Does provider self-reporting of etiquette behaviors improve patient experience? A randomized controlled trial
BACKGROUND
There is a glaring lack of published evidence-based strategies to improve the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores on the physician domain. Strategies that have been used are resource intensive and difficult to sustain.
OBJECTIVE
We hypothesized that prompting providers to assess their own etiquette-based practices every 2 weeks over the course of 1 year would improve patient experience on the physician domain.
DESIGN
Randomized controlled trial.
SETTING
4 acute care hospitals.
PARTICIPANTS
Hospitalists.
INTERVENTION
Hospitalists were randomized to the study or the control arm. The study arm was prompted every 2 weeks for 12 months to report how frequently they engaged in 7 best-practice bedside etiquette behaviors. Control arm participants received similarly worded questions on quality improvement behaviors.
MEASUREMENT
Provider experience scores were calculated from the physician HCAHPS and Press Ganey survey provider items.
RESULTS
Physicians reported high rates of etiquette-based behavior at baseline, and this changed modestly over the study period. Self-reported etiquette behaviors were not associated with experience scores. The difference in difference analysis of the baseline and postintervention physician experience scores between the intervention arm and the control arm was not statistically significant (P = 0.71).
CONCLUSION
In this 12-month study, biweekly reflection and reporting of best-practice bedside etiquette behaviors did not result in significant improvement on physician domain experience scores. It is likely that hospitalists’ self-assessment of their bedside etiquette may not reflect patient perception of these behaviors. Furthermore, hospitalists may be resistant to improvement in this area since they rate themselves highly at baseline. Journal of Hospital Medicine 2017;12:402-406. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Baseline and Study Periods
A 12-month period prior to the enrollment of each hospitalist was considered the baseline period for that individual. Hospitalist eligibility was assessed based on number of unique patients for each hospitalist who responded to the survey during this baseline period. Once enrolled, baseline provider-level patient experience scores were calculated based on the survey responses during this 12-month baseline period. Baseline etiquette behavior performance of the study was calculated from the first survey. After the initial survey, hospitalists received biweekly surveys (EB or QIB) for the 12-month study period for a total of 26 surveys (including the initial survey).
Survey Development, Nature of Survey, Survey Distribution Methods
The EB and QIB physician self-report surveys were developed through an iterative process by the study team. The EB survey included elements from an etiquette-based medicine checklist for hospitalized patients described by Kahn et al. 18 We conducted a review of literature to identify evidence-based practices.19-22 Research team members contributed items on best practices in etiquette-based medicine from their experience. Specifically, behaviors were selected if they met the following 4 criteria: 1) performing the behavior did not lead to significant increase in workload and was relatively easy to incorporate in the work flow; 2) occurrence of the behavior would be easy to note for any outside observer or the providers themselves; 3) the practice was considered to be either an evidence-based or consensus-based best-practice; 4) there was consensus among study team members on including the item. The survey was tested for understandability by hospitalists who were not eligible for the study.
The EB survey contained 7 items related to behaviors that were expected to impact patient experience. The QIB survey contained 4 items related to behaviors that were expected to improve quality (Table 1). The initial survey also included questions about demographic characteristics of the participants.
Survey questionnaires were sent via email every 2 weeks for a period of 12 months. The survey questionnaire became available every other week, between Friday morning and Tuesday midnight, during the study period. Hospitalists received daily email reminders on each of these days with a link to the survey website if they did not complete the survey. They had the opportunity to report that they were not on service in the prior week and opt out of the survey for the specific 2-week period. The survey questions were available online as well as on a mobile device format.
Provider Level Patient Experience Scores
Provider-level patient experience scores were calculated from the physician domain Press Ganey survey items, which included the time that the physician spent with patients, the physician addressed questions/worries, the physician kept patients informed, the friendliness/courtesy of physician, and the skill of physician. Press Ganey responses were scored from 1 to 5 based on the Likert scale responses on the survey such that a response “very good” was scored 5 and a response “very poor” was scored 1. Additionally, physician domain HCAHPS item (doctors treat with courtesy/respect, doctors listen carefully, doctors explain in way patients understand) responses were utilized to calculate another set of HCAHPS provider level experience scores. The responses were scored as 1 for “always” response and “0” for any other response, consistent with CMS dichotomization of these results for public reporting. Weighted scores were calculated for individual hospitalists based on the proportion of days each hospitalist billed for the hospitalization so that experience scores of patients who were cared for by multiple providers were assigned to each provider in proportion to the percent of care delivered.23 Separate composite physician scores were generated from the 5 Press Ganey and for the 3 HCAHPS physician items. Each item was weighted equally, with the maximum possible for Press Ganey composite score of 25 (sum of the maximum possible score of 5 on each of the 5 Press Ganey items) and the HCAHPS possible total was 3 (sum of the maximum possible score of 1 on each of the 3 HCAHPS items).
ANALYSIS AND STATISTICAL METHODS
We analyzed the data to assess for changes in frequency of self-reported behavior over the study period, changes in provider-level patient experience between baseline and study period, and the association between the these 2 outcomes. The self-reported etiquette-based behavior responses were scored as 1 for the lowest response (never) to 4 as the highest (always). With 7 questions, the maximum attainable score was 28. The maximum score was normalized to 100 for ease of interpretation (corresponding to percentage of time etiquette behaviors were employed, by self-report). Similarly, the maximum attainable self-reported QIB-related behavior score on the 4 questions was 16. This was also converted to 0-100 scale for ease of comparison.
