How One Hospital Works to Win Over Patients

This article appears in the August 2012 issue of HealthLeaders magazine.

The Stony Brook (N.Y.) University Medical Center's staff role-plays scenarios about what can go wrong with patients at the 597-staffed-bed hospital and how to make it right. In these make-believe scenarios, "patients" may fuss. Demand. Need above-and-beyond assistance.

They are ... well ... being impatient patients, and the idea is for hospital staff, especially nurses, to keep their cool, while showing that they are concerned. Do the right thing. Care.

The medical center on Long Island's North Shore finds that playacting improves its staff's performance in real life, and it uses this approach to learn more about keeping patients satisfied during their hospital experience. While a hospital stay often lasts for fewer than four days at a time, the patient may encounter dozens of healthcare professionals and other hospital personnel during that time. "We have actors pretending to be patients, and these four-hour sessions are scenario-based, for nurses specifically to hone their communication skills," says Michael Maione, director of customer relations for Stony Brook. Maione is responsible for evaluating patient satisfaction measures for the hospital.

Indeed, the hospital is among thousands across the nation trying to not only improve patient satisfaction, but also obtain ROI for doing so. Under the government's value-based purchasing program, the Centers for Medicare & Medicaid Services plans to pay bonuses from an $850 million pool to hospitals that score above average on certain quality measures. In fiscal 2013, patient satisfaction scores will account for 30% of the bonuses, while clinical process of care will make up 70%.

Stony Brook is among many high-achieving clinical facilities that have done well at improving patient satisfaction scores in some areas while struggling in others. For instance, Stony Brook won awards this year for its cardiology care, but scored only a 73% from patients—compared with 77% for the national average—for how well nurses always communicate with patients. The hospital also scored just 57% from patients about receiving medication information, compared with 61% for the national average.

The scores are part of the Hospital Consumer Assessment of Healthcare Providers and Systems 27-question survey given to a random sample of eligible patients after discharge to assess their perspectives on their healthcare. Questions include: Would you recommend this hospital to your friends and family? How often did nurses explain things in a way you could understand? How often did doctors listen carefully to you? How often did the hospital staff do everything they could to help you with your pain? How often was the area around your room quiet at night?

The high bar of 'always'

In HCAHPS, most of the questions offer four response choices: never, sometimes, usually, and always. But healthcare organizations only receive credit for the "always" responses. "The patient has to feel every single interaction has been correct and there is a right interaction, and that's a high bar," Maione says. "It's a challenge and we're looking for ways to make an impression for patients to have a great experience."

To that end, Stony Brook isn't just playacting its way toward better performance for its patients. It also has taken steps to improve educational programs for physicians and nurses, with hopes of making them more sensitive to the needs of patients and more aware of their concerns. The hospital initiated weekly rounds when hospital leadership visits patients' rooms, asks patients questions, and evaluates the responses in internal reporting and committee meetings. The effort is to continually improve the process.

Hospitals want to give patients that one-on-one feeling whenever they can. They are improving bedside reporting by increasing how frequently nurses relay updates to each other on patients' progress throughout the day; adding time to nurses' visits in patients' rooms; and encouraging physicians to sit down near patients' beds, possibly holding the hand of older patients, and definitely looking them in the eye. Hospitals call patients or write to them—within hours after discharge. An oncology patient recalls just returning from the hospital, still sorting out the prescriptions on the kitchen table when the phone rang. It was the hospital, asking, "How did we treat you?" Hospitals tell the frontline staff, "Be nice. Be friendly." And, they hope, the patients will notice their outstanding efforts to care.

"We really have to put ourselves in the same area as hotels. Patients expect hotel-like service, with the food and people responding to their calls. We have to be able to do that," says Wendy H. Solberg, FACHE, CPHQ, vice president of quality and patient safety at Baptist Health System in San Antonio, Texas, which has 1,674 beds at five acute-care hospitals. But it's not really a hotel, and that's a big issue for hospital leaders, Solberg acknowledges. One of the problems is that "you are dealing with perception," she says. "You can treat [patients] great, but if you aren't nice to them, it takes some of the shine off a great thing you've provided in healthcare."

Hospitals tackle dealing with patient satisfaction in different ways. Some evaluate job applicants with an eye on the prospective hire's personality and possible relationship with patients. Others are continually evaluating how physicians and nurses interact with patients, taking steps to intervene to improve patients' perception of the professionals' care. Most hospitals have a steady stream of action plans and reports that flow to and from the C-suite on how they are doing with patient satisfaction.

Dealing with the disconnect

For those hospitals that have extremely high clinical rankings, when relatively low HCAHPS scores are delivered, it's a wake-up call.

Stephen Weber, MD, chief medical officer and vice president for clinical effectiveness at the 547-licensed-bed University of Chicago Medicine, talks proudly about how UCM has worked diligently to improve infection rates at all of its hospitals, but concedes that it has fallen flat in patient satisfaction. Scores show that UCM falls slightly below state and national averages in measures of how physicians communicate with patients. UCM received a 78% rating in this category, compared with the state and national average of 80%. UCM also received 53% on how often patents received help quickly from hospital staff, compared with the state average of 62% and national average of 65%, according to HCAHPS, as of June 2011.

While Weber offers no excuses, he points to the complex patient mix of a large-scale academic institution. He also suggests that the medical center has had an almost singular focus on improving clinical quality, possibly at the expense of patient satisfaction.

"We need to move away from saying these measures are terrible and not paying attention to them and instead move toward constructive collaboration," says Weber. "We want to enhance the reliability of our numbers. We don't feel we are chasing a number; we feel we have external measures that reflect something uncomfortable and accurate about us," Weber says.

