HCAHPS Doctor Communication:Excelling in The New Reality of Performance

Dan Smith, MD, FACEPEdward Goldberg, CEO St. Alexius Medical Center

What’s Right in Health CareOctober 11, 2012

Nashville TN

Pay for Performance is 

Here 

Now

CAHPS® Family of SurveysConsumer Assessment of Healthcare Providers and Systems

Family of surveys designed to assess patient perceptions of quality • Health Plan CAHPS• Hospital CAHPS (HCAHPS)• Clinician and Group CAHPS (CG-CAHPS)• Home Health Care CAHPS (HH-CAHPS)

D

Value Based Purchasing FY 2013

12 Core Measures

(* 70% Weight)

8 HCAHPS Composites(* 30% Weight)

1% Base operating DRG payments

Performance attainment and improvement 

willdetermine total 

hospital reimbursement

Implementation FY 2013 (October 2012)Source: Value Based Purchasing Program final rule 4.29.11

ImprovementAchievement Consistency

The greater of the two scores will be used for each 

composite

Achievement – Improvement – ConsistencyHCAHPS Scoring

Note:  Implementation FY 2013 (October 2012) 

Source: Value Based Purchasing Program final rule 4.29.11

Based on achievement performance in ALL composites or lowest index composite will be 

used

COMPOSITES/HCAHPS MEASURES FLOORMINIMUM 

ACHIEVEMENT (50th percentile)

BENCHMARK (mean of top decile)

Nurses always communicated well 38.98 75.18 84.70

Doctors always communicated well 51.51 79.42 88.95

Patients always received help quickly 30.25 61.82 77.69

Pain was always well controlled 34.76 68.75 77.90

Staff always explained about medicines 29.27 59.28 70.42

Rooms and bathrooms were always kept clean36.88 62.80 77.64

Area around room was always quiet at night

Yes patients  given info about DC/recovery 50.47 81.93 89.09

Patient’s overall rating of hospital (9 & 10) 29.32 66.02 82.52

HCAHPS Scoring BasicsTop Box Baseline Numbers

Improvement9 improvement points per composite can be

earned based on moving baseline

performance

Achievement10 achievement

points per composite at or above benchmark

Consistency20 consistency points if ALL composites are at or above the 50th

percentile

Value Based Purchasing FY 2014

Core Measures(45% Weight)

HCAHPS Composites(30% Weight)

1.25% Base 

operating DRG 

payments

Performance attainment and improvement 

willdetermine total 

hospital reimbursement

Outcomes(25% Weight)

New 2014 update

Note:  Implementation FY 2014Source: OPPS VBP Final rule 11.1.11

Why does Great Communication Matter?

Global ratings of care are more closely linked to communication than technical skillKey drivers and priority indices indicate preference for physicians skilled in communicationImproved quality outcomes Affects reimbursement to hospitals (HCAHPS/VBP)Reduces malpractice and complaint eventsPrimary driver to attain and retain patients

We can control this one

Shift in Healthcare

Past

“Volume”EffortHMO“Usually”“Good”“7 or >”PaternalisticCare

Future

“Value” PerformanceACO/CI“Always”“Excellent”“9 or 10”MutualisticCare and Perception of Care

How are We doing in Communication?

Research cites fundamental gaps related to:Interruptions during open ended inquiryMissed opportunities related to empathyTime estimates to patients and familiesMedication and test explanationsIntroduction and patient recall of physician name

Principles of Communication

Non-verbal cues and demeanor send a messageBe courteousExplain in a way they understandListening is as important as explainingA picture speaks a thousand wordsCultural sensitivity Language specificityAlign with level of health literacy

Don’t Miss These Core Elements of Your Communication with Patients and Families

CourtesyRespect

Listen Explain

Physician Communication Fitness

Patient satisfaction trendsComplaints ObservationsAIDET® skills lab

Direct Observation and Validation

© 2006 Studer Group

AIDET Observation Feedback – Rounding on Patients Name of Leader _____________________ Date _____________________ Unit Department ____________________ Coach ____________________ E-mail Address _____________________ Reports to ________________

Strengths Identified During Observation

Knocked before entering the room

or

Acknowledged with eye contact and body language

Used patient name

Introduced self, role

Managed up experience/training

Managed up others(co-workers, other depts., physicians, shifts)

Gave a time expectation of how long a test or procedure would take

or

How long they would be in the room interacting with the patient

Explained what would be taking place (rounding, procedure, registration, etc.)

