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Adopt strategies to communicate with compassion
A patient’s lived experience of being in the hospital is shaped by a variety of factors, according to Minesh Patel, MD, Mid-Atlantic regional medical director for the Tacoma, Wash.–based hospitalist performance company Sound Physicians. Some – but not all – of these factors are captured in the “patient experience” questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that is sent to randomly selected patients shortly after their discharge from the hospital.
In March 2020, the COVID-19 pandemic caused hospitals to institute quarantining measures and “no visitor” policies as doctors and other hospital staff donned masks, visors, and other emotionally distancing personal protective equipment (PPE). All of these factors impacted patients’ experience as well as their hospitals’ HCAHPS scores, Dr. Patel said. And since these policies applied to all hospitalized patients, a patient did not need to have COVID-19 to experience many of the same restrictions imposed by the pandemic.
“A lot of the care hospitalists provide involves touch, sitting down and looking at the patient eye to eye, on the same level,” said Dr. Patel, a practicing hospitalist at Frederick (Md.) Health Hospital. “That had to take a back seat to infection control.”
Meanwhile, lengths of stay were longer for COVID-19 patients, who were often very sick and alone in their hospital rooms for prolonged periods, sometimes on mechanical ventilation, isolated without the support of their families. Health care providers tried to minimize time spent at the bedside because of viral exposure risks. Nobody really knew how to treat patients’ severe respiratory distress, especially at first. “So we basically threw the kitchen sink at it, following the evolving CDC guidelines, and hoped it would work,” he explained.
“When we saw our patient experience scores plummeting across the division, we said, ‘This is not good.’ We could see that we weren’t spending as much time at the bedside, and our patients were lonely and scared.” There was also greater fragmentation of care, all of which impacted patients’ experience in partnering hospitals.
Dr. Patel and his team spearheaded a number of processes across their partner hospitals to help patients and their families get the information they needed and understand what was happening during their treatment. “At that moment, real-time feedback was essential,” he explained. “We implemented the TED protocol – Teach back, Empathy and ‘Double-backing,’ which means spending a shorter visit on morning rounds but going back to the patient’s bedside for a second daily visit at the end of the shift, thereby establishing a second touch point.” Teach back is a strategy of asking patients to repeat back in their own words what they understood the doctor to be saying about their care.
The group developed ID buttons – called “Suttons” or Sound Buttons – with a larger picture of the doctor’s smiling face pinned to their medical gowns. The hospitalists started scheduling Zoom calls with families from the ICU rooms of COVID-19 patients. “We employ clinical performance nurses as collaborative influencers. They visit patients’ bedsides and work with staff on improving patient experience,” Dr. Patel said. “And we printed thank-you cards with the doctor’s name, photo, and an individualized message for their patients.” Together these measures measurably improved patient experience scores across partnering hospitals. 
What is patient experience?
Evaluated by the Agency for Healthcare Research and Quality and endorsed by the National Quality Forum, HCAHPS hospital quality surveys ask patients (or their family members, who may be the ones completing the survey) 29 well-tested questions about the recent hospital stay and how they experienced it. Nineteen of those questions explore critical aspects of the patient’s experience in areas such as communication, responsiveness of staff, information about their diagnosis, medications, and discharge – and if they would recommend the hospital to others.
Surveys can be done by mail, phone, or interactive voice recognition and are offered in seven different languages. They can be administered by the hospital itself or by an approved survey vendor. They are sent between 48 hours and 6 weeks after the patient’s hospital discharge.
Nationwide results from HCAHPS survey have been published since 2008 in a searchable, comparable format on the consumer-focused government website Hospital Compare. The data have been used in a value-based incentive purchasing program since 2012. Hospital Compare also incorporates measures of quality such as mortality, readmission, and hospital-acquired infection rates as well as process measures such as how well facilities provide recommended care.
Starting in 2016, overall hospital quality has been encapsulated in a Star rating, which summarizes a variety of measures across seven areas of quality into a single number from one to five for each hospital. One of those seven areas is patient experience.
Hospitals may choose to ask additional questions of their own along with the HCAHPS survey, to gather additional, actionable quality data for internal purposes. Internal surveys with results closer to real time, instead of the months-to-years lag in posting HCAHPS scores, enable the hospital to respond to issues that emerge.
It’s not just the scores
“A lot of leaders in the hospital business will tell you ‘It’s not about the scores,’ ” Dr. Patel related. “But you need scores to tell how your practice is doing. It’s a testament to the kind of care you are providing as a hospital medicine program. These are important questions: Did your doctor listen to you, communicate in ways you understood, and treat you with courtesy?” Scores are scores, he said, but more importantly, are patients getting the information they need? Do they understand what’s going on in their care?
