Hospitalist Communication Training

Setting and Study Design

The study was conducted at Northwestern Memorial Hospital (NMH), an 897‐bed tertiary‐care teaching hospital in Chicago, IL, and was approved by the institutional review board of Northwestern University. This study was a preintervention vs postintervention comparison of patient‐satisfaction scores. The intervention was a communication‐skills training program for all NMH hospitalists. We compared patient‐satisfaction survey data for patients admitted to the nonteaching hospitalist service during the 26 weeks prior to the intervention with data for patients admitted to the same service during the 22 weeks afterward. Hospitalists on this service worked 7 consecutive days, usually followed by 7 days free from clinical duty. Hospitalists cared for approximately 1014 patients per day without the assistance of resident physicians or midlevel providers (ie, physician assistants or nurse practitioners). Nighttime patient care was provided by in‐house hospitalists (ie, nocturnists). A majority of nighttime shifts were staffed by physicians who worked for the group for a single year. As a result of a prior intervention, hospitalists' patients were localized to specific units, each overseen by a hospitalist‐unit medical director.[9] We excluded all patients initially admitted to other services (eg, intensive care unit, surgical services) and patients discharged from other services.

Hospitalist Communication Skills Training Program

Northwestern Memorial Hospital implemented a communication‐skills training program in 2009 intended to enhance patient experience and improve patient‐satisfaction scores. All nonphysician staff were required to attend a 4‐hour training session based on the AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank You) principles developed by the Studer Group.[10] The Studer Group is a well‐known healthcare consulting firm that aims to assist healthcare organizations to improve clinical, operational, and financial outcomes. The acronym AIDET provides a framework for communication‐skills behaviors (Table 1).

We adapted the AIDET framework and designed a communication‐skills training program, specifically for physicians, to emphasize reflection on current communication behaviors, deliberate practice of enhanced communication skills, and feedback based on performance during simulated and real clinical encounters. These educational methods are consistent with recommended strategies to improve behavioral performance.[11] During the first session, we discussed measurement of patient satisfaction, introduced AIDET principles, gave examples of specific behaviors for each principle, and had participants view 2 short videos displaying a range of communication skills followed by facilitated debriefing.[12] The second session included 3 simulation‐based exercises. Participants rotated roles in the scenarios (eg, patient, family member, physician) and facilitated debriefing was co‐led by a hospitalist leader (K.J.O.) and a patient‐experience administrative leader (either T.D. or J.R.). The third session involved direct observation of participants' clinical encounters and immediate feedback. This coaching session was performed for an initial group of 5 hospitalist‐unit medical directors by the manager of patient experience (T.D.) and subsequently by these medical directors for the remaining participants in the program. Each of the 3 sessions lasted 90 minutes. Instructional materials are available from the authors upon request.

The communication‐skills training program began in August 2011 and extended through January 2012. Participation was strongly encouraged but not mandatory. Sessions were offered multiple times to accommodate clinical schedules. One of the co‐investigators took attendance at each session to assess participation rates.

Survey Instruments and Data

During the study period, NMH used a third‐party vendor, Press Ganey Associates, Inc., to administer the HCAHPS survey to a random sample of 40% of hospitalized patients between 48 hours and 6 weeks after discharge. The HCAHPS survey has 27 total questions, including 3 questions assessing doctor communication as a domain.[3] In addition to the HCAHPS questions, the survey administered to NMH patients included questions developed by Press Ganey. Questions in the surveys used ordinal response scales. Specifically, response options for HCAHPS doctor‐communication questions were never, sometimes, usually, and always. Response options for Press Ganey doctor‐communication questions were very poor, poor, fair, good, and very good. Patients provided an overall hospital rating in the HCAHPS survey using a 010 scale, with 0=worst hospital possible and 10=best hospital possible.

We defined the preintervention period as the 26 weeks prior to implementation of the communication‐skills program (patients admitted on or between January 31, 2011, and July 31, 2011) and the postintervention period as the 22 weeks after implementation (patients admitted on or between January 31, 2012, and June 30, 2012). The postintervention period was 1 month shorter than the preintervention period in an effort to avoid confounding due to a number of new hospitalists starting in July 2012. We defined a discharge attending as highly trained if he/she attended all 3 sessions of the communication‐skills training program. The discharge attending was designated as no/low training if he/she attended fewer than the full 3 sessions.