Used key words from the patient satisfaction survey

Asked if there was anything they could do before leaving

Thanked pt. or pt. family

Role modeled other Behavior Standards consistently

Good skill development, able to use AIDET successfully

A natural at AIDET; could mentor leaders who need to learn AIDET

Recognizes staff members for using AIDET; observes when rounding on staff

Areas to Focus on During the Next 90 Days

Verbal skills: “A”cknowledge

Body language (eye contact, distance): “A”cknowledge

Use of name “I”ntroduction

Reference to experience or training “I”ntroduction

Manage up others (co-workers, other depts., physicians, shifts) (“I”ntroduction

Reference to time for interaction “D”uration

“E”xplain each step of interaction in advance

“T”hank patient creatively (i.e., thank youfor your trust, for being a good patient, forletting me take care of you, etc.)

“T”hank family creatively

Ask if there is anything the patient needs before the interaction ends.

Would recommend AIDET Solutions for theorganization

Would recommend review of AIDET video and use of Participant Guide to reinforce skills

Would recommend follow-up AIDET observation on next visit

Additional comments – areas of strength or opportunity to improve:

Dr. Ahmad 04-11-127Neumann Dds mdSparrow

X

X

Male with TIA and s/p CEA

X

Gave a business card

X

X

XX Gave card on intro

Great dyad team care with nurse and inquiry aboutissues in front of patient

X

X

"today, we will plan to go home today..."

Good opportunity to manage-up Vascular Surgeonswhile examining CEA site, "they do great work..."

Good use of humor...

The ideal communication tool

A I D E THCAHPSDoctor courtesy and respect x x xDoctors listen carefully xDoctor explanations are clear x x

VendorListened, Showed Concern and Respect x x xExplained medical findings in a way I could understand

x x

Kept informed of how long things would take xTests and procedures were adequately explained before they were done

x x

Enhanced AIDET®

aka AIDET 2.0Foundational communication toolTactical and pointed communicationTight linkage to what matters most to the healthcare consumerIncorporates essential non-verbal cues Emotional intelligenceHealth literacy

AIDET®

AcknowledgeAcknowledge

IntroduceIntroduce

DurationDuration

ExplanationExplanation

Thank youThank you

Acknowledge

Knock prior to entry (privacy)Confirm roomed patient is same as chart name (HIPAA/safety)Acknowledgement of all members in the roomCordial, eye contact, shake hands“you get one chance to make a first impression”Do the first moments send a message of courtesy and respect

“Mrs. Smith, may I come in…”

Handwash

Hand Hygiene: Inpatient

0

10

20

30

40

50

60

70

80

90

100

Always Usually Sometimes Never

% R

ank,

Lg

PG D

atab

ase

Frequency of Observed Hand Hygiene

Inpatient Patient SatisfactionFilter: How often staff cleaned hands?

Std Overall

Std Doctor

Std Nurse

Introduction

Introduce yourselfGen X and millennium age prefer first name, last name approachBaby boomers and elderly prefer traditional “Dr.__”Role follows nameCite experience and expertise (reduces anxiety) Manage-up other members of the care team (improve patient perception and staff-physician collaboration)

“I am Dr. Dan Smith, I am a staff emergency physician here and will be caring for youtonight. Rest assured, I have practiced for 14 years and we have a great team on tonight.”

Dr:Nurse:

Time:

Provider PostureSeated preferredQuality of interaction is the keyPatients will overestimate time when seated

Provider Attire“Professional” is the keyNo significant difference between formal attire v. hospital scrubs on satisfaction or perception of professionalism

Patient Attitudes Toward Emergency Physician Attire. J Emerg Med 2005; 29(1):1-3.

Johnson R et al. To sit or not to sit? Ann Emerg Med 2008;51:188-193.

Duration

Anticipate the patient’s concernsFrame the visit in time and contentDuration of events/services/tests/proceduresOverestimate if unsure (Disney rule)People expect there may be a waitIt’s not the wait that gets them upset…it’s not knowing “why” or “how long”

Explanation

Diagnosis or Non-Diagnoses

NameTest resultsForecast the usual coursePicture/diagrams/literatureFollow-up plan

Medications

Name“Why” of use and selectionAnticipated effectHow to take itSide effects/monitoringCost considerations

Health Literacy

Explain in a way that aligns with a patient’s education and intellect“Teach Back”“I have given you a fair bit of information today… Would you mind telling me what you understand about this illness?”

