Driving a Screw With a Hammer Peter S Kibbe, MD, FHM

August 1, 2018

I have worked for some years now with hospital administrators who use HCAHPS scores of individual hospitalist physicians as indicators of the communication performance of these individuals.  I have worked also with some who use the scores of an entire group of hospitalist physicians to judge the communication performance of the group.  Both of these approaches are flawed. 

As Leslie Flores points out in a June edition of the official blog of the Society of Hospital Medicine, “Regulators never intended HCAHPS to be used to evaluate the performance of individual doctors, nurses or other hospital staff, or to attribute scores to any physician (or physician group)….HCAHPS is not measuring you on your patient experience performance, contrary to what many of you are being told by hospital and health system leaders.” (emphasis the author’s)

The fact that these scores are not useful in evaluating individuals or groups of individuals such as hospitalists seems self-evident by the manner in which groups of doctors care for individual hospital patients.  We know that the majority of our patients come through the emergency department where they see a doctor and they might then be admitted by one of our group members, then seen by a consulting physician, then be seen and discharged by another member of our group of hospitalists.  The usual method of assigning a physician to be “responsible” for the patient’s responses to the questions on the survey regarding physician communication is to assign the responses to the discharging physician.

In a research paper on physician coaching and its effect on patient experience, Sieler, et al. point out that studies show that less than a third of hospitalized patients can correctly name their physicians.  They also point out that in one large study the discharging hospitalist physician was responsible for only about one third of the patient’s physician encounters.(1)

Some hospital administrators fashion “work arounds” in order to attempt to make the HCAHP surveys reflect individual physician communication performance.  They might insist the discharging hospitalist physician inform the patient that the survey questions regarding “the doctor” are a reflection only of the discharging doctor.  They might also adopt the position that the group of hospitalists is uniquely responsible for raising the scores of the entire hospital medical staff.  They also often publicly publish individual physician scores.  They often financially incentivize hospitalist groups according to their scores.

This is like attempting to drive a screw with a hammer. 

In a May, 2016 JAMA article, 3 CMS officials including the CMS Chief Medical Officer make it clear that HCAHPS surveys were designed to give hospital administrators an aggregate, not individual, picture of patient perceptions.  “Although designed to measure hospital-level performance, some hospitals may be disaggregating their raw HCAHPS data to compare, assess and incentivize individual physicians, nurses and other hospital staff…there are reports that some hospitals link individual physician or physician group financial incentives to performance on disaggregated HCAHPS responses.  This is contrary to the survey’s design and policy aim.  HCAHPS is not suitable for evaluating or incentivizing individuals or groups within a hospital.” (2)

An attempt to raise physician scoring, therefore, cannot be accomplished by attempting to reward or punish individuals or groups.  Improving the patient communication skills of a hospitalist group is laudable but insufficient if the same excellence in communication skills is not expected of all the facility’s physicians and staff.  If the culture of the hospital is consistent with providing a platform for physicians who perform procedures without consulting with and communicating well with attending physicians and the patient and families—working as a team to get to what is the best for the patient—hammering away at the individual scores of hospitalists will not be successful.

Changing the hospital culture of communication is often the indicated measure.  I would argue that it not only includes improving physician communication skills but demands excellent communication among clinicians.  If a consultant is relatively mute in explaining to patients, it is highly likely he or she will be the same with his or her colleagues.

  1. Physician communication coaching effects on patient experience, Adrianne Seiler, et al., PLOS One, July 5, 2017
  2. Measurement of the patient Experience

      Clarifying Facts, Myths and Approaches, Lemeneh Tefera, JAMA, May 24,   2016