By Roni Caryn Rabin
Kaiser Health News
Two years ago, Inova Health System recruited a top executive who was not a physician, had never worked in hospital administration and barely knew the difference between Medicare and Medicaid.
What Paul Westbrook specialized in was customer service. His background is in the hotel business – Marriott and The Ritz-Carlton, to be precise.
He is one of dozens of hospital executives around the country with a new charge. Called chief patient experience officers, their focus is on the service side of hospital care: improving communication with patients and making sure staff are attentive to their needs, whether that’s more face time with nurses or quieter hallways so they can sleep.
It’s a dimension of hospital care that has long been neglected, patient advocates say, and it was put high on hospitals’ agendas only when Medicare started tracking patient satisfaction and, in late 2012, shaving payments to hospitals that fell short.
“There is a new recognition that the patient is important,” said Leah Binder, president and chief executive of the Leapfrog Group, an employer-based coalition that advocates for greater health care quality and safety.
Hospital routines have traditionally been designed to suit employees, not customers, she said. “The patient used to be maybe 10th on the list of a hospital’s priorities.”
BMJ: Bullying among doctors. ~L. Powell
The financial penalties introduced by the Affordable Care Act are part of a broader effort to transform health care delivery and improve quality while reining in costs, increasing transparency and holding hospitals and providers accountable for their work.
The penalties – which for now make up only a fraction of Medicare reimbursements – are based on a hospital’s ranking relative to other hospitals. One component is how they do on surveys of recently discharged patients. The hospitals are judged on answers to such questions as how well their doctors and nurses communicated with them, how clean and quiet the hospital was, whether they received help when they needed it and how well providers explained the drugs they were given.
Many hospitals commission additional surveys to use for their own purposes, such as marketing and branding.
Chief patient experience officers treat these survey results like sacred texts.
“The one thing I’m not trying to do is to put a mint on the pillow,” said Westbrook, who reports directly to Inova’s president and chief operating officer. “This is a different customer, with very different needs.”
But as patients’ out-of-pocket costs have risen, he said, they have become savvier, more demanding consumers.
“They are going to look on the Internet and on Medicare’s site comparing hospitals, and they are going to read comments,” he said, and increasingly, they will select hospitals based on the reviews. “It’s no different from TripAdvisor.”
Lofty goals, practical implementation
Unlike Westbrook, most chief patient experience officers rise through the ranks of a health system. Like him, though, they speak in lofty terms about teamwork, leadership and developing a philosophy and culture of compassion, service and respect at their institutions.
Westbrook, for instance, talks constantly about the “Inova promise” to “meet the unique needs of each person we are privileged to serve – every time, every touch.”
That phrase had “always hung on a wall,” Westbook said. “Now we don’t begin a meeting without an Inova promise story.”
On the ground, the focus is doggedly practical. One common innovation is hourly rounds, a system where nurses are expected to check in on each patient regularly, not wait for the person to use the call button. And the interaction is supposed to be meaningful and thorough.
“This doesn’t mean just pausing at the door, saying, ‘Are you okay? Can I get you anything?’ and off you go,” said Susan Eckert, chief nursing executive at MedStar Washington Hospital Center. “We’re telling our nursing staff that you should actually sit down, look at the patient, talk a little bit and give them several minutes of time during which they are the only thing that exists in the world…. It’s a very powerful experience.”
Hospitals that have put hourly rounding in place say the practice does not require extra staffing because it is more efficient to prevent problems before they occur. Taking time to reposition a patient prevents bedsores, for example, and helping patients to the bathroom prevents falls.
Another priority is having nurses call patients at home within 48 hours of their discharge, to keep their recoveries on track. (One Medicare question specifically asks patients whether they got good instructions about what to do when they get home. Hospitals can also be penalized if too many patients bounce back to them.)
Hospitals are increasingly taking their cues from patients, both by listening to the advice from new patient and family advisory councils and by using the surveys to identify weak spots.
At Yale-New Haven Hospital, where an executive director of patient relations and a medical director work together to improve the patient experience, officials have made a concerted effort to lower noise so patients can get optimal rest. Hospital staff are told to use “library voices 24/seven” and not to “vent” where patients might hear them. Overhead page calls have been eliminated, beepers are kept on vibrate, doors are closed when staff discuss cases and efforts are made to reduce alarms, pings and beeps at the bedside.
The Cleveland Clinic requires all 3,000 staff physicians to take a day-long relationship and communication class. In 2010, the hospital showed each doctor what patients had said about him or her in surveys. About half the comments were negative – and most of those had to do with how physicians talk to patients.
Doctors were stunned when they saw the results, said James Merlino, a surgeon who is Cleveland Clinic’s chief experience officer.
“Physicians were shocked, dismissive, disbelieving. They said, ‘This isn’t true, the methodology is bad, the sample size is too small,’” he said.
Now, he said, “we put physicians through communication training so they learn how to listen better, let the patient set the agenda and organize the encounter better.”
The result is a big increase in physician communication scores since 2008.
EDITOR | The Challenge: Onlookers Are Observing DPC Commentary and Passion Online, good and yes, bad. Rhetoric Is Passionate, however, DPC Comments Should Empathize, Uplift. And, They Should Never [EVER, under ANY circumstances] Villainize Detractors or Differing Opinions.
At UCLA Health System, parents of pediatric patients created an educational video about central-line catheters that is shown to physicians and nursing staff “to remind them how scary that catheter is for patients and their family members,” said Tony Padilla, UCLA’s chief patient experience officer, adding that catheter-related infections can be dangerous and even fatal.
“It drives home the message that during your very busy day as a nurse or physician, please remember: You’re accessing the child’s lifeline.”
Moving the needle
Moving the needle on Medicare surveys can be a hard slog. Inova Mount Vernon’s composite score went up from 66.6 percent to 68.4 percent from 2010-11 to 2012-13. That means that on average, 68.4 percent of patients gave top marks to the hospital on survey questions in 2012-13. Scores at Inova Fairfax dropped and scores at Inova’s other three hospitals remained about the same.
Hospitals face a balancing act.
“We want to be attentive to a patient’s needs and wants, yet not do things just to please the patient, like overprescribing pain medication,” said Atul Grover, chief public policy officer for the Association of American Medical Colleges, which represents nearly 400 major teaching hospitals and health systems, in addition to U.S. medical schools. “You want to make sure patient satisfaction isn’t driving patient care.”
Some question whether the hospitals that score best on patient surveys are also the ones that provide the best care. Grover, for example, worries that hospitals that don’t offer amenities, such as single rooms, will be dinged in the surveys.
But some research suggests a strong correlation between patient satisfaction and outcomes, said Richard Staelin of Duke University’s Fuqua School of Business.
One of his studies, published in the journal Circulation in 2010, found that the death rate among heart attack patients was lower at hospitals where patient satisfaction scores were high, even when researchers controlled for the quality of care, meaning the care was equivalent.
Another study found higher overall patient satisfaction was associated with lower readmission rates a month after patients were discharged.
Studies have also found that hourly nurse rounds result in more satisfied patients, with fewer falls and pressure sores.
“Patients co-produce the service,” Staelin said. “What I mean by that is that when someone is sick, the doctors can’t solve the problem without their help…. As a patient, I have to communicate with the doctor or nurse, I have to listen to the doctor, I have to follow the instructions.”
“There are still lots of doctors who don’t believe it, but gradually the medical profession is coming around,” he added.
Indeed, several patient experience officers said some physicians at their hospitals resisted doing things differently until it was no longer an option.
The financial penalties “are brilliant,” Westbrook said. “That’s what’s driving change.”
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.