“You have to look at the scores and ask, what can we do differently to impact patient experience? What are we doing wrong? What can we do better? If the scores as a collective experience of hospitalized patients are plummeting, it must mean they’re not feeling good about the care they are receiving, and not recognizing what we’re trying to do for them.”
Declining HCAHPS scores last year could easily be explained by what was going on with COVID-19, Dr. Patel said. “But we want our patient experience to be seamless. We have to put ourselves in the patient’s shoes. For them, it’s about whether they felt they were treated well or not. We had to reinvent ourselves and find new ways to compensate for the limitations imposed by the pandemic,” he said.
“We also recognized that our No. 1 job as a group is to take care of our doctors, so that they can take care of their patients. We provided quarantine pay, implemented a buddy system for doctors, used CME dollars to pay for COVID education and, if they felt ill, we said they needed to stay home, while we paid their shift anyway,” he said. “When you do that kind of thing and engage them in your mission, frontline hospitalists can help to improve quality of care, decrease costs, and increase patient safety.”
A sacred encounter
For Sarah Richards, MD, a hospitalist with Nebraska Medicine in Omaha, what happens in the hospital room between the hospitalist and the patient is a sacred encounter. “It’s about relationship and trust,” she said, noting that it’s hard to capture all of that in survey data. It might be better expressed in words: “ ‘How are things going for you?’ To me, that’s the real patient experience. When I talk with physicians about patient experience, I start with why this matters. We know, for example, that when patients trust us, they are more likely to engage with their care and adhere to the treatment plan.”
Dr. Richards said standard hospital quality surveys can be a blunt tool. The HCAHPS survey, conducted around a week after the hospitalization, has a low response rate, and returns are not representative of the demographic served in the hospital. “The inpatient data are not always helpful, but this is what we have to work with. One choice hospitals have is for the leadership to choose not to use the data for individual bonuses, recognition, or discipline, since the questions ask patients about the care they received collectively from all of their doctors,” she said.
But as hospitalists have worked longer shifts under more stress while wearing PPE – which makes it harder to communicate with their patients – there is a dynamic that has emerged, which deserves more study. “I think doctors gave it their all in the pandemic. I’m a hospitalist, and people told me I’m a hero. But did that change my impact at work (on patient experience)?” she said.
Dr. Richards sits on SHM’s Patient Experience Special Interest Group (SIG), which was tasked with providing tools to help mitigate the effects of the pandemic. These include a fact sheet, “Communication Tips for 5 Common Conundrums in the COVID-19 Pandemic”, and a downloadable pocket card called “The 5 Rs of Cultural Humility.”
Also on the SIG is Mark Rudolph, MD, SFHM, Sound Physicians’ chief experience officer, whose job title reflects a growing, systematic attention to patient experience in U.S. hospitals. “Most clinicians are familiar with the surveys and the results of those surveys,” he told The Hospitalist. “People in our field can get frustrated with the surveys, and have a lot to say about the quality of the scores themselves – what is actually being measured. Is the patient upset because the coffee was cold, or due to a bad clinical experience? Is it about the care they received from the hospitalist, or the physical setting of the hospital?”
Doing the right thing
To be a patient hospitalized with an acute illness is a form of suffering, Dr. Rudolph said. “We know patient experience in the hospital since March of 2020 has been frightening and horrible. These people are as sick as can be. Everything about the experience is horrible. Every effort you can make to reduce that suffering is important. If you are a patient in the hospital and don’t know what’s happening to you, that’s terrifying.”
He encourages hospitalists to look beyond the scores or the idea that they are just trying to improve their scores. “Look instead at the actual content of the questions around communication with doctors. The competencies addressed in the survey questions – listening and explaining things clearly, for example – are effective guides for patient experience improvement efforts. You can be confident you’re doing the right thing for the patient by focusing on these skills, even if you don’t see immediate changes in survey scores.”
Hospitals that did not allow visitors had worse clinical outcomes and worse patient experience ratings, and recent research confirms that when family visitors are not allowed, outcomes are worse in areas such as patient ratings of medical staff responsiveness, fall rates, and sepsis rates.1 “None of that should be surprising. Not having family present just ups the ante. Any hospital patients could benefit from an advocate sitting next to them, helping them to the bathroom, and keeping them from falling out of bed,” Dr. Rudolph said.
