Do HCAHPS doctor communication scores reflect the communication skills of the attending on record? A cautionary tale from a tertiary-care medical service
BACKGROUND
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores measure patient satisfaction with hospital care. It is not known if these reflect the communication skills of the attending physician on record. The Four Habits Coding Scheme (4HCS) is a validated instrument that measures bedside physician communication skills according to 4 habits, namely: investing in the beginning, eliciting the patient’s perspective, demonstrating empathy, and investing in the end.
OBJECTIVE
To investigate whether the 4HCS correlates with provider HCAHPS scores.
METHODS
Using a cross-sectional design, consenting hospitalist physicians (n = 28), were observed on inpatient rounds during 3 separate encounters. We compared hospitalists’ 4HCS scores with their doctor communication HCAHPS scores to assess the degree to which these correlated with inpatient physician communication skills. We performed sensitivity analysis excluding scores returned by patients cared for by more than 1 hospitalist.
RESULTS
A total of 1003 HCAHPS survey responses were available. Pearson correlation between 4HCS and doctor communication scores was not significant, at 0.098 (-0.285, 0.455; P = 0.619). Also, no significant correlations were found between each habit and HCAHPS. When including only scores attributable to 1 hospitalist, Pearson correlation between the empathy habit and the HCAHPS respect score was 0.515 (0.176, 0.745; P = 0.005). Between empathy and overall doctor communication, it was 0.442 (0.082, 0.7; P = 0.019).
CONCLUSION
Attending-of-record HCAHPS scores do not correlate with 4HCS. After excluding patients cared for by more than 1 hospitalist, demonstrating empathy did correlate with the doctor communication and respect HCAHPS scores. Journal of Hospital Medicine 2017;12:421-427. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Communication is the foundation of medical care.1 Effective communication can improve health outcomes, safety, adherence, satisfaction, trust, and enable genuine informed consent and decision-making.2-9 Furthermore, high-quality communication increases provider engagement and workplace satisfaction, while reducing stress and malpractice risk.10-15
Direct measurement of communication in the healthcare setting can be challenging. The “Four Habits Model,” which is derived from a synthesis of empiric studies8,16-20 and theoretical models21-24 of communication, offers 1 framework for assessing healthcare communication. The conceptual model underlying the 4 habits has been validated in studies of physician and patient satisfaction.1,4,25-27 The 4 habits are: investing in the beginning, eliciting the patient’s perspective, demonstrating empathy, and investing in the end. Each habit is divided into several identifiable tasks or skill sets, which can be reliably measured using validated tools and checklists.28 One such instrument, the Four Habits Coding Scheme (4HCS), has been evaluated against other tools and demonstrated overall satisfactory inter-rater reliability and validity.29,30
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, developed under the direction of the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality, is an established national standard for measuring patient perceptions of care. HCAHPS retrospectively measures global perceptions of communication, support and empathy from physicians and staff, processes of care, and the overall patient experience. HCAHPS scores were first collected nationally in 2006 and have been publicly reported since 2008.31 With the introduction of value-based purchasing in 2012, health system revenues are now tied to HCAHPS survey performance.32 As a result, hospitals are financially motivated to improve HCAHPS scores but lack evidence-based methods for doing so. Some healthcare organizations have invested in communication training programs based on the available literature and best practices.2,33-35 However, it is not known how, if at all, HCAHPS scores relate to physicians’ real-time observed communication skills.
To examine the relationship between physician communication, as reported by global HCAHPS scores, and the quality of physician communication skills in specific encounters, we observed hospitalist physicians during inpatient bedside rounds and measured their communication skills using the 4HCS.
