Warm and Fuzzy Hospitalists
By Jan Greene
As patient satisfaction gets new attention, hospitalists are trying to change their image
Dry-erase whiteboards are being installed in patient rooms. Physicians and nurses write their names on them so patients remember who they are. Doctors leave test results or exams scheduled for that day, and families post questions if they miss the doctors’ rounds that day. It might seem like a self-intuitive method to address patient satisfaction, but the simple whiteboard is a trend being led by hospitalists—doctors who specialize in inpatient care. To them, better communication with patients and families means happier patients. And happier patients are more likely to assign a higher rating to their hospital stay when they fill out a patient satisfaction survey.
Hospitalists are increasingly sensitive to patient satisfaction scores because they feel pressure from hospital administrators and boards to boost those ratings. As of March 2009, all hospitals wanting to get full reimbursement from Medicare must submit the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey, which is posted for public view on the government’s Hospital Compare Web site.
Hospitalists have some catching up to do when it comes to patient satisfaction. As a group, they tend to have lower scores than other types of doctors in the hospital. But that’s because they usually take on patients coming through the emergency room who have no assigned physician, and those people tend to rate their hospital stays more harshly.
But there’s another disadvantage that hospitalists have: Initially, their patients don’t know them. Hospitalists have taken over for primary care doctors who are so busy with their office practices that they no longer have time to visit patients in the hospital. That means that many patients are meeting the hospitalist for the first time in the stressful environment of an unexpected hospital stay, and they may not be happy about it. It’s up to the hospitalist to win that patient’s confidence.
“That can be an initial hurdle,” says Deirdre Mylod, vice president of the acute business unit at Press Ganey, a major survey firm based in South Bend, Ind. “But it’s a hurdle that education can pretty easily overcome. Generations ago, you called your physician to meet you at the emergency department, but nobody expects that anymore.”
Some hospitalists are concerned that the HCAHPS survey results, which ask general questions about things like communication, noise and cleanliness, will be misused and unfairly focus on a given physician who happens to be in charge of an unhappy patient’s care.
“The matter is made much worse because we’re not even sure the doctor is responsible for satisfaction,” argues Adam Singer, M.D., CEO of IPC The Hospitalist Company, a Southern California-based company that provides hospitalists to 300 hospitals. “A better thing would be to find things in the hospital that we could help change.”
Mylod says the HCAHPS tool isn’t designed to measure a particular doctor’s care, but is a general impression of a hospital stay. “There are challenges when you are linking patients’ responses to what they think of physician care,” Mylod says. “Patients don’t always remember all the different physicians they’ve seen. You have to acknowledge that it is not a perfect measure of a given physician.”
Instead, they recommend that hospitals use additional patient satisfaction surveys that will pinpoint more specifically the medical part of a hospital stay. Many hospitalist groups do their own self-assessments using patient surveys that add additional questions about things that hospitalists do, such as coordination of care.
They may use the information to give physicians feedback about their own performance, but only if they have enough surveys to make the data meaningful. IPC calls patients the day after they go home from the hospital to find out how they felt about their care, and uses the information to provide feedback to its physicians.
“What’s most important about patient satisfaction scores is not where you are today, but the trend of change,” says Matthew Schreiber, M.D., medical director of Piedmont Hospitalist Physicians, which provides inpatient care at Atlanta-based Piedmont Healthcare. “Are you getting better, or stagnating; do you have a strategic plan and is your plan working?”
Hospitalist Ranks Grow
Hospitalists came into being in 1995, and their use is exploding. By 2006 almost half of all hospitals and 84 percent of teaching hospitals had at least three hospitalists, according to an article in the March 12 New England Journal of Medicine.
More than half are employed by hospitals—40 percent as employees of the hospital and another 18 percent as employees of a medical school affiliated with the hospital, according to the Society of Hospital Medicine (SHM). The other 42 percent fall into one of a few models of private practice—they might be members of a multispecialty group, part of a single local hospitalist program that contracts with the hospital, or work for a national hospitalist management company, such as IPC.
Studies examining the impact of hospitalist programs on quality of care and cost have shown mixed results.
The New England Journal of Medicine article characterizes the findings so far as indicating a modest reduction in costs and lengths of stay as well as the added benefit of having a physician available to the patient and the hospital all day. It also notes the drawbacks, such as disrupted continuity of care by primary care doctors. In terms of patient satisfaction, Press Ganey did a study comparing satisfaction scores of hospitals that use hospitalists with those that do not and found significant higher ratings among those that use hospitalists. Hospitals had higher satisfaction on admissions, nursing care, personal issues, treatment and overall assessment.
While hospitalists must overcome an initial barrier with patients who are new to them, Press Ganey’s Mylod says that once it is done the hospital specialist can actually improve the patient experience by making sure the care team is well coordinated and that handoffs are handled well.
Physicians can also have an impact on their scores by being vigilant about the basics of connecting with patients by sitting down with the patient when going into the room, for instance. “If you don’t do it all the time, then you don’t improve your scores,” Schreiber says.
