If either a family member or you have ever been a hospital patient, you understand the importance of good communication with the doctors. You want to be listened to, have things explained in ways you can understand, and be treated with courtesy and respect. Who doesn't? Now, however, patients are rating their doctors' communication skills on the Center for Medicare & Medicaid Services' HCAHPS Survey, and the performance is linked to reimbursement.
Most physicians would agree that communication is the foundation of the doctor-patient relationship and is integral to the clinical practice of medicine. (Clinical quality is both what we deliver to patients, such as technical skills and procedures, as well as how we deliver the care, such as professionalism, kindness and respect, and clear explanations.)
As studies validate, good communication has a therapeutic effect for patients, even reducing pain, improving blood pressure readings and increasing function. Patients who understand their doctors are also more likely to acknowledge health problems, understand treatment options, modify their behaviors and comply with medication schedules.
While most physicians already understand and buy in to this concept, they may need your help in understanding how the HCAHPS survey measures their performance and how results lead to better clinical outcomes for their patients. Begin by showing them the actual HCAHPS data that rate their performance. This moves an abstract concept to a concrete one so that they understand that HCAHPS ratings are not "soft stuff," but rather a reflection of patients' perception of the quality of their care.
Getting to "Always"
When patients at top-performing hospitals are asked on the survey, "How often did doctors treat you with courtesy and respect? Listen carefully to you? Explain things in a way you could understand?" 90 percent of patients answer "always."
Instead of designing new processes, top-performing physicians ask themselves: "How can we ensure that patients understand that our goal is to listen carefully, and always explain things in ways they understand?" They then standardize their communication behaviors so they execute them with every patient every time to hardwire a culture of "always." Here's how you can help your physicians get to "always":
Ensure that physicians treat patients as partners. Patients are the only ones who can determine whether they feel as if they (and their key caregivers) are being treated as true partners in their care. The "listen carefully and explain" questions are a reflection of this perception. In fact, studies show that the average physician in a typical interaction will interrupt a patient within 17 seconds.
Physicians who score high on this composite excel at listening to the patient. At Roper St. Francis Healthcare, a system with more than 90 clinics in Charleston, S.C., the 22-member cardiology group launched a "take two" initiative with its cardiologists for this very purpose.
Medical director of cardiology Michael Grayson, M.D., explains: "This is particularly effective when getting ready to discharge the patient. The results of this small, but effective, action have been powerful." He adds, "One of the strategies we use to demonstrate we are listening carefully is to ensure that the patient can ‘teach back' the most important aspects of their care management, specifically as it relates to their medication regimen. While this takes extra time, it does ensure that the patient understands the purpose and side effects of any medication ordered."
Be sure physicians allow patients to participate in decision-making. It's important that they provide full explanations and both elicit and respond to patient concerns during a patient interaction. Also, they should be willing to modify the treatment plan based on patient input.
Remember, patients are the ones who will be implementing and carrying out the plan when they are discharged, so it is critical to ensure mutual understanding and commitment ahead of time. Physicians often fail to ensure that communication is a two-way process, not just a one-way flow of information from doctor to patient.
Focus on nonverbal communication. The manner in which a physician communicates to a patient is as important as the information being communicated. A patient is looking for both verbal and nonverbal cues. Studies show that a patient's perception of time spent increases if a physician sits down. (This is why sitting at the patient's bedside instead of standing at the door is so effective.)
This is another reason it's important to ask: Do physicians appear unhurried? Available? Do they provide emotional comfort and take time to answer questions? These are factors that impact a patient's perception of physicians. Body language is also important.
Deal with problematic behaviors. On the HCAHPS "always" scale, even one negative interaction with a physician will impact a patient's perception of the overall experience. For example, patients will commonly give a provider a low rating due to lack of communication about delays in the emergency department, overly brief interactions with the covering hospitalist, or jousting between consulting and attending physicians in front of the patient.
Nurse leader rounding on every patient, every day, can identify these seemingly small behavioral issues through targeted questions, and identify opportunities to intervene with behavioral coaching. Physicians modify their behaviors when they understand why a behavior change is important and that there is a compelling need to change. Be sure they also understand how to change by providing training that includes role-playing, observation and feedback. Then, be transparent about performance by measuring the change effort and reporting the results.
How to Engage Physicians
The absolute first step in improving HCAHPS results is to respect that physicians have a difficult job. Ask yourself: Have we removed barriers to efficient practice? Do the physicians have excellent and well-trained staff to carry out their orders? Have we emade sure our hospital is a great place for them to practice medicine? When it comes to HCAHPS, have we trained them on the link between HCAHPS data and clinical outcomes? Have we shared specific data and best practices to impact the results?
Trust is also an important component, so appoint a physician champion who is widely respected to steer change efforts. Finally, recognize those physicians who are modeling new behaviors and getting great results. Too often, we focus only on those who need improvement, so also be sure to recognize those physicians — both publicly and privately — who do an exceptional job of communicating with patients. (Behaviors that are rewarded and recognized get repeated!)
Successful organizations not only partner with physicians in goal-setting and strategic planning, but they also provide structured training to build their skills in leading change. In fact, at Carle Foundation Hospital and Care Physicians Group, an integrated delivery system with 400 physicians and 200 advance practice providers in Urbana, Ill., physicians have used communication training to move their HCAHPS physician communication composite from the 14th to 63rd percentile over a period of two years.
"With our focus on population health, patient and family engagement in their wellness and overall care plan is critical. Communication with physicians is of upmost importance to this, not only from the inpatient perspective, as measured by the HCAHPS survey, but also from the outpatient perspective," explains John Snyder, Carle executive vice president and chief operating officer. "Our physician leaders participate in education forums and cascade information on improving communication to their peers. Then they follow up with individualized coaching as needed. It works!"
Karen Cook, R.N., is a Studer Group coach, speaker and co-author of The HCAHPS Handbook: Tactics to Improve Quality and the Patient Experience.