“In the past year, we have placed a premium on communicating with these patients with kindness and compassion, to help them understand what’s happening to them,” he said. Out of necessity, hospitals have had to rejigger their processes, which has led to more efficient and better care, although the jury is still out on whether that will persist post pandemic.
Communicating with compassion
Swati Mehta, MD, a hospitalist at Sequoia Hospital in Redwood City, Calif., and director of quality performance and patient experience at Vituity, a physician-owned and -led multispecialty partnership, said COVID-19 was a wake-up call for hospitalists. There have been successful models for enhancing hospitalized patients’ experience, but it took the challenges of COVID-19 for many hospitalists to adopt them.
“Early in 2020, our data analysis showed emerging positive trends, reflecting our patients’ appreciation for what doctors were doing in the crisis and awareness of the challenges they faced. But after that uptick, global measures and national data showed drops for health care organizations and providers. Patients’ expectations were not being met. We needed to respond and meet patients where they were at. We needed to do things differently,” she said.
Keeping patients well informed and treating them with respect are paramount – and more important than ever – as reflected in Dr. Mehta’s “6H” model to promote a human connection between doctors and patients.2 As chair of SHM’s Patient Experience SIG, she led the creation of COVID-19–specific communication tips for hospitalists based on the 6H model. “I’m very committed to treating patients with compassion,” she said.
For Vituity, those approaches included making greater use of the hospital at home model for patients who reported to the emergency department but met certain criteria for discharge. They would be sent home with daily nursing visits and 24-hour virtual access to hospitalists. Vituity hospitalists also worked more closely with emergency departments to provide emergency psychiatric interventions for anxious patients, and with primary care physicians. Patient care navigators helped to enhance transitions of care. In addition, their hospitalist team added personalized pictures over their gowns so patients could see the hospitalists’ faces despite PPE.
Another Vituity innovation was virtual rounding, with iPads in the patient’s room and the physician in another room. “I did telerounds at our Redwood City hospital with patients with COVID who were very lonely, anxious, and afraid because they couldn’t have family visitors,” Dr. Mehta said. Telerounds offered greater protection and safety for both providers and patients, reduced the need for PPE, and improved collaboration with the nursing team, primary care providers, and families.
A recent perspective published in the New England Journal of Medicine suggests that the Zoom family conference may offer distinct advantages over in-person family conferences.3 It allows for greater participation by primary care clinicians who knew the patient before the current hospitalization and thus might have important contributions to discharge plans.
The pandemic stimulated many hospitals to take a closer look at all areas of their service delivery, Dr. Rudolph concluded. “We’ve made big changes with a lot of fearlessness in a short amount of time, which is not typical for hospitals. We showed that the pace of innovation can be faster if we lower the threshold of risk.”
References
1. Silvera GA et al. The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: A critical role for subjective advocates. Patient Experience Journal. 8(1) doi: 10.35680/2372-0247.1596.
2. Mehta S. How to truly connect with your patients: Introducing the ‘6H model.’ The Hospitalist. 2020 Aug 14.
3. Lee TH. Zoom family meeting. N Engl J Med. 2021 Apr 29;384(17):1586-7.
Adopt strategies to communicate with compassion
Adopt strategies to communicate with compassion
A patient’s lived experience of being in the hospital is shaped by a variety of factors, according to Minesh Patel, MD, Mid-Atlantic regional medical director for the Tacoma, Wash.–based hospitalist performance company Sound Physicians. Some – but not all – of these factors are captured in the “patient experience” questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that is sent to randomly selected patients shortly after their discharge from the hospital.
In March 2020, the COVID-19 pandemic caused hospitals to institute quarantining measures and “no visitor” policies as doctors and other hospital staff donned masks, visors, and other emotionally distancing personal protective equipment (PPE). All of these factors impacted patients’ experience as well as their hospitals’ HCAHPS scores, Dr. Patel said. And since these policies applied to all hospitalized patients, a patient did not need to have COVID-19 to experience many of the same restrictions imposed by the pandemic.
“A lot of the care hospitalists provide involves touch, sitting down and looking at the patient eye to eye, on the same level,” said Dr. Patel, a practicing hospitalist at Frederick (Md.) Health Hospital. “That had to take a back seat to infection control.”
Meanwhile, lengths of stay were longer for COVID-19 patients, who were often very sick and alone in their hospital rooms for prolonged periods, sometimes on mechanical ventilation, isolated without the support of their families. Health care providers tried to minimize time spent at the bedside because of viral exposure risks. Nobody really knew how to treat patients’ severe respiratory distress, especially at first. “So we basically threw the kitchen sink at it, following the evolving CDC guidelines, and hoped it would work,” he explained.
