There are fundamentally 3 reasons to have a progress note: To communicate with other healthcare providers To provide documentation for medial-legal purposes To provide documentation for billing purposes In the...
The HCAHPS survey measures patient satisfaction with various aspect of their hospitalization. One of the sections of the survey is about doctor communication with the patient. Because a hospital’s HCAHPS results are publicly available, hospitals want to do everything they can to keep their scores up. As a hospital medical director, one of my jobs is to keep the doctor communication scores high.
We are able to analyze our HCAHPS results by nursing unit, physician group, and individual physician. I always find it remarkable that there are some physician groups that routinely score in the national top percentiles for doctor communication. On the other hand, there are other physician groups that routinely score in the bottom percentiles nationally for doctor communication. I’m very familiar with the quality of medical practice that all of these groups practice and it is pretty similar. But the HCAHPS survey does not really measure quality of care, it measures patient’s perceptions about their care. So, it is not good enough to just provide great medical care to the patient, you have to provide great communication to the patient. To use a restaurant analogy, you can serve the absolute best food in town but if the waiter is a jerk, you are going to rate the restaurant poorly. Here are some practical things that doctors can do to improve the patient communication scores on the HCAHPS surveys:
- Commit to sit. Patients are generally laying or sitting up in a hospital bed. If a physician comes into the room and is standing while talking with the patient, then the communication lines between the doctor and the patient are not aligned. On the other hand, if the physician sits down when rounding on that patient, several things change. First, the doctor’s face and the patient’s face are on an equal level and this imparts more of a 2-way communication perception as opposed to the doctor towering over the patient and lecturing to them. Second, the patient’s perception of time changes – the patient will perceive the doctor who spends 3 minutes in the room sitting as having spent more time with them than the doctor who spends 3 minutes in the room standing. Third, simply sitting will create more of an impression of caring about the patient.
- Don’t be a one-and-done. A lot happens to a patient every day in the hospital. They have tests, then get new medications, and they have changes in their symptoms. If the doctor just rounds on the patient once in the early morning each day, then that patient will perceive that the doctor is less engaged in the patient’s care. On the other hand, doing formal rounds in the morning and then brief follow-up rounds on the patients in the afternoons can be reassuring to the patients that the doctor is keeping track of the patient’s status and test results and also creates more of an impression that the physician cares about that individual patient.
- Round with the nurse. Joint rounds, when the nurse and the doctor both go into the patient’s room together, can make a big difference in doctor communication scores. It creates an impression by the patient that everyone is on the same page – that is, that the doctors and nurses are all communicating with each other about the patient. It allows for the nurses to get a lot of information from the doctor about the plans for the day, etc. so that the nurse does not need to page the doctor later in the day with questions about the patient. It allows the nurse to bring up information about the patient’s condition that the patient might night think or know to mention to the doctor (like whether the Foley catheter can come out or that the patient had a fever earlier in the day). However, it is important that these joint rounds occur in the patient’s room and not just in the hallway in order to affect the patient’s perception of doctor communication.
- Speak the patient’s language. For a patient who speaks a foreign language and doesn’t speak English, this is pretty self-explanatory: you get a translator. But every patient has a different level of healthcare literacy and the words that the doctor chooses can make a big difference in whether the patient really understand what the doctor is saying. In our hospital, when a doctor talks with a patient, the complexity of medical terminology used by the doctor is inversely related to how many years that doctor has been practicing. Often, you’ll hear a resident say to a patient: “The cath showed you have a cardiomyopathy with an ejection fraction of 30% so we’re going to start a diuretic and an ACE inhibitor”. An hour later, the more experienced attending physician will walk into the patient’s room and say: “The heart test showed you have heart failure and the heart is not pumping very well so we’re going to start you on a water pill and a heart failure pill”. The bottom line is you need to avoid medical jargon.
- The patient only remembers 3 things. Being an inpatient is pretty overwhelming and patients are trying to remember lots of stuff, at a time that they usually feel pretty lousy. If you tell the patient 6 things about their condition, they are only going to remember 3 of them. So, be judicious in information so that the patient remembers the 3 things you want them to remember rather than the 3 least important things of the 6 that you told them about. Having a white board with a marker to write with in the patient’s room can be a great way of reinforcing information and helping the patient’s family know what is going on that day; for example, write down the name of the new drug being started or the tests/therapies planned for the day. At the end of the encounter, summarize the key points that you want the patient to remember – they will remember the last things you said better than they will remember the first things that you said.
- Listen to the patient. This is probably the hardest part of doctor-patient communication in the hospital. The doctor is under enormous pressure to get in and out of the patient’s room so that he/she can order all of the tests that need to be ordered, get their progress notes written, review consultant reports, get the next patient admitted, and get other patients discharged. But communication is a 2-way event and the patient will perceive that the doctor is a better communicator if that doctor listened to what the patient had to say in addition to talking to the patient. Try to finish each encounter with “What other questions do you have?”.
- There is more to the patient than just a disease. Take time to find out a little bit about the patient other than their lab tests and x-ray results. Learn a little about their family, their recent travels, their occupation, their heritage, or their hobbies. The patient will perceive that the doctor is interested in them as a person and not just as customer.
- Hospitalist face cards. The patient sees lots of people in the hospital and usually has a hard time remembering who is who. Giving the patient a card with the hospitalist’s name and photograph goes a long way in helping the patient sort out all of this information. Furthermore, it changes the mindset of the patient from “That is the doctor” to “That is my doctor”.
- Give the doctor feedback. We give residents and medical students feedback on how they communicate but the attending physicians rarely get feedback. Having a senior physician or a member of the hospital’s patient experience staff round with the physician to give them feedback on their communication style can be very effective in fine-tuning that doctor’s communication with the patients.
- Incentivize communication. In a previous post, I wrote about why you can’t pay hospitalists by the RVU. As with anything in life, you get what you pay for and if all you pay for is patient volume, then you get patient volume. But if you bonus hospitalists on their doctor communication scores, you’ll get better communication scores.
- Don’t let the computer get in the way of the patient. Either do the computer charting after you walk out of the patient’s room or, if you must use the computer in the hospital room, maximize eye contact with the patient and minimize the amount of time you are looking at a computer screen.
- Respect the patient. Patients often feel like a piece of medical merchandise. Treat them like a person by knocking on their door before entering their room, addressing them by their name, introducing yourself, asking them for permission to do a physical exam before laying hands on them, be aware of your body language (fidgeting, checking your cell phone, etc.), and avoid interrupting the patient.
- A picture paints a thousand words, and so does an x-ray. People fear ghosts because they can’t see them. Once you actually see something that you are afraid of, it usually isn’t quite as scary as it was before. Showing a patient what the x-ray or CT scan abnormality is can de-mystify their disease and help them understand it. Having a bedside computer or tablet can help the patient see what the problem is.
Perhaps the most important lesson comes from a quote by George Bernard Shaw: “The single biggest problem with communications the illusion that it has taken place.”
October 10, 2017