Weber provides no explicit details of the institution's plans to improve its HCAHPS scores, though he outlines some broad-brush plans. "This has been a major focus for us. We have had meetings about this with our boards and community stakeholders. We need to deliver the service that matches our science. It's a great little sound bite, but it means we apply the same kind of rigor, the same kind of commitment, to make the patient experience better, setting new expectations. We know we have a lot of work to do, and we have the resources and the expertise to match that."

Benefits of planning and training 

About 22 miles west of Chicago is the 333-licensed-bed Advocate Good Samaritan Hospital in Downers Grove, Ill., which was recently named by Thomson Reuters (now Truven Health Analytics) as among the nation's top healthcare systems. Recognized for a third time as one of the nation's best large community hospitals, Advocate Good Samaritan issued a statement saying the award was a "testament to our physicians and associates who are dedicated to delivering the highest quality of clinical care and health outcomes to the patients we serve."

Unlike the UCM, Advocate Good Samaritan Hospital has had relatively good patient satisfaction scores, for the most part. The HCAHPS scores show that Advocate Good Samaritan is above the national average for how patients rate the hospital overall, how well pain was controlled and how well nurses communicated with patients, and essentially tied with the national rate of how well doctors communicated with patients.

David Fox, president of Advocate Good Samaritan, attributes the high scores to long-term planning by the hospital since 2004 for improved clinical and patient satisfaction—well before the government came into the picture. He attributes much of the success to an intense concentration on training and hiring staff, particularly nurses and other caregivers. "We have gotten very focused on who gets to work here, and how we train them in terms of customer service," Fox adds. "We used to hire for skill and pray for attitude and cultural fit. Now we screen for skill, hire for cultural fit and attitude."

Like other hospital leaders, Fox also points to procedures performed daily in the hospital that can influence HCAHPS scores. Daily rounding is pivotal to not only improve various processes, such as communication, but also to ensure that patients get help going to the bathroom or have their pain routinely monitored, all important considerations for HCAHPS scores.

Regular, personal interaction

At Stony Brook, two Fridays a month, administrators and senior staff personally make rounds and interview patients and staff to ensure quality goals are achieved. If there are any problems, emails are sent to the responsible hospital official, whether it's a nurse manager, administrator, or physician, Maione says. "It's very comprehensive in areas ranging from how well the room is cleaned, to the quietness of the room, to how well they have maintained the patient's pain."

Solberg of Baptist Health agrees that a standardized protocol for nursing staff is a key element for improved patient scores—and the hospital is still working on that element. "Nurse communication is the domain driving the focus [of patient satisfaction]. If you nail that, you can get a lot accomplished," she says. Although much has changed over the years, some patients still have a lower expectation of physicians in their day-to-day care. "If a doc saved your life, do you really care about that stuff?" Solberg asks, referring to meeting the patient's daily needs. "But a hospital staff has to care about that. It has to be accomplished with a number of nurses, the ratio of nurses on the floor, and the education component," she says, referring to how nurses talk to patients to meet their needs.

For many hospital systems, improving clinical techniques is the path they pursue to improve patients' attitudes about their facilities. These medical providers focus on reducing readmissions after 30 days, addressing patient medication adherence, and initiating medical homes to let patients know that their healthcare system cares.

Considering readmissions and care processes

While the Iowa Health System strategic plan examines its clinical improvements such as reducing readmissions, it also focuses on HCAHPS scores to improve care, says Gail A. Nielsen, director of learning and innovation for the 2,421-staffed-bed system based in Des Moines.

The health system has established a patient experience team—which includes physicians, nurses, nurse educators, managers, executives, data analysts, and performance improvement experts—that emphasizes how to communicate with patients in ways that they understand. The team wants healthcare professionals to ask patients whether they will have the help they need at home and to consider what information the patient may need after leaving the hospital.

"These teams are joining the efforts of the readmissions teams because we believe that the best way to improve patient experience is to improve and redesign the processes of care that touch our patients and their families," Nielsen says.

"Patient satisfaction and experience scores have improved as teams and clinical units improved their process of problem-solving and focused on ideal care," says Nielsen.

Maintaining clinical integrity

Some hospital officials have mixed feelings about patient scoring, noting that sometimes patients seek expensive and unjustified treatment. If those requests are denied, it certainly could undermine patient satisfaction.

"HCAHPS are very difficult to get a grip on," says Alan Kaplan, MD, senior vice president and CMO at Iowa Health System. "You can think of it as an outcome but also a process. There's a trade-off between satisfaction and outcomes. Patients may be a lot happier if I gave them inappropriate antibiotics. And I do believe focusing on patient satisfaction will be increasingly challenging as we manage patient populations and move toward accountable care organizations. I believe it has to be approached with integrity."

For now, hospitals are examining the patient evaluations, one question at a time.

One of the toughest issues for hospitals centers on the question of noise: During this hospital stay, how often was the area around your room quiet at night?

Both the University of Chicago Medicine and Advocate Good Samaritan registered their lowest marks in
those categories.

Advocate Good Samaritan tallied a patient score of 44%, compared to the national average of 58%, according to HCAHPS.

Fox attributes the low scores to the fact that the hospital, which opened in 1976, has mostly semiprivate rooms. However, he says the organization is taking steps to reduce noise by converting some rooms to private. "In that way, we are going to make a better experience for the family and a more quiet experience for the patients," he says. "We find when patients are complaining about noise, mostly it's from the noise of a roommate or a caregiver coming. We were at a disadvantage because of the semiprivate rooms. We don't use that as an excuse, but we will have a better experience for the patients."

This article appears in the August 2012 issue of HealthLeaders magazine.

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