“When we saw our patient experience scores plummeting across the division, we said, ‘This is not good.’ We could see that we weren’t spending as much time at the bedside, and our patients were lonely and scared.” There was also greater fragmentation of care, all of which impacted patients’ experience in partnering hospitals.
Dr. Patel and his team spearheaded a number of processes across their partner hospitals to help patients and their families get the information they needed and understand what was happening during their treatment. “At that moment, real-time feedback was essential,” he explained. “We implemented the TED protocol – Teach back, Empathy and ‘Double-backing,’ which means spending a shorter visit on morning rounds but going back to the patient’s bedside for a second daily visit at the end of the shift, thereby establishing a second touch point.” Teach back is a strategy of asking patients to repeat back in their own words what they understood the doctor to be saying about their care.
The group developed ID buttons – called “Suttons” or Sound Buttons – with a larger picture of the doctor’s smiling face pinned to their medical gowns. The hospitalists started scheduling Zoom calls with families from the ICU rooms of COVID-19 patients. “We employ clinical performance nurses as collaborative influencers. They visit patients’ bedsides and work with staff on improving patient experience,” Dr. Patel said. “And we printed thank-you cards with the doctor’s name, photo, and an individualized message for their patients.” Together these measures measurably improved patient experience scores across partnering hospitals.
What is patient experience?
Evaluated by the Agency for Healthcare Research and Quality and endorsed by the National Quality Forum, HCAHPS hospital quality surveys ask patients (or their family members, who may be the ones completing the survey) 29 well-tested questions about the recent hospital stay and how they experienced it. Nineteen of those questions explore critical aspects of the patient’s experience in areas such as communication, responsiveness of staff, information about their diagnosis, medications, and discharge – and if they would recommend the hospital to others.
Surveys can be done by mail, phone, or interactive voice recognition and are offered in seven different languages. They can be administered by the hospital itself or by an approved survey vendor. They are sent between 48 hours and 6 weeks after the patient’s hospital discharge.
Nationwide results from HCAHPS survey have been published since 2008 in a searchable, comparable format on the consumer-focused government website Hospital Compare. The data have been used in a value-based incentive purchasing program since 2012. Hospital Compare also incorporates measures of quality such as mortality, readmission, and hospital-acquired infection rates as well as process measures such as how well facilities provide recommended care.
Starting in 2016, overall hospital quality has been encapsulated in a Star rating, which summarizes a variety of measures across seven areas of quality into a single number from one to five for each hospital. One of those seven areas is patient experience.
Hospitals may choose to ask additional questions of their own along with the HCAHPS survey, to gather additional, actionable quality data for internal purposes. Internal surveys with results closer to real time, instead of the months-to-years lag in posting HCAHPS scores, enable the hospital to respond to issues that emerge.
It’s not just the scores
“A lot of leaders in the hospital business will tell you ‘It’s not about the scores,’ ” Dr. Patel related. “But you need scores to tell how your practice is doing. It’s a testament to the kind of care you are providing as a hospital medicine program. These are important questions: Did your doctor listen to you, communicate in ways you understood, and treat you with courtesy?” Scores are scores, he said, but more importantly, are patients getting the information they need? Do they understand what’s going on in their care?
“You have to look at the scores and ask, what can we do differently to impact patient experience? What are we doing wrong? What can we do better? If the scores as a collective experience of hospitalized patients are plummeting, it must mean they’re not feeling good about the care they are receiving, and not recognizing what we’re trying to do for them.”
Declining HCAHPS scores last year could easily be explained by what was going on with COVID-19, Dr. Patel said. “But we want our patient experience to be seamless. We have to put ourselves in the patient’s shoes. For them, it’s about whether they felt they were treated well or not. We had to reinvent ourselves and find new ways to compensate for the limitations imposed by the pandemic,” he said.
“We also recognized that our No. 1 job as a group is to take care of our doctors, so that they can take care of their patients. We provided quarantine pay, implemented a buddy system for doctors, used CME dollars to pay for COVID education and, if they felt ill, we said they needed to stay home, while we paid their shift anyway,” he said. “When you do that kind of thing and engage them in your mission, frontline hospitalists can help to improve quality of care, decrease costs, and increase patient safety.”
A sacred encounter
For Sarah Richards, MD, a hospitalist with Nebraska Medicine in Omaha, what happens in the hospital room between the hospitalist and the patient is a sacred encounter. “It’s about relationship and trust,” she said, noting that it’s hard to capture all of that in survey data. It might be better expressed in words: “ ‘How are things going for you?’ To me, that’s the real patient experience. When I talk with physicians about patient experience, I start with why this matters. We know, for example, that when patients trust us, they are more likely to engage with their care and adhere to the treatment plan.”
