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Patient Satisfaction Blog Series for CRC 2012

Pat Sat/HCAHPS/P4P – Huh?

This is the first of a series of five postings that will attempt to make sense of some the above.  Patient satisfaction has risen to the top of many a list as the government and other payers are establishing pay for performance (P4P) initiatives. One of the reasons everyone is working on this is there is a clear connection between patient satisfaction and quality. Check out the New England Journal of Medicine for more information on this (2008; 359:1921-1931).

Because patients, payers, and politicians now care about patient satisfaction, the next three posts will provide tips for improving scores on the three physician specific questions on the HCAHPS questionnaire. The last post will tie it all together to show physicians and MSPs how patient satisfaction affects physician performance.

To start, what is HCAHPS? The Hospital Consumer Assessment of Healthcare Providers and Systems is a 27-question survey developed by Centers for Medicare and Medicaid Services with the following goals in mind:

  • To produce data about patients’ perspectives of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers
  • To create incentives for hospitals to improve quality of care by making public survey results
  • To enhance accountability in healthcare by increasing transparency of the quality of hospital care provided in return for public investment (also by making public the survey results)

Although this survey covers a number of areas, my blog posts will cover these three physician-specific questions:

  • During this hospital stay, how often did physicians treat you with courtesy and respect?
  • During this hospital stay, how often did physicians listen carefully to you?
  • During this hospital stay, how often did physicians explain things in a way you could understand?

Until next time, try to get your arms around the fact that improving patient satisfaction will improve quality.  For many of us, this fact will be difficult to swallow, but swallowing (internalizing) this will be critical for our success in the future.

Editor’s note: William Mills, MD, MD, MMM, CPE, FACPE, CMSL, FAAFP, is a featured speaker at the 15th annual Credentialing Resource Center Symposium, May 10-11. He will be speaking on using patient satisfaction scores to drive improvement as well as how to privilege low- and no-volume practitioners. For more information, click here.

Quality differences among hospitals

A recent HealthDay article reports that quality varies in the over 5,000 hospitals reporting outcomes to HealthGrades, a healthcare rating company providing information on physicians and hospital quality outcomes.

The report states that patients are 73% less likely to die at a five-star hospital than a one-star hospital (five-star is the highest rating and one-star the lowest).  As this data came from CMS calculations from this three-year study, it showed that 240,000 less Medicare patient deaths would have occurred if all the patients were treated at a five-star hospital.

Here we go again. Let’s fire up the public using data that may not necessarily be comparable.

Although the data may not be comparable, it does not negate the fact that we need to make our institutions safer and improve quality. We need to be constantly vigilant. We need to embrace evidence-based medicine, patient safety initiatives, and transparency. The public will not allow us to become complacent. Are you, or those at your institution, complacent?

Editor’s note: William Mills, MD, MMM, CPE, FAAFP, CMSL, will be leading a session on how physician leaders and MSPs can use patient satisfaction scores to assess and improve physician performance at the 15th annual Credentialing Resource Center Symposium, May 10-11, in Orlando. For more information on HCPro’s premiere credentialing event, click here.

Want a 50% pay cut?

A recent opinion piece in USA Today responds to a study from Columbia University “blaming” high physician salaries as a significant contributor to rising healthcare costs, including the predicted doubling of family health insurance costs by 2021. Since physicians earn approximately five times the US median income, and earn more than physicians in six other developed countries that were studied, it must be physicians’ fault. Let’s cut physician earnings by 50%; that will fix it, right?

Well, maybe not. What about the educational debt owed by physicians, which is often around $300,000?  What about the 30%50% of gross revenue spent on office overhead?  What about the 60-hour average physician work week? What about the fact that the primary care physician shortage by 2020 is estimated to be 40,000?(I’m sure decreasing earnings will help that!) Lastly, what about the fact that physician take home pay accounts for approximately 10% of healthcare costs?

As a family physician who practiced for 20 years and was forced to juggle many of the above factors, I’m a little offended that folks think physician salaries are to blame for the economic woes of the healthcare system. What do you think?

Is the doctor a ‘doctor’?

A recent article in The New York Times raises some of the issues surrounding the use of the word “doctor.” We are all aware from our undergraduate days that there are many doctorate degrees offered in a large number of academic disciplines.

In the healthcare arena, the word doctor is generally understood to mean a physician with a M.D. or D.O. degree. However, that is now changing. We have doctors of pharmacy, physical therapy, psychology, and nursing to name a few. Yet, when someone wearing a white coat introduces themselves as Dr. Smith to a patient, the patient will most likely assume that person is a physician.

So why the push for so many types of doctorate degrees?  Is it the continual pursuit for knowledge and recognition of the same?  Is it the prestige of the word doctor in the healthcare setting?  Is it motivated by the thought that the word doctor means a higher salary?  Is it an attempt to confuse or mislead patients?  Is it an attempt to allow non-physician healthcare workers an increase in scope of practice and autonomy?

Some states are creating legislation to control the use of the word doctor. Should that have to happen? Or should we, the healthcare providers, decide how to proceed? As you can see, I have raised many more questions than answers. What do you think?

