I have received a number of requests from healthcare organizations to assist physicians who don’t understand the importance of HCAHPS or even the concept of a ‘service culture.’ Most of us were trained to believe that if we do an excellent job in the technical management of our patients and treat them with respect and courtesy, this should be more than sufficient.

There is a growing body of evidence that clinical excellence alone is important but insufficient and that an understanding of both the clinical and service aspects of a problem or question will enable physicians to be far more successful and have a greater impact upon the clinical outcomes of their patients.

I. Superior quality outcomes:

There are now hundreds of articles documenting the direct of impact of optimum communications and service on quality outcomes; however, some of the most impressive data comes from The Studer Group that compares quality outcomes for a number of significant clinical conditions with various HCAHPS box score levels. For instance, lower box HCAHPS scores lead to approximately 16.8% incidence of stage III and IV pressure ulcers whereas top box HCAHPS scores lead to a 4.1% incidence. Similarly, lower box HCAHPS scores lead to approximately 5.3% manifestations of poor glycemic control whereas top box HCAHPS scores lead to approximately 1.7% manifestations of poor glycemic control.

How does service make a difference in this way? It should be intuitive to many thoughtful practitioners that patients who trust and respect their physicians are more likely to follow their evidence based advice and those who do not are more likely to do the opposite. Thus, bedside manner may be a leading determinant of quality outcomes.

II. Reduced inadvertent errors and sentinel events:

The Joint Commission performed a famous study of the root cause of all reported sentinel events between 1995 and 2005 and found that poor communications was by far the most common cause of sentinel events in the United States (68%) whereas lack of technical competence was only responsible for 20%. This may be counterintuitive for those who trained decades ago when the prevailing attitude was that technical expertise was the most important skill that a clinician could acquire. As it turns out, effective communication eclipses the impact of credentialing and privileging and is the most significant cause of inadvertent errors that lead to potential adverse outcomes.

III. Reduced liability risk:

The American Trial Lawyers Association (ATLA) discovered that for each 10%tile decrease in patient satisfaction scores, there is a 6% increase in complaints and a 5% increase in risk management episodes. In addition, 75% of complaints are related to communication and have nothing to do with the technical quality of care. Most importantly, only 3% of patients who are victims of inadvertent negligence will ever sue their physician or healthcare organization and almost all legal actions are secondary to poor communications.

IV. Reduced turnover and cost:

Several studies have demonstrated that poor communications and service result in significant turnover of staff and healthcare personnel (200%-300% higher than expected) which leads to 24% longer lengths of stay and a 28% higher mortality rate. This should not be surprising as high turnover leads to less experienced staff who have not yet mastered the complex healthcare environment and are not yet optimally effective.

Conclusion:

Effective communication and service is a significant driver of: quality outcomes, inadvertent errors, liability costs, staff turnover, length of stay, and morbidity/mortality rates. Therefore, we may need to revise our thinking regarding the importance of a culture of service and effective communication with at least the same motivation once directed us towards technical proficiency and professional mastery.

Jon Burroughs, MD, MBA, FACHE, FACPE
President and CEO, The Burroughs Healthcare Consulting Network, Inc.