Dr. Richards said standard hospital quality surveys can be a blunt tool. The HCAHPS survey, conducted around a week after the hospitalization, has a low response rate, and returns are not representative of the demographic served in the hospital. “The inpatient data are not always helpful, but this is what we have to work with. One choice hospitals have is for the leadership to choose not to use the data for individual bonuses, recognition, or discipline, since the questions ask patients about the care they received collectively from all of their doctors,” she said.
But as hospitalists have worked longer shifts under more stress while wearing PPE – which makes it harder to communicate with their patients – there is a dynamic that has emerged, which deserves more study. “I think doctors gave it their all in the pandemic. I’m a hospitalist, and people told me I’m a hero. But did that change my impact at work (on patient experience)?” she said.
Dr. Richards sits on SHM’s Patient Experience Special Interest Group (SIG), which was tasked with providing tools to help mitigate the effects of the pandemic. These include a fact sheet, “Communication Tips for 5 Common Conundrums in the COVID-19 Pandemic”, and a downloadable pocket card called “The 5 Rs of Cultural Humility.”
Also on the SIG is Mark Rudolph, MD, SFHM, Sound Physicians’ chief experience officer, whose job title reflects a growing, systematic attention to patient experience in U.S. hospitals. “Most clinicians are familiar with the surveys and the results of those surveys,” he told The Hospitalist. “People in our field can get frustrated with the surveys, and have a lot to say about the quality of the scores themselves – what is actually being measured. Is the patient upset because the coffee was cold, or due to a bad clinical experience? Is it about the care they received from the hospitalist, or the physical setting of the hospital?”
Doing the right thing
To be a patient hospitalized with an acute illness is a form of suffering, Dr. Rudolph said. “We know patient experience in the hospital since March of 2020 has been frightening and horrible. These people are as sick as can be. Everything about the experience is horrible. Every effort you can make to reduce that suffering is important. If you are a patient in the hospital and don’t know what’s happening to you, that’s terrifying.”
He encourages hospitalists to look beyond the scores or the idea that they are just trying to improve their scores. “Look instead at the actual content of the questions around communication with doctors. The competencies addressed in the survey questions – listening and explaining things clearly, for example – are effective guides for patient experience improvement efforts. You can be confident you’re doing the right thing for the patient by focusing on these skills, even if you don’t see immediate changes in survey scores.”
Hospitals that did not allow visitors had worse clinical outcomes and worse patient experience ratings, and recent research confirms that when family visitors are not allowed, outcomes are worse in areas such as patient ratings of medical staff responsiveness, fall rates, and sepsis rates.1 “None of that should be surprising. Not having family present just ups the ante. Any hospital patients could benefit from an advocate sitting next to them, helping them to the bathroom, and keeping them from falling out of bed,” Dr. Rudolph said.
“In the past year, we have placed a premium on communicating with these patients with kindness and compassion, to help them understand what’s happening to them,” he said. Out of necessity, hospitals have had to rejigger their processes, which has led to more efficient and better care, although the jury is still out on whether that will persist post pandemic.
Communicating with compassion
Swati Mehta, MD, a hospitalist at Sequoia Hospital in Redwood City, Calif., and director of quality performance and patient experience at Vituity, a physician-owned and -led multispecialty partnership, said COVID-19 was a wake-up call for hospitalists. There have been successful models for enhancing hospitalized patients’ experience, but it took the challenges of COVID-19 for many hospitalists to adopt them.
“Early in 2020, our data analysis showed emerging positive trends, reflecting our patients’ appreciation for what doctors were doing in the crisis and awareness of the challenges they faced. But after that uptick, global measures and national data showed drops for health care organizations and providers. Patients’ expectations were not being met. We needed to respond and meet patients where they were at. We needed to do things differently,” she said.
Keeping patients well informed and treating them with respect are paramount – and more important than ever – as reflected in Dr. Mehta’s “6H” model to promote a human connection between doctors and patients.2 As chair of SHM’s Patient Experience SIG, she led the creation of COVID-19–specific communication tips for hospitalists based on the 6H model. “I’m very committed to treating patients with compassion,” she said.