Centralization of physician performance data

The structure for collecting and trending practitioner data varies from organization to organization. In many, all FPPE and OPPE data is collected, tracked, and trended by medical staff services departments. Incident reports related to patient grievances or other clinical concerns may be tracked and trended through the risk management department while peer review and individual practice deviations may be tracked and trended through the quality review department. In addition to hospital performance, division chiefs may keep division files on any issues that are reported and/or addressed by them.

It is important for organizations to have a clear picture of a practitioner’s performance. Centralizing where practitioner data is tracked will eliminate the possibility that there is performance data missing when conducting performance reviews. Although different departments may handle and/or address different issues related to performance, there should be one central repository for physician data. Departments should then forward all data to this area for safe keeping and filing in the practitioners quality file.

One of the first steps in developing a central repository for practitioner performance data is education. Organizations should spend time educating their division chiefs on how to address concerns that are brought to their attention; when collegial intervention is appropriate and when an issue must be escalated or forwarded to another department and/or a formal medical staff committee. Division chiefs should be educated on how to document performance issues and how to document the steps that they have taken to resolve the concerns. Ensuring that all concerns are well documented helps protect the division chief as well as the organization should an issue arise later which requires further scrutiny or results in due process.

Should an investigation be initiated, having all data centralized saves time and ensures a more thorough review. Having a one-stop shop for all incident reports, collegial interventions, peer review referrals, and all other clinical performance data allows the committee conducting the review to have a full picture of the practitioner’s performance. Organizations should also include all positive feedback in the quality file and should always respond to a practitioner when a review is conducted and the care he or she provided is deemed to have met or exceeded the standard.

Centralization of practitioner performance data not only benefits the committees or division chiefs conducting performance reviews, but also helps protect the organization from claims of negligence should they conduct reviews without all of the information available.

Palliative care in the emergency department?

A recent Washington Post article titled “Hospitals make palliative care a priority to improve patients’ quality of life,” raises the issue of providing palliative care in the emergency department.  This notion is a far cry from the standard ED mentality of fix it all—and quickly. But when you consider that a large percentage of patients presenting to the ED arrive with a flare up of chronic severe illnesses or significant injury that can be life altering, then maybe discussions about end of life care and the institution of palliative care measures should not be such a foreign concept. If we truly strive to be patient-centric, shouldn’t we be abiding by our patients’ wishes and helping them with the tough decisions?  In the fast-paced world of the ED, shouldn’t we be using a checklist to make sure we are addressing more of the patient’s needs than just the presenting symptom? Is our bias that since palliative care grew out of the hospice movement that this should be something addressed by the oncologist or PCP, and not the ED physician?

New York State recently enacted a regulation requiring physicians to discuss and document their interactions with patients about palliative care and end of life issues.  What does that say about healthcare providers being pro-active and patient-centric? So palliative care in the ED—you bet!  But it should not stop there; it should be addressed in every healthcare setting.  To quote an anonymous 16th century writer, our job is to “Cure seldom, relieve often, and comfort always.”

My hospital’s palliative care committee is working hard to ensure that patients are getting what they need, when a “cure” is not possible. How about yours?

Connect the dots

I have been spending most of my time reviewing admission documentation for hospitals across the country, and it is surprising to me that rather few physicians will commit to a diagnosis for incoming patients.  I see “dyspnea” instead of “CHF” or “pneumonia,” “diarrhea” instead of “gastroenteritis” and “dysuria” instead of “urinary infection.”

Emergency physicians seem to be especially reticent to make a diagnosis, but hospitalists are not far behind. It creates a problem for the hospital because medical necessity for inpatient services is based on the presence of a condition that may incur significant morbidity or mortality, and the prescription of a treatment regimen appropriate for the condition. Determining necessity is more certain when a specific diagnosis is made. No one dies from shortness of breath, but one can certainly die from CHF or pneumonia, and there are well-established courses of treatment for those diseases.

I suspect that we started down this slippery slope because the definitive diagnosis of myocardial infarction can be difficult, even when the electrocardiogram and enzymes are abnormal.  This led to the term “R/O MI” as an admitting diagnosis. Ruling out a medical condition is really an observation service. Reticence to commit to a diagnosis can cost the hospital money. If you believe that the chest pain is related to heart disease, why not describe it as “acute coronary syndrome?” If the patient has fever, cough, and hypoxemia, it is appropriate to connect the dots and call it pneumonia, even if the x-ray is unclear. It is understood that admitting diagnoses may differ from the discharge diagnosis as more information becomes available. There is nothing to lose and much to gain from making your best estimate of the patent’s disease on admission.

Celebrate National Medical Staff Services Awareness Week with HCPro

Have you ever stopped to think about how your hospital would operate if the MSSD no longer existed? Who would prepare the hundreds of credentials files? Who would make sure the hospital’s privileging forms were up to date? Who would coordinate the next medical staff leadership retreat? And most importantly, who would remind you when it was time to submit your own credentialing and privileging reapplications?

