With Medicare reimbursement now tied to consumer ratings, many institutions are focusing on the patient experience — and patient-physician communication in particular.
Can you afford an additional 132 seconds to provide better care?
Most patients can convey their relevant clinical information in 150 seconds. Yet studies have shown that physicians interrupt their patients after 18 seconds or so.
“One hundred fifty seconds is not a whole lot of time [to wait] to get the kind of information that will help you work with your patient to provide the best care,” says Lisa Allen, PhD, the chief patient experience officer at Johns Hopkins Medicine.
Waiting those extra seconds could not only improve patient care but improve your hospital’s bottom line now that Medicare reimbursement policies encourage better patient-physician communication. In 2012, Medicare began withholding up to 1% of total Medicare payments from hospitals that did not meet quality measurement standards, but with bonuses paid for high scores. The potential penalty will increase to 2% in 2017.
A large portion of that quality measurement is based on a hospital’s scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys given to a random sample of patients to rate their experiences. That provision has many institutions paying much more attention to their scores and creating new positions to represent patients and families at top decision-making levels. Johns Hopkins Medicine brought Allen on as its first chief patient experience officer in September 2014.
For physicians and nurses, the focus on patient experience means more attention to a key component of HCAHPS score — how well they communicate with patients.
Pinnacle Health System in Harrisburg, Pa., instituted a communication training program for physicians in response to low ratings of doctor-patient communication, and over two years increased their patient satisfaction scores by a remarkable 40 percentile points.
“One hundred fifty seconds is not a whole lot of time [to wait] to get the kind of information that will help you work with your patient to provide the best care,” — Lisa Allen, PhD, chief patient experience officer at Johns Hopkins Medicine.
Free the Hopkins FIVE
That skill is also a consideration at Johns Hopkins. “We are working with our physicians on improving their communication,” Allen says. “Many of our physicians are fantastic communicators, but for those that are struggling or that are new to medicine, [we are] helping them understand the key components to interacting with patients [and] what patients need.”
Allen’s team is developing a program called the Hopkins FIVE:
- F: Familiarizing yourself with the patient, saying hello and introducing yourself so the patient understands who you are, what your role is, and who any team members with you are.
- I: Interacting or connecting with the patient as a real person in the bed, for example, talking at the patient’s eye level if you can.
- V: Voice refers to hearing the patient’s voice — encouraging a discussion to take place that engages the patient and set an agenda.
- E: Exit plan, making sure the patient understands the treatment plan and shares your expectations, followed by a thank you and a good bye.
“If you can develop that relationship with the patient [and] understand what is important in their lives, you will have higher compliance with diet, exercise, and medications. When patients feel valued as partners, they are much more willing participants.” — Lisa Allen, PhD, chief patient experience officer, John Hopkins Medicine.
Do Ask, Do Tell
Allen suggests an “ask, tell, ask” model for this last step, which is a well-known technique for entering serious conversations with patients, and an approach also encouraged by James A. Tulsky, MD, chair of the department of psychosocial oncology and palliative care at the Dana-Farber Cancer Institute and a pioneer researcher in clinical empathy and communication.
The first “ask” is meant to establish how well the patient understands the situation. “You always need to ask a patient their understanding before giving them information,” Tulsky says. Finding out how much or how little a patient knows should affect what information you give them and how you give it.
The “tell” should be in plain English. “You then give information in short bite-size chunks. It is very important not to use jargon and not to talk too much,” Tulsky says. “Then the final ‘ask’ is to ask about their understanding of what you just explained.” This last step is aimed at making sure that the patient understands the treatment plan and that expectations are shared.
Four Habits of Effective Communicators
Many institutions have their own versions of the Hopkins FIVE, such as the “Four Habits” model that has spread widely after originating with Kaiser Permanente: invest in the beginning, elicit the patient’s perspective, demonstrate empathy, and invest in the end.
“A lot of the physician-patient communication programs [have] a shared mental model. What we are trying to do [is to] help the patient build trust, understand what is going on, and understand what the next steps are for the plan of care,” Allen says.
She believes that endocrinologists in particular could benefit from this approach, for example, in working with diabetes patients: “If you can develop that relationship with the patient [and] understand what is important in their lives, you will have higher compliance with diet, exercise, and medications. When patients feel valued as partners, they are much more willing participants.”
Allen notes that an important byproduct of the attention to patient experience is that “it makes for a better work life” because providers find it rewarding when they talk with and understand their patients. They simply feel they are doing a better job: “I do believe it provides greater job satisfaction. It is not all about the patient. It is also about how [physicians] feel about the work they are doing.”
— Seaborg is a freelance writer based in Charlottesville, Va. He wrote about talking to patients about obesity in the March issue.