Hospitalists’ Role in Quality
An informal survey by the SHM indicated that 97 percent of hospitalist programs are involved with quality improvement, and 58 percent of them have some responsibility for patient satisfaction, says Joe Miller, senior vice president of the society.
Not only are they getting involved, they are being held accountable. Increasingly, hospitalist programs are seeing their compensation connected with patient satisfaction scores. Of hospitalists responding to the SHM survey, Miller said, 57 percent reported they have some type of compensation at risk for quality improvement activities.
And for many hospitalists, that’s fine. They want to be at the center of improving the quality and efficiency of care. “Hospitalists in general are agents of change,” says Michael Radzienda, M.D., chief of the section of hospital medicine at the Medical College of Wisconsin in Milwaukee. “It really falls on the hospitalists by the nature of what we do, and also to impact our own survival, to work on these processes.”
Hospitalists will also be on the hot seat for ensuring that patients follow up with their regular doctors after they leave the hospital. That’s because Medicare will soon withhold payment for a readmission for the same diagnosis within 30 days. “The average readmission rate is probably about 18 percent or so,” says Schreiber. “This represents enormous dollars. An average cost of readmission is somewhere around $7,500,” plus the lost Medicare reimbursement for that diagnosis, adding up to a significant potential net loss, he notes.
To get ahead of the problem, the Society of Hospital Medicine is using a $2 million grant to design a better discharge handoff. They’ve created a document that clearly states what the patient was treated for in the hospital, what was learned during the stay, what medications were prescribed and how they might have changed, and what the patient should do to connect with his or her doctor once back home. What’s new is that the discharge planning is being led by doctors, and it requires that the entire care team be better coordinated.
Schreiber says this is vital—discharge planning must be a team effort led by physicians. “If you’re really going to be efficient you can’t have your physicians being a passive element,” says Schreiber whose hospital is one of 30 pilot sites for the SHM project.
The dry-erase whiteboards in patient rooms are a simple and increasingly popular way to improve the rapport between the physician and both the patient and family. The Medical College of Wisconsin actually linked an improvement in its Press Ganey patient satisfaction scores to the use of whiteboards, reports Radzienda.
Hospitalists are trying another new idea: a magnetic business card with the physician’s contact information and photo magnet. “You go into the patient room, hand them your business card and put your photo magnet on the whiteboard,” he explains. “Our theory is that it will enhance provider identification. A frequent complaint is, ‘I don’t know who’s running the show.’ This allows the hospitalist to be better identified as the care manager. This is your doctor.”
The medical college hospital has also found that patients notice when doctors and nurses are getting along. Each unit was assigned a medical director who maintained lines of communication with nurses, who might be dealing with 20 to 30 different physicians. One unit that started using a medical director as liaison jumped from being an underperformer on Press Ganey scores to the top unit in the hospital “because of the perception of coordination and a cohesive team,” Radzienda says.
At the University of Utah Hospital and Clinics, Salt Lake City, hospitalists have tried several tactics to boost lagging patient satisfaction scores, including whiteboards and a bedside table booklet that explains the various types of doctors who make rounds in a teaching hospital—residents, attending physicians, consultants—along with basic information, such as where family members can get something to eat.
Another useful innovation that’s been a hit with patients is adding an afternoon visit to the schedule for hospitalists, who show up on their own without a crowd of residents in tow.
“A patient gets a CT scan in the morning, and they don’t necessarily want to wait until the next day to know the results of that,” says Michael Strong, M.D., director of the hospitalist program. “It has helped a lot to go back in the afternoon” and give patients an update on their conditions, he says.
The Board’s Role
Patient satisfaction ratings are a core issue for hospital boards. That’s because one of the board’s main responsibilities is to monitor quality metrics that include patient satisfaction scores. But trustees are also representatives of the community, and they often hear anecdotes from people they know about their impressions of a hospital stay.
At the University of Utah Hospital, trustees are sources of information about the hospital’s reputation in the community. “Patient satisfaction is very much a topic with our board, and we spend a lot of time getting their input,” says David Entwistle, the hospital’s CEO. “If [the board] is not hearing good things,” hospital administration knows it has some work to do, he says.
When quality and satisfaction scores are made public, the focus becomes more intense. Even if a majority of patients aren’t looking at quality scores online, others in the hospital industry are, and trustees want to be sure the hospital’s reputation is solid, says Press Ganey’s Mylod.
Boards are also holding their executive teams accountable for performance on patient satisfaction. SHM found that for 58 percent of senior managers, compensation is based in part on meeting quality goals, including patient satisfaction. The pressure from boards is passed through administration down to the physicians who spend the most time with patients.
All of that is fine, say hospitalists, but they want to be sure trustees understand the nuances of patient satisfaction results and interpret them accordingly. “What you want to be evaluating is their position as a team leader for each patient they are responsible for,” says Singer. “Those are the kinds of issues that hospitalists are engaged in.”
Jan Greene is a writer based in Alameda, Calif.
This article 1st appeared in the May 2009 issue of Trustee Magazine.
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