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
Educational and feedback strategies used to improve patient experience are very resource intensive. Training sessions provided at some hospitals may take hours, and sustained effects are unproved. The presence of an independent observer in patient rooms to generate feedback for providers is not scalable and sustainable outside of a research study environment.9-11,15,17,26-29 We attempted to use physician repeated self-reporting to reinforce the important and easy to adopt components of etiquette-based behavior to develop a more easily sustainable strategy. This may have failed for several reasons.
When combining “always” and “usually” responses, the physicians in our study reported a high level of etiquette behavior at baseline. If physicians believe that they are performing well at baseline, they would not consider this to be an area in need of improvement. Bigger changes in behavior may have been possible had the physicians rated themselves less favorably at baseline. Inflated or high baseline self-assessment of performance might also have led to limited success of other types of educational interventions had they been employed.
Studies published since the rollout of our study have shown that physicians significantly overestimate how frequently they perform these etiquette behaviors.30,31 It is likely that was the case in our study subjects. This may, at best, indicate that a much higher change in the level of self-reported performance would be needed to result in meaningful actual changes, or worse, may render self-reported etiquette behavior entirely unreliable. Interventions designed to improve etiquette-based behavior might need to provide feedback about performance.
A program that provides education on the importance of etiquette-based behaviors, obtains objective measures of performance of these behaviors, and offers individualized feedback may be more likely to increase the desired behaviors. This is a limitation of our study. However, we aimed to test a method that required limited resources. Additionally, our method for attributing HCAHPS scores to an individual physician, based on weighted scores that were calculated according to the proportion of days each hospitalist billed for the hospitalization, may be inaccurate. It is possible that each interaction does not contribute equally to the overall score. A team-based intervention and experience measurements could overcome this limitation.
CONCLUSION
This randomized trial demonstrated the feasibility of self-assessment of bedside etiquette behaviors by hospitalists but failed to demonstrate a meaningful impact on patient experience through self-report. These findings suggest that more intensive interventions, perhaps involving direct observation, peer-to-peer mentoring, or other techniques may be required to impact significantly physician etiquette behaviors.
Disclosure
Johns Hopkins Hospitalist Scholars Program provided funding support. Dr. Qayyum is a consultant for Sunovion. The other authors have nothing to report.