Data Analysis

Data were obtained from the Northwestern Medicine Enterprise Data Warehouse, a single, integrated database of all clinical and research data from all patients receiving treatment through Northwestern University healthcare affiliates. We used ² and Student t tests to compare patient demographic characteristics preintervention vs postintervention. We used ² tests to compare the percentage of patients giving top‐box ratings to each doctor‐communication question (ie, always for HCAHPS and very good for Press Ganey) and giving an overall hospital rating of 9 or 10. We used top‐box comparisons, rather than comparison of mean or median scores, because patient‐satisfaction data are typically highly skewed toward favorable responses. This approach is consistent with prior HCAHPS research.[4, 5] We calculated composite doctor‐communication scores as the proportion of top‐box responses across items in each survey (ie, HCAHPS and Press Ganey). We first compared all patients during the preintervention and postintervention period. We then identified patients for whom the discharge attending worked as a hospitalist at NMH during both the preintervention and postintervention periods and compared satisfaction for patients discharged by hospitalists who had no/low training and for patients discharged by hospitalists who were highly trained. We performed multivariate logistic regression, using intervention period as the predictor variable and top‐box rating as the outcome variable for each doctor‐communication question and for overall hospital rating of 9 or 10. Covariates included patient age, sex, race, payer, self‐reported education level, and self‐reported health status. Models accounted for clustering of patients within discharge physicians. Similarly, we conducted multivariate logistic regression, using discharge attending category as the predictor variable (no/low training vs highly trained). The various comparisons described were intended to mimic intention to treat and treatment received analyses in light of incomplete participation in the communication‐skills program. All analyses were conducted using Stata version 11.2 (StataCorp, College Station, TX).

Patient Satisfaction With Hospitalist Communication

The HCAHPS and Press Ganey doctor communication domain scores were not significantly different between the preintervention and postintervention periods (75.8 vs 79.2, P=0.42 and 61.4 vs 65.9, P=0.39). Two of the 3 HCAHPS items assessing doctor communication were rated higher during the postintervention period, but no result was statistically significant (Table 3). Similarly, all 5 of the Press Ganey items assessing doctor communication were rated higher during the postintervention period, but no result was statistically significant. The HCAHPS overall rating of hospital care was also not significantly different between the preintervention and postintervention period. Results were similar in multivariate analyses, with no items showing statistically significant differences between the preintervention and postintervention periods.

Pre‐post comparisons based on level of hospitalist participation in the training program are shown in Table 4. For patients discharged by no/low‐training hospitalists, 4 of the 8 total items assessing doctor communication were rated higher during the postintervention period, and 4 were rated lower, but no result was statistically significant. For patients discharged by highly trained hospitalists, all 8 items assessing doctor communication were rated higher during the postintervention period, but no result was statistically significant. Multivariate analyses were similar, with no items showing statistically significant differences between the preintervention and postintervention periods for either group.

Setting and Study Design

The study was conducted at Northwestern Memorial Hospital (NMH), an 897‐bed tertiary‐care teaching hospital in Chicago, IL, and was approved by the institutional review board of Northwestern University. This study was a preintervention vs postintervention comparison of patient‐satisfaction scores. The intervention was a communication‐skills training program for all NMH hospitalists. We compared patient‐satisfaction survey data for patients admitted to the nonteaching hospitalist service during the 26 weeks prior to the intervention with data for patients admitted to the same service during the 22 weeks afterward. Hospitalists on this service worked 7 consecutive days, usually followed by 7 days free from clinical duty. Hospitalists cared for approximately 1014 patients per day without the assistance of resident physicians or midlevel providers (ie, physician assistants or nurse practitioners). Nighttime patient care was provided by in‐house hospitalists (ie, nocturnists). A majority of nighttime shifts were staffed by physicians who worked for the group for a single year. As a result of a prior intervention, hospitalists' patients were localized to specific units, each overseen by a hospitalist‐unit medical director.[9] We excluded all patients initially admitted to other services (eg, intensive care unit, surgical services) and patients discharged from other services.

