More than medicine

For the first time the federal government is reporting how well hospitals satisfy the patients they care for. These are statistics hospitals have looked at internally, but they’ve never been publicly compared before.

Among Syracuse hospitals, the patients at St. Joseph’s Hospital Health Center gave it somewhat higher satisfaction scores. My congratulations to CEO Ted Pasinski & the staff at St. Joe's. Community General Hospital's patient satisfaction is the next best locally, as reported by the federal Centers for Medicare & Medicaid Services (CMS).

Since last year, all hospitals have been required to submit to CMS the results of their patient satisfaction surveys using a standard methodology called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, pronounced “H-caps”). Hospitals that fail to submit such data will have their Medicare payments reduced by two percent – so there is an incentive to comply.

Although the HCAHPS scores were posted only recently, the federal government has been developing its patient satisfaction methodology for years. As a matter of fact, Community was one of 132 hospitals nationwide that helped pilot a version of the HCAHPS survey in 2003.

Last month the HCAHPS scores were posted on the CMS website. In the list below are the patients’ scores for Syracuse hospitals for the first five of ten HCAHPS questions. These data are for patients surveyed during the period October 2006 - June 2007.

Nurses always communicate well
Community - 72%
Crouse - 66%
St. Joseph's - 77%
University - 68%

Doctors always communicate well
Community - 78%
Crouse - 73%
St. Joseph's - 77%
University - 73%

Patients always received help as soon as they wanted
Community - 60%
Crouse - 48%
St. Joseph's - 64%
University - 49%

Pain was always well controlled
Community - 65%
Crouse - 61%
St. Joseph's - 68%
University - 63%

Staff always explained about medicine before giving it to patients
Community - 54%
Crouse - 51%
St. Joseph's - 53%
University - 52%

Notice that the government reports the percentage of responses from patients who said they were “always” satisfied with respect to the specific question.

“Always” is a demanding standard. “Always” means a hospital did not fail to meet the patient’s expectations even a single time during the course of a hospital stay. To give this perspective, would your spouse say that he or she is “always” satisfied with the way you manage the finances, discipline the kids, or maintain the lawn? Would your co-workers or your supervisor report they are “always” satisfied with your performance on the job?

HCAHPS scores do not address the underlying issues of quality care, only its social aspects. But hospital care is a mix of clinical processes and interpersonal communications. Hospital care is "more than medicine." I have written before about the importance of two-way communication and the personal touch. [1]

Patients expect hospital quality to be first rate. They expect us to provide the right care to the right patient on time and as promised. They do not expect errors or omissions. Quality care is baseline. It’s what they need us for. But care that is delivered respectfully and with a personal touch is always recognized, always welcomed, and always appreciated.

That is why we acknowledge members of our staff who are especially kind, helpful, and responsive. Our STAR award honors physicians who demonstrate “sensitivity, thoughtfulness, appreciation and respect,” and our WOW award recognizes employees who make “an extra effort” to assure a patient’s needs have been met, even exceeded.

CMS will update the patient scores on its website each quarter. We as an industry – and we as an individual hospital – have more to do to improve the percentage of patients who say we “always” meet their needs.


[1] See these postings on the “More than Medicine” blog: The importance of listening , Stop me if I say something you don’t understand, and Whatever became of bedside manner

Compelling hospital stories

Please check out Running a Hospital, the notable blog from Paul Levy, President & CEO of Beth Israel Deaconess Medical Center in Boston. Paul is the pioneer of hospital CEO bloggers, notable for the insights, the candor, and the sheer abundance of his entries.

Yesterday he hosted a "Grand Rounds" posting that linked commentaries on experiences at hospitals that changed someone’s behavior or beliefs. Many compelling stories there.

Medical arrogance

My thanks to Dr. Paul Kronenberg, President and CEO of Crouse Hospital, for his op-ed piece on “medical arrogance” in today’s Post-Standard. Dr. Kronenberg writes:

Hospitals are run by people, and people make mistakes. We don't always listen as well as we should. And yes, we sometimes fail to live up to the expectations of our patients and their family members.

Effective communications between caregivers and patients (and among the caregivers themselves) are not just a matter of politeness. Poor communications raise the risk that something is misunderstood, that something is missed – this can foster medical errors.

Dr. Kronenberg is right to emphasize the importance of caregiver communications. For more on this, see these past postings – Stop me if I say something you don’t understand, The importance of listening, and Whatever became of bedside manner?

Whatever became of bedside manner?