For Vituity, those approaches included making greater use of the hospital at home model for patients who reported to the emergency department but met certain criteria for discharge. They would be sent home with daily nursing visits and 24-hour virtual access to hospitalists. Vituity hospitalists also worked more closely with emergency departments to provide emergency psychiatric interventions for anxious patients, and with primary care physicians. Patient care navigators helped to enhance transitions of care. In addition, their hospitalist team added personalized pictures over their gowns so patients could see the hospitalists’ faces despite PPE.
Another Vituity innovation was virtual rounding, with iPads in the patient’s room and the physician in another room. “I did telerounds at our Redwood City hospital with patients with COVID who were very lonely, anxious, and afraid because they couldn’t have family visitors,” Dr. Mehta said. Telerounds offered greater protection and safety for both providers and patients, reduced the need for PPE, and improved collaboration with the nursing team, primary care providers, and families.
A recent perspective published in the New England Journal of Medicine suggests that the Zoom family conference may offer distinct advantages over in-person family conferences.3 It allows for greater participation by primary care clinicians who knew the patient before the current hospitalization and thus might have important contributions to discharge plans.
The pandemic stimulated many hospitals to take a closer look at all areas of their service delivery, Dr. Rudolph concluded. “We’ve made big changes with a lot of fearlessness in a short amount of time, which is not typical for hospitals. We showed that the pace of innovation can be faster if we lower the threshold of risk.”
References
1. Silvera GA et al. The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: A critical role for subjective advocates. Patient Experience Journal. 8(1) doi: 10.35680/2372-0247.1596.
2. Mehta S. How to truly connect with your patients: Introducing the ‘6H model.’ The Hospitalist. 2020 Aug 14.
3. Lee TH. Zoom family meeting. N Engl J Med. 2021 Apr 29;384(17):1586-7.
A patient’s lived experience of being in the hospital is shaped by a variety of factors, according to Minesh Patel, MD, Mid-Atlantic regional medical director for the Tacoma, Wash.–based hospitalist performance company Sound Physicians. Some – but not all – of these factors are captured in the “patient experience” questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that is sent to randomly selected patients shortly after their discharge from the hospital.
In March 2020, the COVID-19 pandemic caused hospitals to institute quarantining measures and “no visitor” policies as doctors and other hospital staff donned masks, visors, and other emotionally distancing personal protective equipment (PPE). All of these factors impacted patients’ experience as well as their hospitals’ HCAHPS scores, Dr. Patel said. And since these policies applied to all hospitalized patients, a patient did not need to have COVID-19 to experience many of the same restrictions imposed by the pandemic.
“A lot of the care hospitalists provide involves touch, sitting down and looking at the patient eye to eye, on the same level,” said Dr. Patel, a practicing hospitalist at Frederick (Md.) Health Hospital. “That had to take a back seat to infection control.”
Meanwhile, lengths of stay were longer for COVID-19 patients, who were often very sick and alone in their hospital rooms for prolonged periods, sometimes on mechanical ventilation, isolated without the support of their families. Health care providers tried to minimize time spent at the bedside because of viral exposure risks. Nobody really knew how to treat patients’ severe respiratory distress, especially at first. “So we basically threw the kitchen sink at it, following the evolving CDC guidelines, and hoped it would work,” he explained.
“When we saw our patient experience scores plummeting across the division, we said, ‘This is not good.’ We could see that we weren’t spending as much time at the bedside, and our patients were lonely and scared.” There was also greater fragmentation of care, all of which impacted patients’ experience in partnering hospitals.
Dr. Patel and his team spearheaded a number of processes across their partner hospitals to help patients and their families get the information they needed and understand what was happening during their treatment. “At that moment, real-time feedback was essential,” he explained. “We implemented the TED protocol – Teach back, Empathy and ‘Double-backing,’ which means spending a shorter visit on morning rounds but going back to the patient’s bedside for a second daily visit at the end of the shift, thereby establishing a second touch point.” Teach back is a strategy of asking patients to repeat back in their own words what they understood the doctor to be saying about their care.
The group developed ID buttons – called “Suttons” or Sound Buttons – with a larger picture of the doctor’s smiling face pinned to their medical gowns. The hospitalists started scheduling Zoom calls with families from the ICU rooms of COVID-19 patients. “We employ clinical performance nurses as collaborative influencers. They visit patients’ bedsides and work with staff on improving patient experience,” Dr. Patel said. “And we printed thank-you cards with the doctor’s name, photo, and an individualized message for their patients.” Together these measures measurably improved patient experience scores across partnering hospitals.
What is patient experience?
