Every healthcare provider will tell you that patients are customers, and customers can take their business elsewhere if they are unhappy about any aspect of their experience. To keep patients, and thus reimbursement, coming in the door, hospitals must focus on achieving strong patient satisfaction scores. Moreover, the Centers for Medicare & Medicaid Services’ (CMS) value-based purchasing program will incorporate Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) scores into its inpatient prospective payment system starting in 2013, so there is no better time to hop on the patient satisfaction wagon.
According to Peter Short, MD, senior vice president of medical affairs at Beverly (MA) Hospital, most patient satisfaction survey tools, including HCAHPS, are multidimensional. Thus, the medical staff, nurses, other care providers, food service, and housekeeping must tackle patient satisfaction scores from multiple angles.
According to www.hcahpsonline.org, the HCAHPS survey contains 18 patient perspectives on care that encompass eight key topics:
- Communication with doctors
- Communication with nurses
- Responsiveness of hospital staff
- Pain management
- Communication about medicines
- Discharge information
- Cleanliness of the hospital environment
- Quietness of the hospital environment
“When you talk about HCAHPS, you are talking about the whole patient experience. To demonstrate to patients that we have their best interests at heart, we have to be a team. It takes a team approach to improve HCAHPS,” says Short. Medical staff leaders can help heighten the team spirit by creating a patient-centered medical staff culture using the following hospitalwide tips.
Implement multidisciplinary rounds
Jonathan Lovins, MD, SFHM, assistant clinical professor of medicine at Duke University Health System and hospitalist at Durham Regional Hospital (DRH) in Durham, NC, says that multidisciplinary rounds have helped improve the organization’s HCAHPS scores by 5% during the past three years because patients perceive a more coordinated approach to their care. “I think one of the things that disheartens patients the most is when they hear different stories from different providers,” says Lovins.
Every morning, nurse managers, case managers, nurses, physicians, and pharmacists meet for 10–20 minutes to discuss each patient. “As a hospitalist, I don’t feel like it saves me time, but at the very least, it seems to make patients more comfortable,” says Lovins.
Not only do multidisciplinary rounds help get all care providers on the same page, but they also help reduce mistakes that result from miscommunication (or noncommunication). In addition, they help all members of the healthcare team feel included in care decisions.
To implement multidisciplinary rounds, the medical staff appointed a physician to serve as the medical director for each of DRH’s two floors. Patients were then distributed geographically, meaning Dr. Jones’ patients are clustered on the first floor, while Dr. Smith’s patients are clustered on the second floor. “That was the hardest part. When we distribute the patients in the morning, we try to make sure that each physician gets patients only on that floor, which was hard because we have to sacrifice things like continuity of care to a degree,” explains Lovins.
For example, although hospitalists, who generally work seven days on and seven days off, were previously not assigned new patients on their last day of work, they sometimes now receive new patients so that patients are located on the correct floor for the hospitalist who starts work the next day.
According to Short, Beverly Hospital also performs multidisciplinary rounds. One of the major benefits, he explains, is that the same group of nurses works with the same handful of physicians, creating a team environment.
“We go in the patient’s room together to see the patient. That way, if anyone has a question, they can get the same answer from the nurse or the doctor, and the patients know it is a team approach. Patient satisfaction is about communication to their family and the rest of the caregiver team,” says Short.
Use electronic discharge instructions and medication reconciliation
DRH recently switched to electronic discharge instructions and medication reconciliation, and it saw an increase in patient satisfaction. “We know patients are more satisfied with an electronic discharge document and electronic medication reconciliation because it is legible and clear,” says Lovins.
Rather than a physician writing out discharge instructions and a list of medications by hand and risking the patient or the pharmacist misunderstanding or misreading instructions, physicians now fill out an electronic form and print it for the patient.
The electronic discharge instructions and medication reconciliation documents also work to reduce errors by helping physicians make decisions. For example, if a physician selects an antacid drug, the computer program automatically eliminates the option for selecting other antacid drugs.
Get an outside opinion
An outside opinion may be just what physicians need to improve their communication scores on the HCAHPS survey, says Gerda Maissel, MD, chief medical officer at Baystate Franklin Medical Center, a 90-bed community hospital in Greenfield, MA.
Physicians at Baystate Franklin consistently scored low on the HCAHPS survey. “As physicians, we were in a little bit of denial, which is classic for physicians. We assumed the scores were wrong,” says Maissel. But after tracking the scores over a period of months, it became clear that the problem didn’t rest with the data.
“We researched the literature and implemented best practices, and we saw a little bit of an improvement, but we were still baffled. We started color coding the data, and if you were below the line, you were red. We wanted to be green,” Maissel explains.
To address the problem, the medical staff brought in an individual with marketing experience and a kind, calming demeanor. She watched physicians interact with patients and gave them concrete, useful tips on how they could improve. Her demeanor was instrumental in relaying information to the physicians without sounding harsh or critical.
Although an evaluator does not need a background in marketing, Maissel notes that this evaluator’s experience helped her articulate to physicians what patients (i.e., consumers) want. It is important for the evaluator to be a nonphysician who can see the patient-physician interaction from the patient’s point of view. “I tried to evaluate physicians when I was in a different role, and I didn’t come close to what [our evaluator] came up with,” says Maissel.