Hospitalist Communication Skills Training Program

Northwestern Memorial Hospital implemented a communication‐skills training program in 2009 intended to enhance patient experience and improve patient‐satisfaction scores. All nonphysician staff were required to attend a 4‐hour training session based on the AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank You) principles developed by the Studer Group.[10] The Studer Group is a well‐known healthcare consulting firm that aims to assist healthcare organizations to improve clinical, operational, and financial outcomes. The acronym AIDET provides a framework for communication‐skills behaviors (Table 1).

We adapted the AIDET framework and designed a communication‐skills training program, specifically for physicians, to emphasize reflection on current communication behaviors, deliberate practice of enhanced communication skills, and feedback based on performance during simulated and real clinical encounters. These educational methods are consistent with recommended strategies to improve behavioral performance.[11] During the first session, we discussed measurement of patient satisfaction, introduced AIDET principles, gave examples of specific behaviors for each principle, and had participants view 2 short videos displaying a range of communication skills followed by facilitated debriefing.[12] The second session included 3 simulation‐based exercises. Participants rotated roles in the scenarios (eg, patient, family member, physician) and facilitated debriefing was co‐led by a hospitalist leader (K.J.O.) and a patient‐experience administrative leader (either T.D. or J.R.). The third session involved direct observation of participants' clinical encounters and immediate feedback. This coaching session was performed for an initial group of 5 hospitalist‐unit medical directors by the manager of patient experience (T.D.) and subsequently by these medical directors for the remaining participants in the program. Each of the 3 sessions lasted 90 minutes. Instructional materials are available from the authors upon request.

The communication‐skills training program began in August 2011 and extended through January 2012. Participation was strongly encouraged but not mandatory. Sessions were offered multiple times to accommodate clinical schedules. One of the co‐investigators took attendance at each session to assess participation rates.

Survey Instruments and Data

During the study period, NMH used a third‐party vendor, Press Ganey Associates, Inc., to administer the HCAHPS survey to a random sample of 40% of hospitalized patients between 48 hours and 6 weeks after discharge. The HCAHPS survey has 27 total questions, including 3 questions assessing doctor communication as a domain.[3] In addition to the HCAHPS questions, the survey administered to NMH patients included questions developed by Press Ganey. Questions in the surveys used ordinal response scales. Specifically, response options for HCAHPS doctor‐communication questions were never, sometimes, usually, and always. Response options for Press Ganey doctor‐communication questions were very poor, poor, fair, good, and very good. Patients provided an overall hospital rating in the HCAHPS survey using a 010 scale, with 0=worst hospital possible and 10=best hospital possible.

We defined the preintervention period as the 26 weeks prior to implementation of the communication‐skills program (patients admitted on or between January 31, 2011, and July 31, 2011) and the postintervention period as the 22 weeks after implementation (patients admitted on or between January 31, 2012, and June 30, 2012). The postintervention period was 1 month shorter than the preintervention period in an effort to avoid confounding due to a number of new hospitalists starting in July 2012. We defined a discharge attending as highly trained if he/she attended all 3 sessions of the communication‐skills training program. The discharge attending was designated as no/low training if he/she attended fewer than the full 3 sessions.

Data Analysis

Data were obtained from the Northwestern Medicine Enterprise Data Warehouse, a single, integrated database of all clinical and research data from all patients receiving treatment through Northwestern University healthcare affiliates. We used ² and Student t tests to compare patient demographic characteristics preintervention vs postintervention. We used ² tests to compare the percentage of patients giving top‐box ratings to each doctor‐communication question (ie, always for HCAHPS and very good for Press Ganey) and giving an overall hospital rating of 9 or 10. We used top‐box comparisons, rather than comparison of mean or median scores, because patient‐satisfaction data are typically highly skewed toward favorable responses. This approach is consistent with prior HCAHPS research.[4, 5] We calculated composite doctor‐communication scores as the proportion of top‐box responses across items in each survey (ie, HCAHPS and Press Ganey). We first compared all patients during the preintervention and postintervention period. We then identified patients for whom the discharge attending worked as a hospitalist at NMH during both the preintervention and postintervention periods and compared satisfaction for patients discharged by hospitalists who had no/low training and for patients discharged by hospitalists who were highly trained. We performed multivariate logistic regression, using intervention period as the predictor variable and top‐box rating as the outcome variable for each doctor‐communication question and for overall hospital rating of 9 or 10. Covariates included patient age, sex, race, payer, self‐reported education level, and self‐reported health status. Models accounted for clustering of patients within discharge physicians. Similarly, we conducted multivariate logistic regression, using discharge attending category as the predictor variable (no/low training vs highly trained). The various comparisons described were intended to mimic intention to treat and treatment received analyses in light of incomplete participation in the communication‐skills program. All analyses were conducted using Stata version 11.2 (StataCorp, College Station, TX).

