The impact of HCAHPS on hospitals is being felt, and while always concerned with the patient experience, hospitals have significantly ramped up their efforts to ensure that they are providing both quality clinical care and exceptional patient experiences in measurable ways. With HCAHPS — and, soon, CG-CAHPS — measurement has become a mandate.
Hospitals, and soon, medical practices will feel the impact of the patient experience on reimbursement. For the first time, reimbursement is tied to patients' perception of care and their experience.
Clearly a primary impact on patients' perceptions are the interactions they have with their providers — nurses and physicians, primarily. In the clinic setting, the physician-patient connection is even more acute. Yet, little effort has traditionally been spent in activities to ensure that physician-patient interactions are positively perceived. There are a variety of reasons for this:
- Until HCAHPS, and the specter of CGCAHPS, there just hasn't been a burning platform to move into what has historically been perceived as a somewhat sacrosanct interaction
- Concern about how physicians might respond to interference in this area
- Lack of time
- Lack of readily identifiable need
- Lack of information. While most would likely agree that improving the physician-patient relationship is a good idea, exactly how should health care organizations go about it?
Physicians clearly have the opportunity for a marked impact on the patient experience. While the vast majority are highly committed to making that experience an exceptional one, like all of us, they may sometimes be unaware of the little things they do — or don't do — that may have a negative impact. They also may not recognize the special things they do that delight the patients they interact with.
The role of "shadow/coach"
One of the most revealing opportunities to gain insights into the patient experience is through shadowing and coaching the clinicians, including physicians, who interact with patients. This process includes two key elements:
- A "shadow," basically an astute observer, someone who can effectively pick up on both the objective and subjective nuances of a physician-patient encounter.
- A "coach," someone who fosters learning, transformation and growth.
By combining the elements of shadowing and coaching healthcare organizations can identify both best practices and opportunities for improvement.
BayCare Health System's use of shadow/coach
George Hutter, MD, vice president medical affairs with Mease Hospitals at BayCare Health System in the Tampa Bay, Fla., area, explains that BayCare chose to pursue physician shadowing and coaching for two reasons. "One, because we saw an opportunity to positively impact our HCAHPS scores and, two, because like many other hospitals we didn't feel the scores clearly reflected the actual patient experience," he says. "In addition, the financial incentives are a component of value-based purchasing are definitely a driver for BayCare and other organizations."
Other BayCare hospitals have had other patient satisfaction related initiatives in place, he says, but after hearing a presentation on physician shadowing, what it entails and the results it can generate, he was sold on the idea. A cross-functional team was formed at Mease to explore the concept and, ultimately, the team decided that the next step was to offer physicians the opportunity to participate. At Mease, hospitalists are employed, and the decision was made for these physicians to be the first to go through the shadowing process. The opportunity will eventually be extended to non-employed, non-contracted physicians as well.
While Dr. Hutter acknowledges that the leverage hospitals have with employed or contracted physicians is greater than in situations where there aren't these formalized relationships, he says he is optimistic that, at least at his hospital, the process will go smoothly. "I've done a lot of groundwork at my hospital in terms of discussing shadowing at department meetings, with the medical executive committee and during one-on-one meetings with certain key hospitalists." Given the inherent benefits of the process in terms of impacting patient satisfaction and outcomes as well as the impact on HCAHPS scores and related financial incentives, a very compelling case can be made for participation.
Physician response
While some may still believe that physicians are likely to be averse to anyone — particularly a non-physician — monitoring and commenting on their practice behaviors, the opposite is true. Physicians are, generally, quite eager to hone their patient interaction skills. Not only are they well aware of the implications of HCAHPS and CGCAHPS, but they are also aware that these relationships have a significant impact on patient compliance and clinical outcomes.
An important aspect of these initiatives that can serve to drive acceptance, notes Dr. Hutter, is that the information attained be kept confidential. "Opinions on this issue may vary," he acknowledges, "but, at Mease, we've assured them that we're not getting reports back from the coaches." Ensuring this level of integrity and privacy is a big positive for physician acceptance and, importantly, it doesn't detract from the value the hospital will attain.
Shadow/ coaching should not be about weeding out "bad" providers or about punishing; instead, it's a tool for goal-setting and personal improvement. Entering into a trusting partnership during this process, where both the shadow/coach and the physician recognize the value of these interactions, is critical. The outcomes of effectively implementing a shadowing and coaching process have both internal and external impacts.
External impacts: Patient engagement
- Improve patient satisfaction and resulting scores
- Improve patient adherence and outcomes
- Increase patient loyalty
Internal impacts: Physician engagement
- Improve staff relationships
- Improve culture of safety and decrease "never-events"
- Decrease disruptive behaviors
- Decrease malpractice costs
"Most physicians want to, and believe that they are, providing good patient service," notes Dr. Hutter."Sometimes, though, the numbers may indicate otherwise and this is where coaching can be useful. Often, physicians may not even be aware of subtle things that they may be doing — or not doing — that may impact patient perceptions."
For instance, says Dr. Hutter, the shadow may point out things like, "Did you realize that you never addressed the patient by her name?," or "You may not have realized this, but you never introduced yourself," or "By the way, Dr. Jones, I noted that when you were explaining to the patient that she had heart failure, you consistently used medical terms that I'm not really sure the patient understood based on my observation of her reactions during the encounter."
Mease, and BayCare, are in the early stages of their work with physician shadow/coaching. As they move forward, they will take steps to ensure that they have staff, on site, who are trained and skillful in taking on the roles of shadow and coach.
Training the trainer
Developing an effective physician shadowing program isn't a "once and done" event. There is a need both to continually evaluate the patient interactions of current physicians over time, as well as to ensure that new physicians have the opportunity to go through this process. Effective shadowing and coaching programs should be done on an ongoing basis. As new physicians are hired, as they move into new roles, or simply as time goes by, it's important to continually monitor physician/patient interactions with an eye toward continual improvement.
There are five essential steps involved in creating and implementing a program that will generate positive results. These steps can be conveyed through the acronym COACH:
1. Clarify specific criteria on which the provider will be assessed.
2. Observe baseline behaviors and identify any strengths or gaps between behaviors and desired best practices.
3. Identify Actions needed to close any identified gaps.
4. Communicate.
5. Help shape new habits through examples and teach back.
The coaching relationship is a partnership designed to help physicians identify and address areas where there may be gaps in desired performance and to reinforce areas in which they already have strengths.
Engaging physicians in the process is critical. Through communication, demonstration and the creation of a trusting partnership between the hospital, the coach and the physician, even stubborn scores can be nudged upward over time.
Kristin Baird, RN, BSN, MHA is president/CEO of Baird Group, a consulting group specializing in customer service improvement and mystery shopping for healthcare organizations. With more than 30 years of experience in patient care, healthcare marketing, business development and administration, Ms. Baird is a talented author, speaker and consultant with a passion for service excellence.