To perform the study,4 chiefs of hospital medicine divisions at five independent hospitals located in Baltimore and Washington identified their most clinically excellent hospitalists. Then, an investigator observed each hospitalist during a routine clinical shift and recorded behaviors believed to be associated with excellent behavior and communication using the hospital medicine comportment and communication observation tool (HMCCOT), said Susrutha Kotwal, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, and lead author. The investigators collected basic demographic information while observing hospitalists for an average of 280 minutes; 26 physicians were observed for 181 separate clinical encounters. Each provider’s mean HMCCOT score was compared with patient satisfaction surveys such as Press Ganey (PG) scores.
Dr. Susrutha Kotwal
The most frequently observed behaviors were physicians washing their hands after leaving the patient’s room in 170 (94%) of the encounters and smiling (83%), according to the study’s results. Behaviors that were observed with the least regularity included using an empathic statement (26% of encounters), and employing teach back (13% of encounters). “Teach back” refers to asking patients what they have learned during their visit. They use their own words to explain what they should know about their health, or what they need to do to get better. A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients’ personal histories and their interests.
Noteworthy is the fact that the distribution of HMCCOT scores were similar when analyzed by age, gender, race, amount of clinical experience, the hospitalist’s clinical workload, hospital, or time spent observing the hospitalist. But the distribution of HMCCOT scores was quite different in new patient encounters, compared with follow-ups (68.1% versus 39.7%). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes versus 8.7 minutes). The physicians’ HMCCOT scores were also associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might also translate into enhanced patient satisfaction.
As a result of the study, a comportment and communication tool was established and validated by following clinically excellent hospitalists at the bedside. “Even among clinically respected hospitalists, the results reveal that there is wide variability in behaviors and communication practices at the bedside,” Dr. Kotwal said.
Employing the tool
Hospitalists can choose whether to perform behaviors in the HMCCOT themselves, while others may wish to watch other hospitalists to give them feedback tied to specific behaviors. “These simple behaviors are intimately linked to excellent communication and comportment, which can serve as the foundation for delivering patient-centered care,” Dr. Kotwal said.
A positive correlation was found between spending more time with patients and higher HMCCOT scores. “Patients’ complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that they did not convey information in a clear manner,” Dr. Kotwal said. “When successfully achieved, patient-centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self-management of chronic disease. Many of the components of the HMCCOT described in our study are at the heart of patient-centered care.”
Dr. Kotwal believes HMCCOT is a better strategy to improve patient satisfaction than patient satisfaction surveys because patients can’t always recall which specific provider saw them. In addition, patients’ recall about the provider may be poor because surveys are sent to patients days after they return home. In addition, patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Therefore, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.5
The study authors conclude that, “Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies are then needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication be established as a goal for every encounter.”
The effectiveness of care team rounds at the bedside
Investigators at the UMass Memorial Medical Center, in Worcester, Mass., studied the effectiveness of assembling the entire care team (i.e., physicians, including residents and attendings, nursing, and clinical pharmacy) to round at the patient’s bedside each morning – in lieu of its traditionally separate rounding strategies – on one unit of its academic hospitalist service for an internal quality program, said Patricia Seymour, MD, FAAFP, assistant professor and family medicine hospitalist education director.