HCAHPS Doctor Communication: Excelling in The New Reality of Performance

Dan Smith, MD, FACEP Edward Goldberg, CEO St. Alexius Medical Center

What’s Right in Health Care October 11, 2012

Nashville TN

Pay for Performance is

Here

Now

CAHPS® Family of Surveys Consumer 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

will determine total

hospital reimbursement

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

Improvement Achievement Consistency

The greater of the two scores will be used for each

composite

Achievement – Improvement – Consistency HCAHPS 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 FLOOR MINIMUM

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 clean 36.88 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 Basics Top Box Baseline Numbers

Improvement 9 improvement points per composite can be

earned based on moving baseline

performance

Achievement 10 achievement

points per composite at or above benchmark

Consistency 20 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

will determine total

hospital reimbursement

Outcomes (25% Weight)

New 2014

update

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

Why does Great Communication Matter?

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

We can control this one

Shift in Healthcare

Past

“Volume” Effort HMO “Usually” “Good” “7 or >” Paternalistic Care

Future

“Value” Performance ACO/CI “Always” “Excellent” “9 or 10” Mutualistic Care and Perception of Care

How are We doing in Communication?

Research cites fundamental gaps related to: Interruptions during open ended inquiry Missed opportunities related to empathy Time estimates to patients and families Medication and test explanations Introduction and patient recall of physician name

Principles of Communication

Non-verbal cues and demeanor send a message Be courteous Explain in a way they understand Listening is as important as explaining A picture speaks a thousand words Cultural sensitivity Language specificity Align with level of health literacy

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

Courtesy Respect

Listen Explain

Physician Communication Fitness

Patient satisfaction trends Complaints Observations AIDET® skills lab

Direct Observation and Validation

The ideal communication tool

A I D E T HCAHPS Doctor courtesy and respect x x x Doctors listen carefully x Doctor explanations are clear x x

Vendor Listened, Showed Concern and Respect x x x Explained medical findings in a way I could understand

x x

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

x x

Enhanced AIDET®

aka AIDET 2.0 Foundational communication tool Tactical and pointed communication Tight linkage to what matters most to the healthcare consumer Incorporates essential non-verbal cues Emotional intelligence Health literacy

AIDET®

Acknowledge

Introduce

Duration

Explanation

Thank you

Acknowledge

Knock prior to entry (privacy) Confirm roomed patient is same as chart name (HIPAA/safety) Acknowledgement of all members in the room Cordial, 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 Satisfaction Filter: How often staff cleaned hands?

Std Overall

Std Doctor

Std Nurse

Introduction

Introduce yourself Gen X and millennium age prefer first name, last name approach Baby boomers and elderly prefer traditional “Dr.__” Role follows name Cite 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 you tonight. Rest assured, I have practiced for 14 years and we have a great team on tonight.”

Dr: Nurse: Time:

Provider Posture Seated preferred Quality of interaction is the key Patients will overestimate time when seated

Provider Attire “Professional” is the key No 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 concerns Frame the visit in time and content Duration of events/services/tests/procedures Overestimate if unsure (Disney rule) People expect there may be a wait It’s not the wait that gets them upset…it’s not knowing “why” or “how long”

Explanation

Diagnosis or Non-Diagnoses

Name Test results Forecast the usual course Picture/diagrams/literature Follow-up plan

Medications

Name “Why” of use and selection Anticipated effect How to take it Side effects/monitoring Cost 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 verbiage Verbal 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

Empathy noun

the ability to understand and share the feelings of another

Emotional Intelligence (EI)

Describes characteristics beyond technical skill and cognitive intelligence Awareness of one’s emotional responses Modulation of one’s responses to cope with environmental demands Recognition of a patient’s emotional state and employment of empathy Helps physicians align with contemporary models of patient-centered and humanistic care

Thank you for making a difference!

dan.smith@studergroup.com

Edward M. Goldberg President 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? 2 Own 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 tips Spoke at Medical Staff department meetings Doctor 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 hospital Are our customers/partners They 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/Respect Listen Explain

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 90 Always quiet at night -6 -5 -3 -2 -1 0 1 2 3 3 4 6 Doctors always communicated well -4 -3 -2 -1 -1 0 0 1 2 2 2 4 Nurses always communicated well -4 -3 -1 -1 -1 0 1 1 2 3 3 4 Pain was always well controlled -6 -4 -2 -2 -1 -1 0 1 2 3 3 5 Patients 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 6 Room was always clean -6 -5 -2 -2 -1 0 1 2 3 3 4 6 Staff 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 practice We 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 Idol We 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 Care It 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 behavior 2. A polite remark or gesture

“so you got to try a little tenderness a little tenderness a little tenderness a little tenderness” Otis Redding

RESPECT

1. To show or feel differential regard: esteem 2. To relate to: Concern 3. Willingness to show consideration or appreciation 4. 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 hear 2. To pay heed

How Physicians can Demonstrate that You have LISTENED

Cordial, provide eye contact, shake hands Acknowledgement of all members in the room Please remember for pediatric patients the parents are also the customers and for geriatric patients their children can also be customers Try 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 time People 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 clarify 2.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 illness 3. Repeat back to them what you think they are

requesting of you 4. Summarize your explanation at the end of the visit

EXPLAIN

Criteria for Uninsured Charity Care ER Call and Outpatient Call Roster

for Primary Care Physicians We 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, 2010 Criteria established and plan announced July 1, 2011 Evaluation period against established criteria began November 2011 Call schedule period began January 1, 2012

Plan Developed July 1, 2010:

Plan announced July 1, 2011 Evaluation period began November 2011 Call 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 Research and 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 Points 1 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 Points 4 Courtesy and Respect Question

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

½ 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 % Always

½ 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 % Always

½ 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 point 8 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 Roster 6/1/12 – 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