Here we are, at Natividad Medical Center, a 172-bed safety net, teaching hospital and Level II Trauma Center in Salinas, California. We also have an accredited CME program. 

My CME committee chair and I decide to offer a PI CME activity to address one of the issues identified by the hospital’s strategic plan. And, we wanted to give the PI CME format a test spin before we really roll it out (looking for all the problems, gaps and process failures that might befall my learners). We were trying to avoid being too ambitious for our first time out, so we only invited all of our service directors (medical staff leadership) as learners.  We decided to tackle an easy one: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and physician communication. 

We wanted to improve how our patients perceive our doctors’ communication skills. You’re sitting down, right? Actually, that’s part of it: Sitting down with patients helps improve patients’ perceptions of physician communications. Here is the hypothesis of the PI project: Provider communication training improves patients’ perceptions of doctor communication. We used the nomenclature of the HCAHP tool, but we all know that the reality is that patients’ perceptions of “doctors” may include any provider. In addition to improving our patients’ perceptions, we also wanted to see if CME is a credible tool for moving the needle on doctor performance.

From the Start    

A review of the literature on doctor communications and patient experience (measured by HCAHPS scores) was conducted, and the results indicated that “[e]vidence is strong in the case of adherence to recommended medical treatment. A meta-analysis included in this study showed positive associations between the quality of clinician–patient communications and adherence to medical treatment in 125 of 127 studies analysed …” (BMJ Open 2013;3;e001570). Therefore, this PI project was designed to address this measure and implement interventions that might enhance patient experience with respect to doctor communications during their care at Natividad. The interventions we selected? CME activities! 

This research further “showed the odds of patient adherence was 1.62 times higher where physicians had communication training… ” (BMJ Open 2013;3;e001570).  Using HCAHPS scores in doctor communication to measure our test of change, our PI interventions (ie, our CME activities) focused on doctor communication education.

And Here It Is in a Nutshell (Spoiler Alert)

From September 2018 through October 2019, the Medical Staff Leadership conducted a performance improvement (PI) project on improving doctor communications.  Front-line physicians and residents were included in the process and the HCAHPS patient surveys were the outcome measures.  Following the Institute for Healthcare Improvement Plan-Do-Study-Act (IHI-PDSA) model, we developed this PI project to analyze doctor-training interventions for our test of change in improvements of HCAHPS doctor communication scores.

The measurable goal of a 3% increase in weekly median doctor communication raw (unadjusted) HCAHPS scores was selected.  Halfway through the project, educational-focused interventions were implemented and sustained.  These interventions included live continuing medical education (CME) courses; bedside doctor observation, coaching and feedback; and literature discussion sessions (CME Journal Club).  Weekly monitoring of the patient HCAHPS response to the “ALWAYS” frequency of doctor communication was analyzed.  Results: Our interventions were successful. Our weekly median raw HCAHPS scores on the doctor communication domain increased 5%. 

The Long Version

Natividad participates in public reporting systems, including Center for Medicare and Medicaid Services (CMS) Hospital Compare and the Leapfrog Group’s Hospital Safety Grade.  An analysis of Leapfrog’s Hospital Safety Grade revealed that Natividad has improved its overall hospital scores, but we had not moved from “red” to “green” for best practices in the doctor communication measure based on the HCAHPS survey.

Goals and Measures

Directed by our hospital’s strategic plan, we set our project’s goal of a 3% increase in weekly median raw (unadjusted) HCAHPS scores in the doctor communication domain to demonstrate improvement.  Based on the hypothesis that provider communication training improves patients’ perceptions of doctor communication, a random sample of adult patients discharged between Sept. 17, 2018 and Oct. 13, 2019 were surveyed using the HCAHPS telephone instrument.  We collected their “ALWAYS” responses to the doctor communication questions:

“…how often did doctors treat you with courtesy and respect?”

“…how often did doctors listen carefully to you?”

“…how often did doctors explain things in a way you could understand?”

In addition, we collected patient language preference.  We reviewed 882 surveys:  436 surveys completed before our doctor communication educational interventions; 446 surveys after our interventions.  The patient language preferences for this data was 478 English (before 237, after 241) and 404 Spanish (before 199, after 205).

We started our interventions on March 25, 2019: 

• Review and continuous monitoring by medical staff leadership through routine meetings and monthly CME Patient Experience Journal Club for all providers.
• Physical modifications to the doctor work areas to improve healthcare team communications, including educational signage and tools.
• Daily bedside observation, coaching and feedback to doctors/residents by PI team members
• Education on doctor/patient communication electronic resources
• Eight CME activities for doctors/residents on improving doctor/patient communication
• Weekly analysis of survey results, adding new educational interventions based upon successes and any newly identified barriers

Our Champions

Natividad’s hospital leadership allocated staff, CME faculty and material resources to help support the success of the project.  Medical Staff Leadership participated in the project as Champions who had responsibility for planning, ensuring smooth integration of interventions, monitoring the project’s progress, and authorizing and implementing new interventions as newly identified barriers arose and were addressed.