Three Ways to Inquire about Understanding

(a) You don’t have any questions, do you?(b) Do you have any questions?(c) What questions do you have?

Thank you

Value statement/Appreciation“Thank you for entrusting your health to us…”

“Thank you for complying with the treatment plan…you are doing great.”“Thanks for enduring the long waits today…your health is important to us.”Considered “wow” factor

Key Words at Key Times (KWKT)

Not “laminated” scripting verbiageVerbal cue which links an action to the “why”“Let me have Joan get you some nausea medicine as we want you to be comfortable”“Let me explain this again as I want to be sure you understand the information”“I will close the door for your privacy”

KWKT adds meaning (not time) to a visit

Empathynoun

the ability to understand and share the feelings of another

Emotional Intelligence (EI)

Describes characteristics beyond technical skill and cognitive intelligenceAwareness of one’s emotional responsesModulation of one’s responses to cope with environmental demandsRecognition of a patient’s emotional state and employment of empathyHelps physicians align with contemporary models of patient-centered and humanistic care

Thank you for making a difference!

dan.smith@studergroup.com

Edward M. GoldbergPresident and CEO

St. Alexius Medical Center

How do You Improve Patients Perception of Physician Care

H C A H P S C O M P O S I T E S   A N D   Q U E S T I O N S

C o m p o s i t e     Q u e s t i o n   S u m m a r y R e s p o n s e   S c a l e

8 Value Based Purchasing Measures

Nursing Communication

Nurse courtesy and respect ALWAYS, Usually, Sometimes, Never

Nurses listen carefully ALWAYS, Usually, Sometimes, Never

Nurse explanations are clear ALWAYS, Usually, Sometimes, Never

Doctor Communication

Doctor courtesy and respect ALWAYS, Usually, Sometimes, Never

Doctors listen carefully ALWAYS, Usually, Sometimes, Never

Doctor explanations are clear ALWAYS, Usually, Sometimes, Never

Responsiveness of Staff

Did you need help in getting to bathroom? 2 Yes No (screening question)

Staff helped with bathroom needs ALWAYS, Usually, Sometimes, Never

Call button answered ALWAYS, Usually, Sometimes, Never

Pain Management

Did you need medicine for pain? 2 Yes, No (screening question)

Pain well controlled ALWAYS, Usually, Sometimes, Never

Staff helped patient with pain ALWAYS, Usually, Sometimes, Never

Communication of 

Medications

Were you given any new meds? 2 Yes, No (screening question)

Staff explained medicine ALWAYS, Usually, Sometimes, Never

Staff clearly described side effects ALWAYS, Usually, Sometimes, Never

Discharge Information

Did you go home, someone else’s home, or to another facility? 2Own home, Someone else’s home, Another facility (screening 

question)

Staff discussed help need after discharge YES, No

Written symptom/health info provided  YES, No

Cleanliness  and Quietness of Hospital 

Environment

Area around room kept quiet at night  ALWAYS, Usually, Sometimes, Never

Room and bathroom kept clean ALWAYS, Usually, Sometimes, Never

Overall Rating Hospital Rating Question  0 to 10 point scale (percent 9 and 10 reported)

Source: Value Based Purchasing Program final rule 4.29.11

At St. Alexius Medical Center We Struggled with Low Scores on our HCAHPS Doctor Communication Questions

Our Directors of Nursing and Quality and our Corporate Leaders looked to me as the

President/CEO to Improve the Medical Staff Scores

We tried many mechanisms to improve our scores:Distributed overall scores and tips to all members of the medical staff on several occasions Distributed individual physician scores and tipsSpoke at Medical Staff department meetingsDoctor Smith came and provided a presentation and a one-on-one coaching and although he was extremely well received, all of these efforts had limited impact on our scores

The Majority of Our Medical Staff

Are not employed by the hospitalAre our customers/partnersThey decide what kind of care the patients receive and where the patients are going to receive that care

Nationally, even at facilities that have employed physicians, the three HCAHPS questions that directly relate to physician performance are among the hardest composite to improve:Courtesy/RespectListenExplain