The New York Times ran a series of letters to the editor last month under the heading: “What ever became of bedside manner?” [1]

The nine letters were mostly from doctors, who offered their own advice for improving doctor-patient communications. The doctors recommended good manners, such as making eye contact, remaining seated while a patient recounts symptoms, washing hands in the presence of a patient, returning phones calls and accepting appointments promptly for established patients. [2]

Some letters also pointed out a patient’s responsibility for effective communications. “So often patients come to us without organized information or prior records,” one wrote. [3] Another physician noted that patients can waste time by speaking of irrelevant things. He wrote about a recent example where a patient recounted a lengthy medical experience from the Korean War. The physician said,

I listened patiently as the minutes ticked by, wondering what the story had to do with his eye condition or general medical history. It eventually became evident that it was simply an interesting anecdote that the patient felt like sharing…[4]

Several weeks after the first set of letters, the Times printed more letters on bedside manners. Several suggested that better communications training is (or should be) available for health care professionals. One writer suggested that health care workers “ask themselves, ‘Is this how I would want my family member to be cared for? Is this how I would want a family member to be addressed?’” [5]

I have been in the hospital field for over 30 years, and I am still amazed at how much we sometimes talk past each other. We must all have examples of people misunderstanding one another – not because they were not listening, but because they applied different frames of reference to what was being said.

Messages we think we are sending may not be the same messages the other is receiving. We have different training, different experiences. We cannot automatically assume that our own perspective is shared by another. Sometimes our different frame of reference may cause us to make assumptions about another’s motivation. We may not even know we’re making an assumption, but what we think about the other fellow can affect the way we listen to – and accept or dismiss – what is being said.

I can imagine, for example, that the gentleman who rambled on about his Korean War experience (in the example above) may have done so because he was nervous at seeing a doctor – and his nervousness prompted too much talking. Or perhaps his long-winded story was an attempt to establish a relationship with the doctor before he brought up an embarrassing problem or a scary health complaint.

The point is, we may not know what motivates the other party, but our communications can improve if we imagine reasons why the other party might say or do something that is otherwise inexplicable. Keeping an open mind about the other person can help get past distracting or annoying communications. How might the caregiver’s communication with the Korean veteran have changed if he had considered reasons for the patient’s story other than mindless prattle?

When communications prompt an emotional reaction in the caregiver or the patient the focus can move away from what is being done or what has to be learned. If we’re thinking “How rude!” or “Who knows what she meant by that!” we’ve already changed the focus of our attention. When the focus moves away from the communication process, we risk not hearing something, forgetting to say something, not paying attention to something.

Good manners in health care communications are not just the “extra” that we bring to the bedside. They are an important part of the caring that we do, facilitating unambiguous understanding and reducing the chance for a mistake.


[1] “What’s Become of Bedside Manner? (Nine Letters),” New York Times, December 4, 2005.
[2] “Some Simple Guidelines for (seeing) Patients,”, Sharon Lewin, MD, New York Times, December 4, 2005
[3] Allan B. Ettinger, MD & Deborah M. Wesibot, MD, New York Times, December 4, 2005
[4] Mark Melamed, MD, New York Times, December 4, 2005
[5] Judith A. Erlen, New York Times, January 17, 2006

What they say

Community General Hospital was one of 132 hospitals nationwide that voluntarily participated in a patient survey undertaken by the federal government last year. The Centers for Medicare and Medicaid (CMS) conducted a pilot project involving 61 hospitals in New York, 45 in Maryland, and 26 in Arizona.

CMS will use the project to develop a standard way of evaluating hospital performance by patients. When the project is finished, we can expect CMS to look for ways to link the how hospitals are paid to how well patients rate their care.

The CMS surveys were conduced on Community's medical-surgical patients who were discharged in December 2002 and January 2003. For obstetric patients, the sample was drawn from patients in the November 2002 and January 2003 period. Patients received a pre-survey letter, a mail-in questionnaire, and a thank you card. Those who did not return questionnaires received up to five follow-up telephone calls to improve the response. As a result, of the 900 Community patients who were surveyed, fully one-half responded (49.9%).

Patients were asked to score the hospital from 0 to 10 with 0 being the “worst possible” hospital experience and 10 being “best possible.” 35% percent gave Community a “perfect 10” and 63% scored “9 or 10.” Most people had very good experiences here, but surveys like this one help us focus on improving performance by using information from those who rated us less favorably.

The CMS survey results also suggest how we compare with other hospitals in the state and nation. For example, on the “worst possible/ best possible” question, 59% of the patients scored “9 or 10” among the 61 New York hospitals that participated.

We looked at another survey this week at a meeting of the Medical Executive Committee. That survey, conducted at a recent meeting of the Medical Staff, helps us understand physician opinion. This is a snapshot of the views of the doctors on whom we depend for patient referrals and medical management.

In all 52 physicians completed the survey, and they said the quality of physician care at Community is comparable to other hospitals – one-fifth reported it as “better.” Only 2% forecast a decrease in their work at Community with 23% saying they anticipate using Community more in the future.

One question asked: “Is Community's image in 2004 better, worse or the same as 2002?” In reviewing the results this week, one Department Chairman said he was pleased that 69% of the doctors think our image improved. “And I think that’s right,” he said. “Community is better.”

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This text was originally sent to the employees of Community General Hospital, Syracuse, NY, as one of a series of letters from the CEO. The text was subsequently posted on the CEO's blog, More than Medicine, started in June 2007.