This title may be a bit misleading.  Of course you can’t change the past.  Your inpatient customer service experience is over, but you can make your feelings known to your doctor and the institution’s administrative staff.  Your experience can prompt changes that can improve the experience for future patients.  While hospitals and outpatient facilities typically poll their patients to conduct Satisfaction Surveys, I think a better way to make your experience known in a way that can bring about change is to send a letter to the appropriate individuals at the facility.  Depending on the issue, these are the people to whom I would address the letter:

• President or CEO of the Hospital
• Head of the Department of Quality
• If appropriate, Director of Nursing
• If appropriate, Head of Clinical Services or Chief of Medicine

I would also send a copy to your physician as well as to the Quality Department of your health insurer.  I think notifying the insurer makes sense especially when issues result in unnecessary tests and procedures for which they will be asked to pay on your behalf.  (Remember the chest x-ray & blood tests my friend had due to that erroneous fever? If not, check her experience here.) Since these titles vary among institutions, you will need to contact the specific facility to get the correct title and the names of the individuals in these positions.

Present your experience and, if possible, what you hoped would have been a better outcome.  Then ask for a response that you wish to include what they will do in the future to prevent a recurrence to another patient.

If you experience exemplary service, also send a letter citing the high points of your experience and the staff that deserve credit.

What About Satisfaction Surveys?

Satisfaction surveys are commonly used by organizations to learn how they are doing from the perspective of their customers.  Starting in 2002, Centers for Medicare & Medicaid Services (CMS) partnered with the Agency for Healthcare Research and Quality (AHRQ), another agency in the federal Department of Health and Human Services, to develop and test the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey. In fact, since 2008 hospitals have been using the standardized HCAHPS Survey to get feedback from patients.  In July 2013, 3,928 hospitals publicly reported HCAHPS scores based on 3.1 million completed surveys.

You can check out a hospital’s results by going to the Hospital Compare Web site, www.medicare.gov/hospitalcompare.

Linking Quality to Payment

Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions (“subsection (d) hospitals”) must collect and submit HCAHPS data in order to receive their full annual payment update. The incentive for IPPS hospitals to improve patient experience of care was further strengthened by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing (VBP) program.   This began with October 2012 discharges.

HCAHPS and Hospital VBP Scoring

Eight HCAHPS measures, or “dimensions,” are included in Hospital VBP: the six HCAHPS composites (Communication with Nurses, Communication with Doctors, Staff Responsiveness, Pain Management, Communication about Medicines, and Discharge Information); a composite that combines the Cleanliness and Quietness items; and one global item (Overall Rating of Hospital). The percentage of a hospital’s patients who chose the most positive survey response is used to calculate the Patient Experience of Care Domain score.

How Surveys Are Used To Improve Quality

While satisfaction surveys identify areas that should be improved, those areas are often not very specific.  The satisfaction survey can be considered the first step in the quality improvement process.  Once the general area that needs improvement is identified, then an analysis is done to find the specific issues that need to be addressed.   To draw an analogy from medicine, the survey determines if there is a fever, but doesn’t readily point to the cause.  Your letter of complaint can help the institution more quickly identify the issues they must address to improve their quality.

So, by all means respond to satisfaction surveys after your inpatient experience, but also take the time to share constructive criticism with the hospital or outpatient facility.

By the way, the information I provided about HCAHPS was taken from http://www.hcahpsonline.org/files/August_2013_HCAHPS_Fact_Sheet3.pdf.

As always, your comments are welcome.

For Your Health – Dr. Bob

In my last post I talked about steps you can take prior to an elective hospitalization or procedure to try to make sure that you experience quality care from a customer care perspective.  Now I’ll turn to what you can do while you are in the hospital or other healthcare facility.

It’s a little more difficult for you alone to assure you get quality customer service there.  For one thing, you will meet several healthcare professionals there whose actions will contribute to the level of customer service you experience plus, in most instances, you won’t be fully aware of what’s going on.  Remember, the staff take direction from your physician though they usually report to the institution’s Nursing Supervisor.  Most healthcare teams look to the attending physician to set the tone.  If you experience any issues, discuss them with the Nursing Supervisor or your physician.  The following tips should help prevent such issues from arising.

Don’t Go It Alone

Perhaps the most important thing you should do while hospitalized is to have a friend or relative with you as much as possible during your stay.  Between the stress of being ill and side effects of anesthesia and other medications, you will not be as alert nor as mentally sharp as usual.  Your communication skills will be diminished during this time.  You need a knowledgeable advocate at your bedside who can help you communicate with your caregivers.

