Physician communication as a key factor in patient experience
Mamta Gautam, MD
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Patient experience is fast becoming one of the top priorities for hospital leaders. Understanding a patient’s experience during his or her hospital stay is central to improving patient-centred care.
Patient experience is the sum of clinical quality and service quality. Clinical quality is what we deliver to patients: the technical and cognitive skills to medically manage a patient, procedures performed, patient safety practices, and the science of medicine. Service quality is how we deliver the care; it includes professionalism, kindness and respect, clear communication, and the art of medicine. Top
Measuring patient experience
In Canada, capturing and reporting information on the patient experience is an important part of the Canadian Institute for Health Information’s (CIHI) effort to measure health system performance. CIHI has worked with a variety of experts to develop the Canadian Patient Experiences Survey—Inpatient Care (CPES-IC) and the Canadian Patient Experiences Reporting System (CPERS).1 This standardized questionnaire enables patients to provide feedback about the quality of care they received during their most recent stay in a Canadian acute care hospital. It also provides standards and supporting documentation for those who are administering the survey. The survey was created by leading experts and includes 22 items from the United States’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, as well as questions relevant to the Canadian context (e.g., discharge and transitions) and demographic information. Starting in spring 2015, the CPERS was to start receiving CPES-IC data, and during 2015–2016, field tested data will be used to validate the survey measures. Top
The HCAHPS is a US survey instrument and data collection method for measuring patients’ perceptions of their hospital experience. In use since 2006, the survey asks discharged patients 27 questions about their recent hospital stay, including 18 core questions about critical aspects of their experience. As the first national standard for collecting and publicly reporting information about patient experience of care, it allows valid comparisons across hospitals locally, regionally, and nationally.2,3 Top
Three specific questions make up the HCAHPS’s “communication with doctors” domain. These same questions are included in the CPES-IC survey. Patients are asked: During this hospital stay, how often did doctors:
In each case, patients are given four choices: never, sometimes, usually, and always. Doctors are only given credit if a patient rates them as having “always” done this. A US report from April 2015 shows that a patient response of 82% “always” is the national average. After “discharge information,” this is the second highest scoring HCAHPS domain. The best performing hospitals in the country (95th percentile) get 85% or more “always” choices in this section.4
Other countries have also instituted or are planning to institute similar patient surveys. In the United Kingdom, the National Health Service (NHS) patient survey program systematically gathers the views of patients about the care they have recently received, on behalf of the Care Quality Commission.5 In 2012, the Australia Commission on Safety and Quality in Healthcare conducted a comprehensive review of patient experience and satisfaction surveys in use, with the goal of informing the development of a national approach to measuring hospital patient experience.6
Focusing on communication
With an increasing amount of revenue at stake in the US, hospital leaders there are looking for strategies to improve the patient experience and boost their HCAHPS scores. Regardless of the existence of a direct impact on hospital revenues, hospitals everywhere are now focusing on performance measures and efforts to improve patient satisfaction. It is my understanding that doctors consistently score well in the first question above, but have room for improvement based on responses to questions 2 and 3. In recent years, I have consulted at several US hospitals to assist them in boosting their patient experience. Understanding the patient experience of care is not an add-on activity: it should be a fundamental element in other hospital improvement efforts. Patient-centred care is a driver of clinical outcomes. Changing hospital culture and processes to improve the patient experience can lead to substantial improvements in safety and quality.7 Top
Typically, I shadow identified physicians to observe their interaction with patients, and then offer detailed individual feedback on communication skills and several follow-up coaching sessions to help them enhance this interaction. It is hoped that this will, in turn, lead to improvement in patient satisfaction and patient care.
Factors affecting physician communication
HCAHPS scores in the area of physician communication are known to be influenced by three main factors: physician behaviours, team communication, and system issues.8 Although I focus on physician behaviours, I have also been able to recognize key issues related to team communication and system issues and offer strategic and practical recommendations to address these. Top
From a patient perspective, positive aspects of physician communication behaviours include:
Physician behaviours become problematic for patients when there are longer wait times, less responsiveness, greater complexity of communication by specialists, disorganized care, and lack of team communication.
It is important to be aware of differences in patient and physician perspectives. Olsen and Windish9 found that 98% of physicians said they discussed patients’ fears and anxieties at least sometimes; but 54% of patients said their physicians never did this. Patients correctly identified the diagnosis 57% of the time and the name of their physician 18% of the time; physicians thought that patients knew the diagnosis 77% of the time and their name 67% of the time.