At the conclusion of the PI project, when presented with the results, the Medical Staff Leadership reflected on the project — the planning, interventions, analyses, actions — and unanimously chose to continue the project with doctor communication education.

The Troops

Our doctors, residents and advanced practice practitioners were also involved in the design and implementation of the interventions, as well as the monitoring process performance changes, through reviewing HCAHPS raw survey data in monthly Patient Experience Journal Club (CME) activities.  In addition, to help evaluate and develop new ideas for educational communication interventions, participants reviewed current evidence-based literature where subject experts were addressing these same issues.

Front-line staff were also involved during bedside training when our doctor Champions engaged them with coaching and feedback, encouraging them to identify any barriers in doctor/patient/team communication processes.

Everyone Benefits

Working on improving patient experience is all about engaging our patients.  Deploying HCAHPS surveys to our patients is one way of continually monitoring our progress and interventions.  Working on and improving those survey scores is one way to say to our patients “we care about your healthcare experience.”  An increase in our HCAHPS scores signals that we are better engaging our patients through those interventions in measurable ways.  And the benefit is to, ultimately, improve patient clinical outcomes and patient adherence to therapy in a sustainable way. 

There is always an opportunity for patient engagement at the bedside.  We focused on patients’ perceptions of doctor behaviors including how to demonstrate respect in our culturally diverse community and listening to the patient, especially when there might be language barriers involved in explaining care to the patient.  We implemented bedside coaching intervention sessions that allowed direct observation of the patient interactions with doctors, incorporating patients directly in the feedback and training of their doctors.

The Bottom Line

During this 13-month project, overall, Natividad exceeded its goal of a 3% increase by achieving a 5% increase in the weekly median raw (unadjusted) HCAHPS scores in the domain of doctor communication.  The baseline data was collected from 9/17/18-3/24/19.  Our interventions began on 3/25/19.  

Natividad – Hospital-wide n=882
Metric – HCAHPS Doctor Communication Questions response of  ALWAYS	Desired Direction	n=436 Baseline Median by  week 9/17/18-3/24/19	n=446 Interventions Performance Median by week 3/25/19-10/13/19	Results Change
Doctor Communication Domain	↑3%	82%	87%	↑5%
…how often did doctors treat you with courtesy and respect	↑	83%	89%	↑6%
…how often did doctors listen carefully to you	↑	80%	89%	↑9%
…how often did doctors explain things in a way you could understand	↑	82%	82%	↔

A language preference analysis with 478 surveys conducted with English as the patient’s preferred language (237 prior/241 after interventions) revealed:

Natividad – Hospital-wide by Language Preference – English n=478
Metric – HCAHPS Doctor Communication Questions response of  ALWAYS	Desired Direction	n=237 Baseline Median by week 9/17/18-3/24/19	n=241 Interventions Performance Median by week 3/25/19-10/13/19	Results Change
…how often… respect	↑	82%	83%	↑1%
…how often… listen	↑	78%	88%	↑10%
…how often… explain	↑	82%	83%	↑1%

A language preference breakdown of our data with 404 surveys conducted with Spanish as the patient’s preferred language (199 prior/205 after interventions) revealed: 

Natividad – Hospital-wide by Language Preference – Spanish n=404
Metric – HCAHPS Doctor Communication Questions response of  ALWAYS	Desired Direction	n=199 Baseline Median by week 9/17/18-3/24/19	n=205 Interventions Performance Median by week 3/25/19-10/13/19	Results Change
…how often… respect	↑	87%	92%	↑9%
…how often… listen	↑	86%	100%	↑14%
…how often… explain	↑	93%	80%	â13%

Analyzing the patient language preference results helped us highlight linguistic barriers and have led us to new interventions and best practice performance improvement opportunities.  And, our educational interventions continue to evolve.

Our Hypothesis Is TRUE

Using the IHI-PDSA model for performance improvement, Natividad tested the hypothesis that provider communication training improves patient’s perceptions of doctor communication.  As revealed through our PI project and improved HCAHPS scores, the hypothesis appears TRUE.

First, we engaged all senior medical staff leadership in our process to help promote a culture of change and emphasize Natividad’s commitment to our goal.  We also incorporated their expertise and experience in the planning of our strategies.  We then designed our interventions to include a variety of educational delivery formats (live, journal club print articles, digital, online resources and educational posters) to provide wide-ranging exposure to the participants, thus striving for maximum intervention impact.  We hosted renowned experts in the field of physician communication to lead our live communication courses.  Ongoing journal review kept our PI Team informed; it was also a source for ideas about new interventions and ways to mitigate barriers.  

Through bedside coaching and feedback, the best practices for communication behaviors in a culturally and linguistically diverse patient population — with regard to respect, listening and explaining — supported all educational initiatives by revealing practice barriers and then by putting educational theory into practice.

The Future

Natividad identified doctor communication as a key component of our strategic plan. And, conducting our PI CME activity has shown our leadership that CME can help them achieve the institution’s goals. Continuing doctor communication training through these and new educational interventions is key to sustaining improvement in HCAHPS doctor communication domain scores. We commit to “Keeping it REAL:  Respect – Explain – ALWAYS – Listen.”  Give it a try!

#Outcomes