Communication Is Critical

Part of effective communication includes maintaining a positive relationship with the staff taking care of you.  It should be obvious that a positive relationship will naturally cause the staff to be more likely to go the extra mile for you. It’s important to understand their perspective.  Each of them has been trained to do his or her job to maximize your clinical outcomes, but not every one of them is encouraged to vary from standard procedures.  They don’t usually have the authority to change how they perform their tasks.  However, if you ask them respectfully to make an exception and do something differently, most will either follow your suggestions, if they can, or ask their supervisor.  Think of the example of the Nursing Assistant checking my friend’s temperature on her neck after it had been covered with a blanket and finding the temperature to be above normal (Details).  She should have rechecked it later after the blanket was off for a while.  My friend had been a bit curt with the Nursing Assistant.  When you act rudely, you may feel you make your point, but the staff member who is the target of your tirade will only do what they are required to do.  It comes down to showing respect and putting yourself in their place.  I have personally seen patients get arrogant and rude with some healthcare staff which alienates the very people they should want to have on their side.

In summary, I believe the key to helping assure you get quality customer care during a hospital or outpatient stay is Communication.  This includes:

• Having someone present who can help you communicate with the clinical staff,
• Discussing your concerns with the appropriate staff, &
• Doing so in a respectful way. Keep in mind the Golden Rule!

Next time I’ll discuss what you can do after your hospitalization or procedure to optimize the quality of the customer service that is part of the healthcare experience.  Comments are welcome!

For Your Health – Dr. Bob

This post will be a continuation of a discussion on the role of Customer Care (Service) in healthcare delivery.  The experience of a friend prompted me to begin talking about this a few posts ago in Does Customer Care Trump Technical Skill in Health Care Quality?  My last post, How Does Customer Care Fit in Health Care Quality? began to explore the role of Customer Care.  Now we’ll get more practical.

So how do you make sure your care is the best, both from a clinical and personal or customer service perspective?  Depending on the medical issue and urgency of getting treatment, you may have a chance to do some investigation before the procedure.  Over the next 3 posts, I will discuss activities to be done during each of these 3 time periods:.

1. Before your procedure
2. During your stay in the healthcare facility
3. After you go home

Let’s start with what you can do before the procedure.

Clinical Quality

Since many healthcare needs occur suddenly and their treatment can be critical, you may think it is impossible to know which doctor to choose or where to get the care.  If it is an emergency and you’re in the Emergency Room (ER), unless you know of a specific specialist for your problem, you will get the specialist appropriate for your condition who is on-call for the ER.  These on-call physicians have had their credentials reviewed and approved by the hospital, though customer service or what is sometimes called “bedside manner” is not usually a quality that gets reviewed.  If you already have a primary care physician (PCP), you can always ask the ER physician to contact your PCP to get the PCP’s recommendation for a specialist.  So even if an emergency occurs, you don’t have to go it alone.  It’s another good reason to establish yourself with a PCP while you’re well.

If you will be having an elective procedure, like a thyroidectomy or hysterectomy for non-urgent reasons, ask the surgeon about the number of procedures they do per month as well as their success & complication rates.  The more experience, the better.  Also, make sure they are Board Certified in the appropriate area of specialization.  In most states you can also look at an individual physician’s information on the state’s Board of Medicine website.  The exact name of the board varies from state to state but a search for board of medicine and your state’s name should help you find it.  This information gives you an indication of the clinical competence of the physician.

Customer Service (Bedside Manner)

Judging bedside manner is a little more difficult.  Some websites, such as ones provided by health insurers, give patient reviews of physicians and their practices.  If you know someone who has the same medical issue, ask them about the specialist and the care they’ve received.  Ask if they’d recommend getting treatment from that physician and facility.

Finally, if you happen to know a nurse or another health professional, ask them if they know about the specialist you are planning to see.  Perhaps, they’ve worked with the physician and know firsthand the kind of care he or she provides.

In the next post I’ll talk about some of the steps you can take while you’re in the healthcare facility during your treatment or while having your procedure.  I welcome your comments.

For Your Health – Dr. Bob

In my previous post I cited an example from real life how a hospital experience with a good clinical outcome was negatively affected by poor customer service.

Customer Care has taken on an even greater role in our society thanks to the internet and social media.  Bad customer experiences get spread quickly, often with significant negative results to the individual or organization providing the service.  More of us check out Customer Reviews of services and products before we make our purchases.  It is only natural that this means of evaluation is being applied to the delivery of health care.