Evaluated by the Agency for Healthcare Research and Quality and endorsed by the National Quality Forum, HCAHPS hospital quality surveys ask patients (or their family members, who may be the ones completing the survey) 29 well-tested questions about the recent hospital stay and how they experienced it. Nineteen of those questions explore critical aspects of the patient’s experience in areas such as communication, responsiveness of staff, information about their diagnosis, medications, and discharge – and if they would recommend the hospital to others.
Surveys can be done by mail, phone, or interactive voice recognition and are offered in seven different languages. They can be administered by the hospital itself or by an approved survey vendor. They are sent between 48 hours and 6 weeks after the patient’s hospital discharge.
Nationwide results from HCAHPS survey have been published since 2008 in a searchable, comparable format on the consumer-focused government website Hospital Compare. The data have been used in a value-based incentive purchasing program since 2012. Hospital Compare also incorporates measures of quality such as mortality, readmission, and hospital-acquired infection rates as well as process measures such as how well facilities provide recommended care.
Starting in 2016, overall hospital quality has been encapsulated in a Star rating, which summarizes a variety of measures across seven areas of quality into a single number from one to five for each hospital. One of those seven areas is patient experience.
Hospitals may choose to ask additional questions of their own along with the HCAHPS survey, to gather additional, actionable quality data for internal purposes. Internal surveys with results closer to real time, instead of the months-to-years lag in posting HCAHPS scores, enable the hospital to respond to issues that emerge.
It’s not just the scores
“A lot of leaders in the hospital business will tell you ‘It’s not about the scores,’ ” Dr. Patel related. “But you need scores to tell how your practice is doing. It’s a testament to the kind of care you are providing as a hospital medicine program. These are important questions: Did your doctor listen to you, communicate in ways you understood, and treat you with courtesy?” Scores are scores, he said, but more importantly, are patients getting the information they need? Do they understand what’s going on in their care?
“You have to look at the scores and ask, what can we do differently to impact patient experience? What are we doing wrong? What can we do better? If the scores as a collective experience of hospitalized patients are plummeting, it must mean they’re not feeling good about the care they are receiving, and not recognizing what we’re trying to do for them.”
Declining HCAHPS scores last year could easily be explained by what was going on with COVID-19, Dr. Patel said. “But we want our patient experience to be seamless. We have to put ourselves in the patient’s shoes. For them, it’s about whether they felt they were treated well or not. We had to reinvent ourselves and find new ways to compensate for the limitations imposed by the pandemic,” he said.
“We also recognized that our No. 1 job as a group is to take care of our doctors, so that they can take care of their patients. We provided quarantine pay, implemented a buddy system for doctors, used CME dollars to pay for COVID education and, if they felt ill, we said they needed to stay home, while we paid their shift anyway,” he said. “When you do that kind of thing and engage them in your mission, frontline hospitalists can help to improve quality of care, decrease costs, and increase patient safety.”
A sacred encounter
For Sarah Richards, MD, a hospitalist with Nebraska Medicine in Omaha, what happens in the hospital room between the hospitalist and the patient is a sacred encounter. “It’s about relationship and trust,” she said, noting that it’s hard to capture all of that in survey data. It might be better expressed in words: “ ‘How are things going for you?’ To me, that’s the real patient experience. When I talk with physicians about patient experience, I start with why this matters. We know, for example, that when patients trust us, they are more likely to engage with their care and adhere to the treatment plan.”
Dr. Richards said standard hospital quality surveys can be a blunt tool. The HCAHPS survey, conducted around a week after the hospitalization, has a low response rate, and returns are not representative of the demographic served in the hospital. “The inpatient data are not always helpful, but this is what we have to work with. One choice hospitals have is for the leadership to choose not to use the data for individual bonuses, recognition, or discipline, since the questions ask patients about the care they received collectively from all of their doctors,” she said.
But as hospitalists have worked longer shifts under more stress while wearing PPE – which makes it harder to communicate with their patients – there is a dynamic that has emerged, which deserves more study. “I think doctors gave it their all in the pandemic. I’m a hospitalist, and people told me I’m a hero. But did that change my impact at work (on patient experience)?” she said.
Dr. Richards sits on SHM’s Patient Experience Special Interest Group (SIG), which was tasked with providing tools to help mitigate the effects of the pandemic. These include a fact sheet, “Communication Tips for 5 Common Conundrums in the COVID-19 Pandemic”, and a downloadable pocket card called “The 5 Rs of Cultural Humility.”
Also on the SIG is Mark Rudolph, MD, SFHM, Sound Physicians’ chief experience officer, whose job title reflects a growing, systematic attention to patient experience in U.S. hospitals. “Most clinicians are familiar with the surveys and the results of those surveys,” he told The Hospitalist. “People in our field can get frustrated with the surveys, and have a lot to say about the quality of the scores themselves – what is actually being measured. Is the patient upset because the coffee was cold, or due to a bad clinical experience? Is it about the care they received from the hospitalist, or the physical setting of the hospital?”