Physicians often ask me why they should focus on the patient experience. They know the clinical quality of the care they provide is high; should that not be enough? Focusing on patient experience is good for the physician, patient, and organization. Top
Enhanced team communication results in greater consistency and continuity of care and leads to improved patient satisfaction. System issues are also critical to ensuring patient satisfaction. There must be a strategic organization-wide focus on creating a culture of care. The Cleveland Clinic has invested in this area and, in 2007, created an Office of Patient Experience. The clinic offers lessons for achieving similar success: focus on culture, quickly; get physicians on board, despite their recalcitrance; and just get started.10 They suggest aligning organizational culture around a “patients first” philosophy, engaging all employees, mandating physician communications training, and just getting started without waiting for the perfectly defined initiative.
Turning resisters into allies
Continued attention to improving and sustaining positive physician behaviours, team communication, and system issues will ensure success. However, patient engagement cannot occur without physician engagement. Hospitals must be simultaneously patient-centred and provider-centred.11 Providers, especially physicians, are the biggest resisters of change and often the main barrier to community engagement. Involving them proactively and including them in the process by also addressing their needs will be a key step. As hospital physicians and staff feel engaged, supported, and valued by the hospital, they will become the greatest allies in this process. The biggest barriers can become the biggest enablers.
Translating data into action
The increased emphasis on patient satisfaction data collection systems in North America is important. Yet, it is only the first step. To be truly valuable, it must inform and translate into action. The Cleveland Clinic has effectively used its data to change hospital culture; modify processes; and improve patient safety, quality, and satisfaction.7 Such positive action will be a greater challenge at a national level. Top
There are lessons to be learned from other health care systems. In the UK, the NHS has been collecting data for over 10 years, but relatively few providers systematically use the information to improve patient services.12 Coulter and her associates12 suggest the establishment of a national institute of “user” experience to draw the data together, determine how to interpret the results, and put them into practice.
There will likely be other solutions; we will need to keep exploring options. As health care leaders, we must focus not just on obtaining these data, but also on how to use this knowledge to best effect positive changes in the delivery of health care. Top
1.Patient experience. Ottawa: Canadian Institute for Health Information; 2015. Available: https://www.cihi.ca/en/health-system-performance/quality-of-care-and-outcomes/patient-experience (accessed 2 July 2015).
2.Hospital Consumer Assessment of Healthcare Providers and Systems. CAHPS hospital survey. Baltimore: Centers for Medicare & Medicaid Services. Available: http://www.hcahpsonline.org/home.aspx (accessed 30 June 2015).
3.HCAHPS: patients’ perspectives of care survey. Baltimore: Centers for Medicare & Medicaid Services. Available: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-instruments/HospitalQualityInits/HospitalHCAHPS.html (accessed 3 July 2015).
4.HCAHPS: hospital characteristics comparison charts. Baltimore: Centers for Medicare & Medicaid Services. Available: http://www.safetyandquality.gov.au/wp-content/uploads/2012/03/Review-of-Hospital-Patient-Experience-Surveys-conducted-by-Australian-Hospitals-30-March-2012-FINAL.pdf (accessed 5 July 2015).
5.Surveys. Newcastle upon Tyne, UK: Care Quality Commission; 2015. Available http://www.cqc.org.uk/content/surveys (accessed 17 August 2015).
6.Review of patient experience and satisfaction surveys conducted within public and private hospitals in Australia. Sydney: Australian Commission on Safety and Quality in Healthcare; 2012. Available http://www.safetyandquality.gov.au/wp-content/uploads/2012/03/Review-of-Hospital-Patient-Experience-Surveys-conducted-by-Australian-Hospitals-30-March-2012-FINAL.pdf (accessed 17 August 2015).
7.Merlino JI, Raman A. Health care’s service fanatics. HBR 2013;91(5):108-16. Available https://hbr.org/2013/05/health-cares-service-fanatics (accessed 17 August 2015).
8.Wild DM, Kwon N, Dutta S, Tessier-Sherman B, Woddor N, Sipsma HL, et al. Who’s behind an HCAHPS score? Jt Comm J Qual Patient Saf 2011;37(10):461-8.
9.Olson DP, Windish DM. Communication discrepancies between physicians and hospitalized patients. Arch Intern Med 2010; 170(15):1302-7.
10.Letourneau R. Investing in patient experience protects hospital revenue. HealthLeaders Media 2014;May 19. Available: http://healthleadersmedia.com/content.cfm?topic=FIN&content_id=304643 (accessed 15 April 2015).
11.Gautam M. Enhancing community engagement at the Ottawa Hospital. MBA thesis. Ottawa: University of Ottawa; 2013.
12.Coulter A, Locock L, Ziebland S, Calabrese J. Collecting data on patient experience is not enough: they must be used to improve care. BMJ 2014;348:g2225.
Mamta Gautam, MD, MBA, FRCPC, CPDC, CCPE — a psychiatrist with 25 years of experience treating physicians and physician leaders — is also a coach, author, and president of Peak MD, Ottawa, Ontario.
Correspondence to: firstname.lastname@example.org
This article has been reviewed by a panel of physician leaders.