Many patients take technical quality for granted.  For example, they assume that all Board Certified interventional cardiologists perform cardiac catheterizations equally well, just like all auto mechanics perform oil changes equally well.  For the diagnosis and treatment of the non-complicated cases, that assumption is pretty much correct.  It is with the more unusual or complicated cases that the level of competence plays a role in outcomes.

Since most patients can’t judge the clinical quality of most aspects of medical care, they often look to the quality of customer service to judge the quality of their care.  In addition, patients these days expect both technical and customer service excellence.  Gone are the days when the doctor is placed on a pedestal, where he can do no wrong and his advice must be followed without question.  This change in perspective underscores the importance of good physician-patient communication.  Ideally, the experienced physician should anticipate the questions and concerns of his patients and address them proactively.  He must take a personal approach with every patient.  My friend’s experience with the physician who saved her life but didn’t communicate with her left a lot to be desired in this dimension of her care experience.

The personalized approach also applies to the other staff who interact with patients, from the medical office receptionist to the nurse in the office or hospital.  In my friend’s case, the Nursing Assistant could have looked beyond the task she had to do and realize that she should have made adjustments in when and how she measured my friend’s temperature.  Likewise, the nurse who noted that my friend did not have a fever, but claimed that she was powerless to stop the unnecessary tests, should have used her common sense and contacted her supervisor to prevent the waste of resources and inconvenience to my friend.  Had they put themselves in my friend’s place, I think they would have found a way.

I don’t think we have to compromise on the extent of the quality of care that is delivered.  We shouldn’t have to settle and compromise because the technical procedure was a success.  We should have quality in all aspects of patient care, and, as the episode with the fictitious fever in my previous post demonstrates, save money in the process.

The question remains, what can the average patient do to get optimal care from both the technical and customer service perspectives?  I’ll offer some suggestions in my next post.

For Your Health – Dr. Bob

Recently, a close friend of mine, whom I’ll call Judy, suffered a heart attack and went into shock.  Without reversing the shock, she would die.  The on-call cardiologist saved her life by opening up the blocked artery and inserting a temporary pump to assist her heart until it was able to maintain a normal blood pressure on its own.  He saved Judy’s life for which we were all extremely grateful.

Exemplary care so far.  But…

My friend began to have misgivings about this cardiologist who didn’t see her the next day, and, when he did see her, it was difficult to communicate with him.  The nurses also indicated that they continually had communication issues with this doctor.  Based upon this, Judy was determined to find another cardiologist after her hospitalization.

More Questionable Quality

While she was in the hospital, several other incidents left Judy doubting the quality of the care she was getting.  One incident occurred while she was trying to get some sleep at night.  Because she was cold she covered her head with a blanket.  About an hour later a Nursing Assistant (NA) took her temperature with a device that measures the temperature of the patient’s skin.  It should be taken on exposed skin, ideally the forehead.  Instead the NA checked the temperature on my friend’s neck that had been covered by the blanket.  Naturally, the temperature was high suggesting my friend had a fever.  Rather than checking it again later after the blanket had been off, she charted that Judy had a fever.  Because an infection after a procedure can cause serious complications, doctors often write standing orders for their post-procedure patients specifying what tests should be performed and what treatments should be given if a patient develops a fever.  So, charting that “fever” set the ball rolling and that included a chest x-ray, blood draws for blood tests, blood cultures and getting a urine sample.  All this happened in the wee hours of the morning so Judy couldn’t get any sleep.

What added insult to injury was the fact that shortly after the erroneous temperature was recorded in the computer, a Registered Nurse (RN) rechecked my friend’s temperature and it was normal.  But the nurse said she couldn’t stop the testing once it was charted.  Consequently, Judy was needlessly inconvenienced and unnecessary charges were generated that her insurance will have to pay.

Here are the areas that raised questions about quality during this 3 day hospital stay from Judy’s perspective:

• Poor communication by the physician
• Lack of training & common sense on the part of the Nursing Assistant
• Either lack of training on the part of the Registered Nurse on how to override the computer, or
• Poorly devised computer system that doesn’t allow for legitimate overrides

Since it’s true that the most important thing was the fact this doctor and the care at this hospital saved Judy’s life, someone might say that these few quality concerns should be overlooked.  Indeed, most of these concerns really fall under the category of Customer Care or Service.  How important is customer care in the delivery of health care?  Does poor customer care trump technical clinical quality?

In my next post, I’ll explore customer service and health care.  Please share your thoughts on this topic.

For Your Health – Dr. Bob