You may not even be aware of all of the work that goes on in the MSSD. But this week is your chance to find out and to thank the members of your MSSD for their hard work. In 1992, President George Bush declared the first week of November as National Medical Staff Services Awareness Week.

In honor of this, HCPro is offering you and your colleagues a 15% discount on all of HCPro’s medical staff and credentialing products from Nov. 6-12. Visit the HCMarketplace and enter EO107658A during check out to receive your discount.  And don’t forget to thank your MSPs!

Drug shortages: The government “fix”?

If your hospital is anything like mine, you have been struggling recently with the unavailability of various pharmaceuticals. One has to wonder why intravenous furosemide (Lasix) is not available. Maybe you could understand why some chemotherapeutic agents are in short supply—or maybe you can’t. Something is really wrong with the system when patients can’t receive critical, potentially life-saving treatments because the pharmaceutical industry isn’t manufacturing the necessary quantity.  An Oct. 31 article in The New York Times addresses an executive order by President Obama to “fix” the problem. He is instructing the FDA to do the following three things:

  • Broaden reporting of potential shortages of certain prescription drugs
  • Speed reviews of applications to begin or alter production of theses drugs
  • Provide more information to the Justice Department about possible instance of collusion or price gouging

That’s certainly telling them Mr. President. And if this doesn’t work, maybe we should threaten to ground them, or better yet, spank them and send them to bed without dinner. Is he serious? Are we supposed to treat cancer with a governmental report?

If Big Pharma is the issue, maybe a plan with some teeth is in order. If the delay is bureaucratic, maybe we need to streamline that process. I think it is time for quick action—not political rhetoric. We are all trying to be efficient patient care advocates so let’s us stop wasting money on trying to track down necessary medications.

So I expect you get my drift.  At our hospital we realize that a governmental fix is not in our immediate future, so here are a couple of things we have done to help patients get what they need:

  • We have connected with our sister hospital that has a different pharmaceutical supplier. Although shortages are national, sometimes one supplier will have more than another.
  • We have also borrowed from other hospitals in our region and returned the product when our supply is better.
  • Then there is the age old “hoarding” that hospitals and pharmacies have done throughout the ages. Although this can be selfish, we do share with others.

Do you have any other suggestions until this crisis is corrected?

Nocturnist: A new concept?

One of my colleagues, Richard Rohr, MD, MMM, FACP, FHM, posts frequently about hospitalist issues. I thought I would poke a little too.

In a recent issue of the Tennessean, the concept of “nocturnists” was discussed. The article states what we all know: Hospitals are not safe places. Truth be told, we all knew this prior to the Institute for Medicine’s 1999 report, but it was one of healthcare’s dirty little secrets that we kept from the public. However this article cited several studies showing that hospitals are even less safe on nights and weekends. (Would that be another of our secrets?)

So is a nocturnist a new concept or is this a better dressed house doctor of yesterday? Should the goal of a hospital be to have physicians at night, or should the nocturnist really be a member of an integrated hospitalist system? I’ll agree that if there isn’t a physician in house at night (exclusive of the ED) that having one is a great first step. However having a nocturnist should not be the end game. Consistent coverage by a team of well-trained, experience hospitalists should be the goal. Thoughts?

Featured webcast: Managing adverse actions

Adverse actions are a serious matter that requires serious attention. From prevention to investigation to reporting, how can you ensure your organization has the best processes in place? In the 90-minute live webcast, “Adverse Actions: Steps to Prevent, Manage and Report,” Joanne Hopkins, JD, and Anne Roberts, CPCS, CPMSM, will discuss how deal with an adverse action from beginning to end. Listeners will learn how to prevent adverse actions through education, how to prepare for an investigation, how to set clear guidelines and expectations for the peer review committee, what types of corrective action can be used, due process obligations, and reporting obligations.

Sponsored by the 15th Annual Credentialing Resource Center Symposium, the webcast will be held on Thursday, Oct. 27 at 1 p.m. EST. Participating in the live webcast or purchasing the CD to listen to at a later date cost just $159.20. For more information, click here.


One of the newest plans being proposed for Medicare payment involves combining the payments for hospital and physician services into a single amount to be divided between the parties as they see fit. The goal for Medicare is to pay less in total than is currently going to doctors and hospitals separately, by encouraging the two parties to work together on economies. 

It reminds me of a practice in Colonial times, also called bundling, in which two persons would be placed in a bed with a board between them in order to conserve heat during the night. Either form of bundling requires the parties to respect each other’s space while drawing together as closely as possible to achieve maximum efficiency. 

Hospital-employed physicians are effectively bundled already, while independent groups are likely to face this issue in the near future. It is closely connected to the subsidy issue, as the parties must determine how much money each needs to live on. Bundling increases the stakes by bringing multiple specialties into the negotiation. Hospitalists in medical specialties will need to advocate their case effectively against that of procedural specialists who have long been the darlings of hospital administrators because they bring money into the institution. Hospitalists need to generate visible cost savings to avoid being smothered by their bedmates.