Doing the right thing
To be a patient hospitalized with an acute illness is a form of suffering, Dr. Rudolph said. “We know patient experience in the hospital since March of 2020 has been frightening and horrible. These people are as sick as can be. Everything about the experience is horrible. Every effort you can make to reduce that suffering is important. If you are a patient in the hospital and don’t know what’s happening to you, that’s terrifying.”
He encourages hospitalists to look beyond the scores or the idea that they are just trying to improve their scores. “Look instead at the actual content of the questions around communication with doctors. The competencies addressed in the survey questions – listening and explaining things clearly, for example – are effective guides for patient experience improvement efforts. You can be confident you’re doing the right thing for the patient by focusing on these skills, even if you don’t see immediate changes in survey scores.”
Hospitals that did not allow visitors had worse clinical outcomes and worse patient experience ratings, and recent research confirms that when family visitors are not allowed, outcomes are worse in areas such as patient ratings of medical staff responsiveness, fall rates, and sepsis rates.1 “None of that should be surprising. Not having family present just ups the ante. Any hospital patients could benefit from an advocate sitting next to them, helping them to the bathroom, and keeping them from falling out of bed,” Dr. Rudolph said.
“In the past year, we have placed a premium on communicating with these patients with kindness and compassion, to help them understand what’s happening to them,” he said. Out of necessity, hospitals have had to rejigger their processes, which has led to more efficient and better care, although the jury is still out on whether that will persist post pandemic.
Communicating with compassion
Swati Mehta, MD, a hospitalist at Sequoia Hospital in Redwood City, Calif., and director of quality performance and patient experience at Vituity, a physician-owned and -led multispecialty partnership, said COVID-19 was a wake-up call for hospitalists. There have been successful models for enhancing hospitalized patients’ experience, but it took the challenges of COVID-19 for many hospitalists to adopt them.
“Early in 2020, our data analysis showed emerging positive trends, reflecting our patients’ appreciation for what doctors were doing in the crisis and awareness of the challenges they faced. But after that uptick, global measures and national data showed drops for health care organizations and providers. Patients’ expectations were not being met. We needed to respond and meet patients where they were at. We needed to do things differently,” she said.
Keeping patients well informed and treating them with respect are paramount – and more important than ever – as reflected in Dr. Mehta’s “6H” model to promote a human connection between doctors and patients.2 As chair of SHM’s Patient Experience SIG, she led the creation of COVID-19–specific communication tips for hospitalists based on the 6H model. “I’m very committed to treating patients with compassion,” she said.
For Vituity, those approaches included making greater use of the hospital at home model for patients who reported to the emergency department but met certain criteria for discharge. They would be sent home with daily nursing visits and 24-hour virtual access to hospitalists. Vituity hospitalists also worked more closely with emergency departments to provide emergency psychiatric interventions for anxious patients, and with primary care physicians. Patient care navigators helped to enhance transitions of care. In addition, their hospitalist team added personalized pictures over their gowns so patients could see the hospitalists’ faces despite PPE.
Another Vituity innovation was virtual rounding, with iPads in the patient’s room and the physician in another room. “I did telerounds at our Redwood City hospital with patients with COVID who were very lonely, anxious, and afraid because they couldn’t have family visitors,” Dr. Mehta said. Telerounds offered greater protection and safety for both providers and patients, reduced the need for PPE, and improved collaboration with the nursing team, primary care providers, and families.
A recent perspective published in the New England Journal of Medicine suggests that the Zoom family conference may offer distinct advantages over in-person family conferences.3 It allows for greater participation by primary care clinicians who knew the patient before the current hospitalization and thus might have important contributions to discharge plans.
The pandemic stimulated many hospitals to take a closer look at all areas of their service delivery, Dr. Rudolph concluded. “We’ve made big changes with a lot of fearlessness in a short amount of time, which is not typical for hospitals. We showed that the pace of innovation can be faster if we lower the threshold of risk.”
References
1. Silvera GA et al. The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: A critical role for subjective advocates. Patient Experience Journal. 8(1) doi: 10.35680/2372-0247.1596.
2. Mehta S. How to truly connect with your patients: Introducing the ‘6H model.’ The Hospitalist. 2020 Aug 14.
3. Lee TH. Zoom family meeting. N Engl J Med. 2021 Apr 29;384(17):1586-7.