Rush University Medical Center significantly improved its hospitalists' HCAHPS scores by launching a program to prioritize "the patient perspective and experience," three hospital leaders write in NEJM.
Hospitalists face unique challenges related to patient experience, write Suparna Dutta and Francis Fullam—medical director of the attending-directed service and senior director of marketing research, respectively, at Rush University Medical Center—and Jay Behel, assistant dean of academic development at Rush Medical College.
For instance, hospitalists must quickly build "trust and rapport with acutely ill patients" who may be confused by the "numerous medical personnel they encounter."
This may help explain why hospitalists typically have lower HCAHPS scores than other physicians, Dutta, Fullam, and Behel say. That was certainly the case at Rush in 2008, when its hospitalists' HCAHPS communication scores were near the seventh percentile nationally. Its non-hospitalists were at the 47th percentile.
Officials felt the low scores among hospitalists didn't match the high quality of care at Rush, so they launched a program to improve hospitalist-patient communication. The program began in 2007, but Rush launched a "more focused initiative" in 2013, which had seven main components.
Facecards: Each hospitalist received business cards with a photograph, description of their role, and contact information. "These were to be handed to each patient to initiate conversation about the hospitalist's role and his or her responsibility around care coordination," Dutta, Fullam, and Behel write.
Checklists: Starting in 2008, Rush produced several iterations of a checklist—some long and some short—to structure hospitalist-patient interactions. They included items such as distributing facecards, making daily afternoon rounds, and using in-room whiteboards to communicate with patients.
Clinician feedback: At the beginning of the program, hospitalists received feedback on patient communication in a simulated clinical setting. Later, psychologists observed hospitalists interactions with real patients and provided one-on-one feedback. Also, medical students monitored how frequently hospitalists used checklists, and hospital staff regularly interviewed patients on their exeriences with invididual clinicians.
Transparency and collaboration: Hospitalists met monthly to review HCAHPS scores, process bedside-interview feedback, and monitor checklist utilization.
Incentives: A portion of the hospitalist group's incentive bonus was based on achieving a group HCAHPS metric.
Education: Hospitalists received annual best-practice training "focused on effective communication, introduction of our best practices checklist, and information regarding the HCAHPS survey," Dutta, Fullam, and Behel write. In addition, top-performing doctors trained other clinicians on communication best practices.
Benchmarking: Rush also built a database of HCAHPS scores from hospitalists at other academic medical centers to put its "performance in context."
Results and lessons learned
Rush hospitalists' patient communication HCAHPS scores improved from the seventh percentile in 2008 to the 66th percentile in 2015. The rate of improvement in hospitalists' communication HCAHPS scores was nearly double the rate among non-hospitalists, at 14 percent versus 7.3 percent.
Meanwhile, the percentage of hospitalist patients who rated the hospital a nine or ten overall increased from 67.8 to 76.9 percent.
Going forward, Rush hopes to improve the program with more robust benchmarking, a standardized nurse-doctor rounding protocol, and other process improvements.
"This ongoing effort is one of continuous improvement, until the performance gap between hospitalists and non-hospitalist colleagues closes completely," Dutta, Fullam, and Behel conclude (Dutta et al., NEJM Catalyst, 4/6).
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In most hospitals, hospitalists care for over 50% of patients and are an inflection point for many of the metrics used in pay-for-performance programs. A high-performing hospitalist program is a key strategic asset, yet few hospital leaders feel they have fully leveraged their hospitalist program to advance outcomes.
With the right support and expectations, hospitalists can have a profound impact on quality and culture across the organization. However, there are many barriers hospitalist programs must overcome to optimize performance