react to all of these changes,” Dr. Knight says.

Continued below...

Whats My Name Again

A particularly frustrating aspect of patient satisfaction surveys can be the difficulty in getting patients to remember the hospitalists who cared for them. With numerous studies suggesting that a lack of recognition can be a huge stumbling block for accurate and fair surveys, hospitalists are employing a range of memory aids.2

Doctors and nurses are writing their names on dry-erase boards, where they can post test results or scheduled exams, and invite patients and their families to ask questions. Other hospitals are handing out pocket cards or using bedside printouts that explain the types of doctors the patient may encounter, with pictures of the team members.

Newer survey-based tools, such as the Communication Assessment Tool and Press Ganey’s Hospitalist Insight, also include photos of individual hospitalists to help improve the validity and accuracy of the data. “If you get a survey with a picture on it, that’s going to go a long way toward helping you recall that experience, and so that’s where we went,” Press Ganey researcher Brad Fulton, PhD, says.

At the University of Colorado Denver’s Acute Care for the Elderly (ACE) Service, hospitalists were first educated about the importance of introducing themselves and making sure patients understood who was in charge of their care and who was on their team. “And then we moved from that to actually providing for our patients a handout that includes the names and pictures of the members of their team, individualized for that month, so they would know who was coming in and where they fit into their care,” says ACE director Ethan Cumbler, MD, FACP.

The double-sided page also established expectations of care: when the patients should expect to see their doctor, and what they should expect in communication between their doctor and PCP. The handout explicitly requested that patients bring up questions and invited family members to be part of the discussion on rounds.

“That’s getting beyond the individual provider behavior and into more of a programmatic intervention,” Dr. Cumbler says. “But the goal is the same: to make patients understand what’s going on with them here in the hospital and to help the hospital experience be a more comprehensible, less frightening, and more patient-centered experience.”

A Hopeful Trend

So far, evidence that the HM model is more broadly raising patient satisfaction scores is largely anecdotal. But a few analyses suggest the trend is moving in the right direction. A recent study in the American Journal of Medical Quality, for instance, concludes that facilities with hospitalists might have an advantage in patient satisfaction with nursing and such personal issues as privacy, emotional needs, and response to complaints.11 The study also posits that teaching facilities employing hospitalists could see benefits in overall satisfaction, while large facilities with hospitalists might see gains in satisfaction with admissions, nursing, and tests and treatments.

Brad Fulton, PhD, a researcher at South Bend, Ind.-based healthcare consulting firm Press Ganey and the study’s lead author, says the 30,000-foot view of patient satisfaction at the facility level can get foggy in a hurry due to differences in the kind and size of hospitalist programs. “And despite all of that fog, we’re still able to see through that and find something,” he says.

One limitation is that the study findings could also reflect differences in the culture of facilities that choose to add hospitalists. That caveat means it might not be possible to completely untangle the effect of an HM group on inpatient care from the larger, hospitalwide values that have allowed the group to set up shop. The wrinkle brings its own fascinating questions, according to Fulton. For example, is that kind of culture necessary for hospitalists to function as well as they do?

The hospital is never without a hospitalist, and our nurses know that they can rely on them. They’re available, they’re within a few minutes away, and patients’ needs get met very efficiently and rapidly.

—Lynn Barnes, vice president of hospital operations, Carle Foundation Hospital, Urbana, Ill.

Such considerations will become more important as the healthcare system places additional emphasis on patient satisfaction, as Medicare’s value-based purchasing program is doing through its HCAHPS scores. With all the changes, success or failure on the patient experience front is going to carry “not just a reputational import, but also a financial impact,” says Ethan Cumbler, MD, FACP, director of Acute Care for the Elderly (ACE) Service at the University of Colorado Denver.

So how can HM fairly and accurately assess its own practitioners? “I think one starts by trying to apply some of the rigor that we have learned from our experience as hospitalists in quality improvement to the more warm and fuzzy field of patient experience,” Dr. Cumbler says. Many hospitals employ surveys supplied by consultants like Press Ganey to track the global patient satisfaction for their institution, he says.

“But for an individual hospitalist or hospitalist group, that kind of tool often lacks both the specificity and the timeliness necessary to make good decisions about impact of interventions on patient satisfaction,” he says.

Mark Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, agrees that such imprecision could lead to unfair assessments. “You can imagine a scenario where a patient actually liked their hospitalist very much,” he says, “but when they got the survey, they said [their stay] was terrible and the reasons being because maybe the nurse call button was not answered and the food was terrible and medications were given to them incorrectly, or it was noisy at night so they couldn’t sleep.”