Apr 2010‐Mar 2011 "Percent Always" Change in Top Box Score in One Year Percentile Rank of Change (Percentile Rank shown in Red)Composite 5 10 20 25 30 40 50 60 70 75 80 90Always quiet at night -6 -5 -3 -2 -1 0 1 2 3 3 4 6Doctors always communicated well -4 -3 -2 -1 -1 0 0 1 2 2 2 4Nurses always communicated well -4 -3 -1 -1 -1 0 1 1 2 3 3 4Pain was always well controlled -6 -4 -2 -2 -1 -1 0 1 2 3 3 5Patients always received help as soon as they wanted

-6 -5 -3 -2 -1 0 1 1 2 3 4 6

Patients who gave a rating of 9 or 10 (high) -6 -4 -2 -1 -1 0 1 2 3 4 4 6Room was always clean -6 -5 -2 -2 -1 0 1 2 3 3 4 6Staff always explained about medicines before giving them to patients.

-6 -4 -2 -2 -1 0 1 2 3 4 4 6

Yes, patients were given information about what to do during their recovery

-4 -3 -1 -1 0 0 1 1 2 3 3 5

YES, patients would definitely recommend the hospital

-6 -4 -3 -2 -1 0 1 1 2 3 4 6

Clean and Quiet -5 -4 -2 -2 -1 0 1 2 2 3 4 5

We had to Think Out of the Box

We came up with something that we hoped would help the physicians connect with the appropriate key words at key times to improve their scores.We tried to explain how it would benefit their practiceWe thought outside the box and came up with humorous musical vignettes that would hopefully link something unusual, funny and musical with the appropriate Key Words at Key Times.

We Did Not Seek to be an American IdolWe wanted the vignettes to feel home made and humorous. We utilized several mechanisms including but not limited to humor and rock and roll to enhance communications with employees and physicians

For Example…We know proper hand washing is an important component to providing quality and safe patient care and we developed this following video to promote proper hand washing.

“Keep on Washing for a Clean World”

Patient Protection and Affordable Care Act signed into law (March 2010) Focused on Patient Centered, High Quality CareIt is how we are being paid

The focus is on HCAHPS (the patients’ perception of their care) and Core Measures results

Value Based Purchasing

For Physicians there are 3 Questions in the HCAHPS Survey that Directly relates to the Physicians Behavior towards Patients:1. COURTESY/RESPECT (During this hospital stay, how

often did the doctor treat you/family member with COURTESY/RESPECT?)

2. LISTEN (During this hospital stay, how often did the doctor LISTEN carefully to you/your family member?)

3. EXPLAIN (During this hospital stay, how often did doctors EXPLAIN things in a way that you/your family member could understand?)

It is an Open Book Test

Patients are asked to Rate each of These Categories

Regarding how often the physician showed them courtesy, respect, listened and explained.

This is the only response that counts

It is a 4 point scale

According to Webster’s II Riverside Dictionary:

COURTESY:1. Courteous behavior2. A polite remark or gesture

“so you got to try a little tendernessa little tendernessa little tendernessa little tenderness”

Otis Redding

RESPECT

1. To show or feel differential regard: esteem2. To relate to: Concern3. Willingness to show consideration or appreciation4. Polite expressions of consideration or deference

How Physicians can Improve Their Scores in COURTESY and RESPECT:

Always knock before entering the room (privacy)Confirm roomed patient is same as chart name (HIPAA/safety)Wash Your Hands …it’s your first interaction with the patient, provide them with a business card and introduce yourself explaining your experience and expertise and how they were assigned to you.Close the door or curtain and utilize words that work – “I’m closing the door/curtain for your privacy” If you are a consultant, please indicate the Primary Care Physician called you in.During your first moments with a patient send a message of Courtesy and Respect?

COURTESY and RESPECT

LISTEN

According to Webster’s II New Riverside Dictionary:1. To try to hear2. To pay heed

How Physicians can Demonstrate that You have LISTENED

Cordial, provide eye contact, shake handsAcknowledgement of all members in the roomPlease remember for pediatric patients the parents are also the customers and for geriatric patients their children can also be customersTry to anticipate the patient’s concerns

Repeat what the patient has communicated to you by saying, “I understand you are asking….”Tell the patient that you are available for questions, you have the timePeople expect there may be a wait…it’s not the wait that gets them upset…it’s not knowing “why” or “how long”.

