Discussion

A key component of delivering high-quality care is effective physician–patient communication, which correlates with medication compliance, readmission rates, clinical outcomes and the patient experience.1–3 Through standardised communication protocols, training sessions, educational tools, real-time feedback and incentive programme, several studies have shown improved physician communication, the overall patient experience and HCAHPS scores.4–10 Most of these interventions focus on the ‘knowledge’ aspect of communication, targeting delivery of medical information and patient education. However, behavioural aspects of communication are more subjective and difficult to measure.

Many hospitals assess the quality of their communication using the HCAHPS surveys, which assess how often physicians treat patients with courtesy and respect, listen carefully and explain things in ways patients can understand. However, these surveys are only provided to a small group of patients and are often returned months after their hospitalisation. The small sample size and delayed return make it difficult to accurately measure and provide feedback to physicians in real time. It is also difficult to determine which behaviours individual providers need to change to improve their communication skills. No study has yet related specific communication behaviours to patient experience scores. Therefore, this study’s objective was to design a tool to assess communication practices in the inpatient setting, provide physicians with personalised feedback in real time and relate specific communication behaviours to patient experience measures. Furthermore, this tool provides the opportunity to relay communication concerns to the medical team prior to the patient’s discharge so that issues can be addressed proactively. This allows for iterative improvement in physician–patient communication if, for example, a patient did not understand something the first day, it could be reinforced on the second.

Ten communication behaviours were identified as fundamental for establishing a strong physician–patient relationship. These include knocking before entering the room, introducing yourself, explaining your role, introducing the other members of the team, addressing patients by name, addressing family/friends in the room, attempting to be at eye level, asking permission before performing a physical examination, asking if patients have questions and asking if patients understand the plan of care. It was hypothesised these fundamental behaviours would correlate with patient experience measures. The correlation analysis revealed several variables correlated with higher HCAHPS scores; however, addressing patients by name and introducing other members of the team were statistically significant. However, for other behaviours, this study may not have had enough power to detect a difference.

This communication tool identified several behaviours to improve, including physician and team member introduction, role explanation, addressing patients by name and friends/family in the room, attempting to be at eye level, asking permission before performing physical examinations, asking if patients have questions and asking if patients understand the plan of care. This tool also indicated room for improvement in patient education as many patients reported not fully understanding their diagnosis or plan of care despite 87% reporting being asked if they had questions and 72% reporting being asked if they understood the plan of care. The low percentage of patients who knew their physician’s name suggests introductions may need to be made more than once or reinforced by other team members/visual aids. This tool also revealed nurse presence during rounds and communication between teams were lacking. Furthermore, this tool identified several discrepancies between what was observed on rounds and what patients reported with patients tending to report higher frequencies. As the perception of care is associated with its quality, patients’ perception of communication behaviours may be more important than what was performed/observed.11

It is important to discuss limitations and areas for future research. The small number of physicians and patients, as well as the narrow spread of HCAHPS scores, limited the power and correlation analysis, and thus limited the ability to make statistically significant conclusions about behaviours that should be addressed. Therefore, this study may need to be repeated with a hospitalist group both containing a wider breadth of HCAHPS scores and more physicians to determine whether associations between additional behaviours and HCAHPS scores can be achieved. Furthermore, this study did not observe physician–patient interactions outside of inpatient rounds, and physician behaviour may have been altered simply due to being observed by a third party. To limit recall bias, patient surveys were administered the same day that rounds were observed. It would also be interesting to compare communication practices between first and subsequent encounters as it may be important to perform some behaviours with each encounter. Additionally, expanding the fundamental behaviours identified in this study to all physicians and incorporating them into medical school and resident curricula can improve the communication behaviours of future physicians and physicians in training to create a culture of ‘always’ for every patient, every interaction, every day. Furthermore, using students, residents and volunteers can establish a sustainable model for continuous assessment using this tool.