A recent study by Dr. Williams and his colleagues, in which they employed a new assessment method called the Communication Assessment Tool (CAT), confirmed the group’s suspicions: “that the results from the Press Ganey didn’t match up with the CAT, which was a direct assessment of the patient’s perception of the hospitalist’s communication skills,” he says.12

The validated tool, he adds, provides directed feedback to the physician based on the percentage of patients rating that provider as excellent, instead of on the average total score. Hospitalists have felt vindicated by the results. “They were very nervous because the hospital talked about basing an incentive off of the Press Ganey scores, and we said, ‘You can’t do that,’ because we didn’t feel they were accurate, and this study proved that,” Dr. Williams explains.

Fortunately, the message has reached researchers and consultants alike, and better tools are starting to reach hospitals around the country. At HM11 in May, Press Ganey unveiled a new survey designed to help patients assess the care delivered by two hospitalists, the average for inpatient stays. The item set is specific to HM functions, and includes the photo and name of each hospitalist, which Fulton says should improve the validity and accuracy of the data.

Listen to Ethan Cumbler

“The early response looks really good,” Fulton says, though it’s too early to say whether the tool, called Hospitalist Insight, will live up to its billing. If it proves its mettle, Fulton says, the survey could be used to reward top-performing hospitalists, and the growing dataset could allow hospitals to compare themselves with appropriate peer groups for fairer comparisons.

Meanwhile, researchers are testing out checklists to score hospitalist etiquette, and tracking and paging systems to help ensure continuity of care. They have found increased patient satisfaction when doctors engage in verbal communication during a discharge, in interdisciplinary team rounding, and in efforts to address religious and spiritual concerns.

Since 2000, when Montefiore’s hospitalist program began, Dr. Southern says the hospital has explained to patients the tradeoff accompanying the HM model. “I say something like this to every patient: ‘I know I’m not the doctor that you know, and you’re just meeting me. The downside is that you haven’t met me before and I’m a new face, but the upside is that if you need me during the day, I’m here all the time, I’m not someplace else. And so if you need something, I can be here quickly.’ ”

Being very explicit about that tradeoff, he says, has made patients very comfortable with the model of care, especially during a crisis moment in their lives. “I think it’s really important to say, ‘I know you don’t know me, but here’s the upside.’ And my experience is that patients easily understand that tradeoff and are very positive,” Dr. Southern says.

The Verdict

Available evidence suggests that practitioners of the HM model have pivoted from defending against early criticism that they may harm patient satisfaction to pitching themselves as team leaders who can boost facilitywide perceptions of care. So far, too little research has been conducted to suggest whether that optimism is fully warranted, but early signs look promising.

At facilities like Chicago’s Northwestern Memorial Hospital, medical floors staffed by hospitalists are beginning to beat out surgical floors for the traveling patient satisfaction award. And experts like Dr. Cumbler are pondering how ongoing initiatives to boost scores can follow in the footsteps of efficiency and quality-raising efforts by making the transition from focusing on individual doctors to adopting a more programmatic approach. “What’s happening to that patient during the 23 hours and 45 minutes of their hospital day that you are not sitting by the bedside? And what influence should a hospitalist have in affecting that other 23 hours and 45 minutes?” he says.

Handoffs, discharges, communication with PCPs, and other potential weak points in maintaining high levels of patient satisfaction, Dr. Cumbler says, all are amenable to systems-based improvement. “As hospitalists, we are in a unique position to influence not only our one-one-one interaction with the patient, but also to influence that system of care in a way that patients will notice in a real and tangible way,” he says. “I think we’ve recognized for some time that a healthy heart but a miserable patient is not a healthy person.”

Teaching Hospitals Gain Ground in Patient Satisfaction

Listen to Diane Sliwka

One widely accepted truism about teaching facilities is that they’re known to have lower patient satisfaction scores than nonteaching hospitals. Brad Fulton, researcher for South Bend, Ind.-based consultant firm Press Ganey, attributes the difference in part to the fact that many doctors at teaching facilities must divide their time among patient care, education, and research. Such hospitals also tend to have some of the more medically difficult patients, he says, some of who may be more apt to feel like they’re on display with the abundance of students and residents.

In one of his recent studies, however, teaching facilities with hospitalists scored higher on patient satisfaction than nonteaching facilities or teaching facilities that lacked hospitalists. One potential follow-up question could have broad implications: “What is it about having hospitalists in teaching facilities that works so well in terms of patient satisfaction?” Can that be replicated elsewhere, he wonders? And is there an essential element that could be applied to nonteaching facilities?

