HCAHPS Doctor Communication: Excelling in The New Reality of Performance

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 1% Base operating DRG payments Implementation FY 2013 (October 2012) Source: Value Based Purchasing Program final rule 4.29.11 12 Core Measures (* 70% Weight) 8 HCAHPS Composites (* 30% Weight) Performance attainment and improvement will determine total hospital reimbursement

Achievement Improvement Consistency HCAHPS Scoring Achievement Improvement Consistency The greater of the two scores will be used for each composite Note: Implementation FY 2013 (October 2012) Based on achievement performance in ALL composites or lowest index composite will be used Source: Value Based Purchasing Program final rule 4.29.11

HCAHPS Scoring Basics Top Box Baseline Numbers COMPOSITES/HCAHPS MEASURES FLOOR MINIMUM ACHIEVEMENT (50 th 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 Area around room was always quiet at night 36.88 62.80 77.64 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 Improvement 9 improvement points per composite can be earned based on moving baseline performance Consistency 20 consistency points if ALL composites are at or above the 50th percentile Achievement 10 achievement points per composite at or above benchmark

Value Based Purchasing FY 2014 Core Measures (45% Weight) New 2014 update 1.25% Base operating DRG payments Note: Implementation FY 2014 Source: OPPS VBP Final rule 11.1.11 HCAHPS Composites (30% Weight) Outcomes (25% Weight) Performance attainment and improvement will determine total hospital reimbursement

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 X X X X X X X X AIDET Observation Feedback Rounding on Patients Name of Leader Dr. Ahmad Date 04-11-12 Unit Department 7Neumann Sparrow Coach Dds md E-mail Address Reports to Male with TIA and s/p CEA Strengths Identified During Observation Areas to Focus on During the Next 90 Days 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 "today, we will plan to go home today..." 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 Gave card on intro 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 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 you for your trust, for being a good patient, for letting 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 the organization Would recommend review of AIDET video and use of Participant Guide to reinforce skills Would recommend follow-up AIDET observation on next visit Gave a business card Additional comments areas of strength or opportunity to improve: Great dyad team care with nurse and inquiry about Good use of humor... issues in front of patient Good opportunity to manage-up Vascular Surgeons while examining CEA site, "they do great work..." X 2006 Studer Group

The ideal communication tool HCAHPS A I D E T Doctor courtesy and respect x x x Doctors listen carefully Doctor explanations are clear x x Vendor Listened, Showed Concern and Respect x x x Explained medical findings in a way I could understand Kept informed of how long things would take Tests and procedures were adequately explained before they were done x x x x 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) Handwash 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

Hand Hygiene: Inpatient 100 90 80 Inpatient Patient Satisfaction Filter: How often staff cleaned hands? % Rank, Lg PG Database 70 60 50 40 30 20 Std Overall Std Doctor Std Nurse 10 0 Always Usually Sometimes Never Frequency of Observed Hand Hygiene

Introduction Introduce yourself Dr: Nurse: 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. 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

How do You Improve Patients Perception of Physician Care Edward M. Goldberg President and CEO St. Alexius Medical Center

At St. Alexius Medical Center We Struggled with Low Scores 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 on Composite our HCAHPS Doctor Question Communication Summary Questions Response Scale Nurse courtesy and respect ALWAYS, Usually, Sometimes, Never Nursing Communication Nurses listen carefully ALWAYS, Usually, Sometimes, Never Nurse explanations are clear ALWAYS, Usually, Sometimes, Never Doctor courtesy and respect ALWAYS, Usually, Sometimes, Never Doctor Communication Doctors listen carefully ALWAYS, Usually, Sometimes, Never Doctor explanations are clear ALWAYS, Usually, Sometimes, Never Did you need help in getting to bathroom? 2 Yes No (screening question) Responsiveness of Staff Staff helped with bathroom needs ALWAYS, Usually, Sometimes, Never 8 Value Based Purchasing Measures Pain Management Communication of Medications Discharge Information Call button answered Did you need medicine for pain? 2 Pain well controlled Staff helped patient with pain Were you given any new meds? 2 Staff explained medicine Staff clearly described side effects Did you go home, someone else s home, or to another facility? 2 Staff discussed help need after discharge ALWAYS, Usually, Sometimes, Never Yes, No (screening question) ALWAYS, Usually, Sometimes, Never ALWAYS, Usually, Sometimes, Never Yes, No (screening question) ALWAYS, Usually, Sometimes, Never ALWAYS, Usually, Sometimes, Never Own home, Someone else s home, Another facility (screening question) YES, No Written symptom/health info provided YES, No Cleanliness and Quietness of Hospital Area around room kept quiet at night ALWAYS, Usually, Sometimes, Never Environment 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

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 -6-5 -3-2 -1 0 1 1 2 3 4 6 wanted 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 -6-4 -2-2 -1 0 1 2 3 4 4 6 giving them to patients. Yes, patients were given information about -4-3 -1-1 0 0 1 1 2 3 3 5 what to do during their recovery YES, patients would definitely recommend the -6-4 -3-2 -1 0 1 1 2 3 4 6 hospital 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

Value Based Purchasing 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

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

It is a 4 point scale This is the only response that counts Patients are asked to Rate each of These Categories Regarding how often the physician showed them courtesy, respect, listened and explained.

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 1 Pneumonia Readmissions *Audits completed on all charts in which the physician is the Attending 2 AMI Readmissions *Audits completed on all charts in which the physician is the Attending 3 CHF Readmissions *Audits completed on all charts in which the physician is the Attending 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 18.3% and lower 1 point 19.3% ½ point 19.9% and lower 1 point 20.9% ½ point 24.7% and lower 1 point 25.7% ½ point

HCAHPS 4 Courtesy and Respect Question *% Always on the HCAHPS Question 16 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 Achievement of between the 50 th and 60 th percentile rank for % Always Points ½ point 5 Listen Carefully Question *% Always on the HCAHPS Question 17 6 Accreditation *% Always on the HCAHPS Question 18 Achievement of >61 st percentile rank for % Always Achievement of between the 50 th and 60 th percentile rank for % Always Achievement of >61 st percentile rank for % Always Achievement of between the 50 th and 60 th percentile rank for % Always Achievement of >61 st percentile rank for % Always 1 point ½ point 1 point ½ point 1 point

ACCREDITATION 7 Date, time and Sign *Random Audit 8 Not appearing on Suspension of Medical Staff Privileges list *Audits completed on all charts 9 Dictated Discharge Summary on Day of Discharge *Audits completed on all charts 10 Dictates History and Physicals *Audits completed on all charts 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 Above 80% Points 1 point 70%-80% ½ point Not on list for 2 to 3 month evaluation period 1 point 80% of medical records 1 point 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