Empathy

Noun….

LISTEN

EXPLAIN

According to Webster’s II New Riverside Dictionary:1.To make understandable: To clarify2.To give the reason for: To account for

How Physicians can Improve Their Scores in EXPLAIN (AIDET)

1. Informing the patient what you are going to do ie. Order lab tests, imaging, surgery, other consultants

2. Inform them of the nature of their illness3. Repeat back to them what you think they are

requesting of you4. Summarize your explanation at the end of the visit

EXPLAIN

Criteria for Uninsured Charity Care ER Call and Outpatient Call Roster

for Primary Care PhysiciansWe worked with Legal Council, the Medical Executive Committee, Medical Staff Leadership and primary care physicians to develop criteria for ER call for both insured and uninsured patients for Primary Care.The hospital agreed to pay Fair Market Value per admission and up to four follow-up out patient visits for uninsured patients.Readmissions within 30 days are not reimbursed

Uninsured Charity Care ER Call:

Development of plan initiated on July 1, 2010Criteria established and plan announced July 1, 2011Evaluation period against established criteria began November 2011Call schedule period began January 1, 2012

Plan Developed July 1, 2010:

Plan announced July 1, 2011Evaluation period began November 2011Call schedule period began January 1, 2012

READMISSIONS

READMISSIONS: The Center for Medicare and Medicaid (CMS) has targeted readmission to the hospital within 30 days of discharge as a marker of poor quality of c are. Research sponsored by the agency for Healthcare Researchand Quality (AHR) found that more than one-third of patients who leave the hospital do not receive the follow-up care they need and many of the medical problems that send patients back to the hospital could have been avoided.

Achievement Requirement Points1 Pneumonia Readmissions

*Audits completed on all charts in which the physician is the Attending

18.3% and lower 1 point

19.3% ½ point

2 AMI Readmissions*Audits completed on all charts in which the physician is the Attending

19.9% and lower 1 point

20.9% ½ point

3 CHF Readmissions*Audits completed on all charts in which the physician is the Attending

24.7% and lower 1 point

25.7% ½ point

HCAHPS

HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems survey is administered to discharged patients and measures the patient’s perspective on care. CMS introduced Hospital Value-Based Purchasing for IPPS hospitals., beginning with inpatients discharged in October 2012. HCAHPS performance will account for30% of Hospital VBP Total Performance Score in FY 2013. The data is cumulative.

Achievement Requirement Points4 Courtesy and Respect Question

*% Always on the HCAHPS Question 16Achievement of between the 50th and 60th

percentile rank for % Always½ point

Achievement of >61st percentile rank for % Always

1 point

5 Listen Carefully Question*% Always on the HCAHPS Question 17

Achievement of between the 50th and 60th

percentile rank for % Always½ point

Achievement of >61st percentile rank for % Always

1 point

6 Accreditation*% Always on the HCAHPS Question 18

Achievement of between the 50th and 60th

percentile rank for % Always½ point

Achievement of >61st percentile rank for % Always

1 point

ACCREDITATION

ACCREDITATION : Accreditation by the Joint Commission is considered the gold standard in health care and a willingness to be measured against the highest standards of performance.

Achievement Requirement Points

7 Date, time and Sign*Random Audit

Above 80% 1 point

70%-80% ½ point8 Not appearing on Suspension

of Medical Staff Privileges list*Audits completed on all charts

Not on list for 2 to 3 month evaluation period

1 point

9 Dictated Discharge Summary on Day of Discharge*Audits completed on all charts

80% of medical records 1 point

10 Dictates History and Physicals *Audits completed on all charts

80% of medical records 1 point

Points Required for Call Roster6/1/12 – 8/31/12

n/a = no cases available to review (overall total possible points is reduced; indicator is excluded if no cases)

Scores Did Improve Dramatically above Prior Efforts

Many physicians indicated that the humorous vignettes and songs helped them to associate the key words at key times.Many got a kick out of their bald CEO wearing a hair piece and although off key they felt it helped reinforce the correct Key Words at Key Times in their minds.

THAT’S A RAP

This was meant to provide another potential tool for your tool kit to impact this challenging area of improving physician satisfaction scores