A separate study also defied expectations by finding that teaching bedside procedures to inexperienced residents can be reassuring to patients, if done correctly. In a teaching model instituted at the University of California San Francisco, an experienced hospitalist with extra training supervises a novice during bedside procedures such as lumbar punctures and paracentesis. Study coauthor Diane Sliwka, MD, associate clinical professor of medicine and a hospitalist, says the feedback so far suggests that the model can improve safety, boost education, and deliver a positive patient experience.

Patients may be hesitant about having trainees do procedures, she says, but surveys suggest those patients are reassured when they know an expert is in the room and watching. They also want to hear what will happen next to counteract the anxiety of feeling pain or encountering something unexpected.

As the study suggested, what patients may find to be the most difficult or nerve-wracking can be quite different from what doctors expect. “You would think it was actually the procedure that was most painful part, but actually that was after we had given lidocaine,” Dr. Sliwka says. Patients repeatedly reacted to the doctors using a plastic pen cap to imprint the site where they would insert a needle. “Over and over we would hear people say, ‘That is actually the most painful part and you didn’t warn me about that,’ ” she recalls. “And we didn’t warn people about that because we didn’t think it was a big deal.”

Procedures can take longer with trainees, another tradeoff that can leading to lower satisfaction scores. But what the study also showed is that in academic settings, involving residents doesn’t harm the overall patient experience and can in fact improve it. “Anecdotally, what we hear from patients a lot is, ‘Oh, I had this procedure done before and it went horribly.’ They would tell stories of previous bad experiences, and then really be thankful for the experience that they had in our setting,” Dr. Sliwka says.

The extended face-to-face time can yield another positive effect. Dr. Sliwka found that hospitalists and residents often learned medical and historical information about the patient that the primary care team hadn’t yet had an opportunity to glean. “Patients just start to tell you about their families, their lives, their medical problems, their experiences,” she says, a product of building more rapport with them. “We would often find ourselves telling the primary medical team, ‘By the way, we found this out and you should probably know it: the patient is very concerned about this that’s been going on,’ and the patient hasn’t had a chance to tell the team because there isn’t that kind of time.”

Even without the specific model, Dr. Sliwka says, several principles can be applied to daily interactions. Framing things appropriately, she says, helps patients gain confidence in the doctors and allows them to safely conduct bedside teaching and openly discuss procedures. Even correcting mistakes can be a positive experience. “That actually makes the patient feel more confident in you than less confident,” Dr. Sliwka says.

Ultimately, the teaching experience can help residents broaden their thinking about patient satisfaction. “I think when trainees are starting, their real focus is, ‘How do I deal with this correctly?’ ” Dr. Sliwka says. “It takes a level of comfort with the basic skills to then go beyond that and start thinking about, ‘How is the patient perceiving this?’”

Bryn Nelson is a freelance medical journalist based in Seattle.

References

  1. Williams M, Flanders SA, Whitcomb WF. Comprehensive hospital medicine: an evidence based approach. Elsevier;2007:971-976.
  2. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199-201.
  3. Singer AS, et al. Hospitalists meeting the challenge of patient satisfaction. The Phoenix Group. 2008;1-5.
  4. Manian FA. Whither continuity of care? N Engl J Med. 1999;340:1362-1363.
  5. Correspondence. Whither continuity of care? N Engl J Med. 1999;341:850-852.
  6. Davis KM, Koch KE, Harvey JK, et al. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Amer J Med. 2000;108(8):621-626.
  7. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287(4):487-494.
  8. Coffman J, Rundall TG. The impact of hospitalists on the cost and quality of inpatient care in the United States (a research synthesis). Med Care Res Rev. 2005;62:379–406.
  9. Dhuper S, Choksi S. Replacing an academic internal medicine residency program with a physician assistant-hospitalist model: a comparative analysis study. Am J Med Qual. 2009;24(2):132-139.
  10. Roy CL, Liang CL, Lund M, et al. Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes. J Hosp Med. 2008;3(5):361-368.
  11. Fulton BR, Drevs KE, Ayala LJ, Malott DL Jr. Patient satisfaction with hospitalists: facility-level analyses. Am J Med Qual. 2011;26(2):95-102.
  12. Ferranti DE, Makoul G, Forth VE, Rauworth J, Lee J, Williams MV. Assessing patient perceptions of hospitalist communication skills using the Communication Assessment Tool (CAT). J Hosp Med. 2010;5(9):522-527.

Next Article:

   Comments ()