As it turned out, the little things were what made all the difference. One physician wasn’t listening to patients long enough, and the evaluator suggested that the physician wait three to five seconds before responding to the patient to make sure the patient was done speaking. Another physician was overloading patients with information, making them feel overwhelmed. A third physician rushed when she explained things.
“It is not that anyone was being rude to patients or behaving outrageously where we had to discipline them, but there were subtleties that, when addressed, helped us cross the line from red to green,” explains Maissel.
Institute hourly nursing rounds
Medical staff leaders can encourage their respective nursing departments to institute hourly rounds. At DRH, hourly nursing rounds have improved patient satisfaction scores because they ensure patients don’t feel forgotten. DRH nurses check each patient for the four P’s:
- Partner (nurses work with nursing assistants)
“Potty is really important. By far the most common cause of falls is patients getting up to go to the bathroom. It has been shown many places that if you ask patients every hour if they need to potty, you can get your fall rate down to almost zero,” says Lovins.
Beverly Hospital’s nurses also round hourly. In addition, the hospital has a rule that a nurse should never ignore a call bell; even if the patient is not assigned to the nurse who notices the call bell, that nurse should still respond. The initiative forces nurses to think outside of their own workloads and focus on the needs of all patients on the unit.
Make each patient feel like the only patient
Physicians can have a profound effect on the patient experience by simply focusing on the patient in front of them and not succumbing to the buzz of distractions. When Short, a pediatrician, enters a patient’s room, the first thing he does is introduce himself. The second thing he does is say, “Let me wash my hands before I examine your child.” He then washes his hands in front of the parents. After examining the patient, he washes his hands again and makes a point of sitting down with the parents to talk. “Sitting down sends the message that you are not rushed, even if you are,” says Short.
“All of us need to understand that we are not just taking care of the medical problems of the person who is admitted; we are taking care of the person and the family. As long as you keep that in mind, you are going to have great patient satisfaction scores,” he says.
Take time to talk to nurses
When dealing with sicker patients, physicians should take the time to explain their thought processes to nurses. “I explain what I am doing and ask the nurse if he or she is comfortable with that. In the end, they are in the front lines. The benefit [physicians] get on the other end is if you communicate up front, you don’t get all these calls on the back end,” Short explains.
Be a team player
Caregivers often operate with blinders on. Nurses focus on their nursing responsibilities, and physicians focus on medical decision-making. In the process, they may both overlook the dirty towel on the floor or the empty juice cup on the bedside table.
“Patient satisfaction is everyone’s job in every area, which means if there is stuff on the floor, you don’t call housekeeping—you pick it up. If there is a spill on the floor, I clean it up because if I don’t, someone is going to slip,” says Short.
Remind caregivers of their commitment
At Beverly Hospital, each floor receives its own patient satisfaction scores. “Sometimes, just knowing your scores and having a little competition is healthy,” says Short. The hospital also reviews Press Ganey and HCAHPS scores weekly. If a physician, nurse, or other caregiver receives a compliment from a patient, the hospital recognizes that individual. If a physician goes the extra mile, Short writes him or her a personal thank-you note.
At DRH, physicians see a group patient satisfaction score, but they don’t see their colleagues’ individual scores. “We don’t compare with other departments, but the interesting thing is that our incentive is based on the hospital’s score and our individual scores, not the hospitalist group’s score,” explains Lovins.
Consider giving patients health-related gifts at discharge
Giving patients a gift at discharge, such as a pedometer, calorie counter, or pillbox, has two benefits: Patients may perceive their experience more positively, and the gift may help motivate them to follow their discharge plan, says Bradley Flansbaum, MD, a hospitalist engaged in a patient satisfaction improvement experiment at Lenox Hill Hospital in New York City.
Flansbaum notes that hospitals are constantly trying to improve the patient experience by offering Wi-Fi or installing bigger television sets. “If you are giving patients something that is useful for health, I would argue that you are doing more for the patient experience than putting a fountain in the lobby,” he says.
Patients should be given gifts that will help them stick with their discharge plans. For example, if a physician talks to a patient about cutting out soda to reduce insulin spikes, a calorie counter would help the patient keep track of his or her intake. If a physician prescribes more exercise, a pedometer will help the patient reach that goal. “As long as the item itself has a health-related meaning, I think it is legitimate,” says Flansbaum.
Hospitals may question whether the return in healthy habits is worth the investment in purchasing the gifts. “If one person changed their lifestyle for every 50 or 100 pedometers you give out, it may be worth it,” Flansbaum says.
With CMS incorporating HCAHPS and other patient satisfaction measures into the inpatient prospective payment system in the near future, hospitals must begin thinking creatively about ways to improve patient satisfaction. These tips can get you started without much monetary investment and serve as a jumping-off point for bigger initiatives.
For more tips on patient satisfaction , conflict resolution and recruitment, check out the following articles from our Strategies for Nurse Managers site and the Leaders' Lounge Blog!