Patient Satisfaction With Hospitalist Communication

The HCAHPS and Press Ganey doctor communication domain scores were not significantly different between the preintervention and postintervention periods (75.8 vs 79.2, P=0.42 and 61.4 vs 65.9, P=0.39). Two of the 3 HCAHPS items assessing doctor communication were rated higher during the postintervention period, but no result was statistically significant (Table 3). Similarly, all 5 of the Press Ganey items assessing doctor communication were rated higher during the postintervention period, but no result was statistically significant. The HCAHPS overall rating of hospital care was also not significantly different between the preintervention and postintervention period. Results were similar in multivariate analyses, with no items showing statistically significant differences between the preintervention and postintervention periods.

Pre‐post comparisons based on level of hospitalist participation in the training program are shown in Table 4. For patients discharged by no/low‐training hospitalists, 4 of the 8 total items assessing doctor communication were rated higher during the postintervention period, and 4 were rated lower, but no result was statistically significant. For patients discharged by highly trained hospitalists, all 8 items assessing doctor communication were rated higher during the postintervention period, but no result was statistically significant. Multivariate analyses were similar, with no items showing statistically significant differences between the preintervention and postintervention periods for either group.

Setting and Study Design

The study was conducted at Northwestern Memorial Hospital (NMH), an 897‐bed tertiary‐care teaching hospital in Chicago, IL, and was approved by the institutional review board of Northwestern University. This study was a preintervention vs postintervention comparison of patient‐satisfaction scores. The intervention was a communication‐skills training program for all NMH hospitalists. We compared patient‐satisfaction survey data for patients admitted to the nonteaching hospitalist service during the 26 weeks prior to the intervention with data for patients admitted to the same service during the 22 weeks afterward. Hospitalists on this service worked 7 consecutive days, usually followed by 7 days free from clinical duty. Hospitalists cared for approximately 1014 patients per day without the assistance of resident physicians or midlevel providers (ie, physician assistants or nurse practitioners). Nighttime patient care was provided by in‐house hospitalists (ie, nocturnists). A majority of nighttime shifts were staffed by physicians who worked for the group for a single year. As a result of a prior intervention, hospitalists' patients were localized to specific units, each overseen by a hospitalist‐unit medical director.[9] We excluded all patients initially admitted to other services (eg, intensive care unit, surgical services) and patients discharged from other services.

Hospitalist Communication Skills Training Program

Northwestern Memorial Hospital implemented a communication‐skills training program in 2009 intended to enhance patient experience and improve patient‐satisfaction scores. All nonphysician staff were required to attend a 4‐hour training session based on the AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank You) principles developed by the Studer Group.[10] The Studer Group is a well‐known healthcare consulting firm that aims to assist healthcare organizations to improve clinical, operational, and financial outcomes. The acronym AIDET provides a framework for communication‐skills behaviors (Table 1).

We adapted the AIDET framework and designed a communication‐skills training program, specifically for physicians, to emphasize reflection on current communication behaviors, deliberate practice of enhanced communication skills, and feedback based on performance during simulated and real clinical encounters. These educational methods are consistent with recommended strategies to improve behavioral performance.[11] During the first session, we discussed measurement of patient satisfaction, introduced AIDET principles, gave examples of specific behaviors for each principle, and had participants view 2 short videos displaying a range of communication skills followed by facilitated debriefing.[12] The second session included 3 simulation‐based exercises. Participants rotated roles in the scenarios (eg, patient, family member, physician) and facilitated debriefing was co‐led by a hospitalist leader (K.J.O.) and a patient‐experience administrative leader (either T.D. or J.R.). The third session involved direct observation of participants' clinical encounters and immediate feedback. This coaching session was performed for an initial group of 5 hospitalist‐unit medical directors by the manager of patient experience (T.D.) and subsequently by these medical directors for the remaining participants in the program. Each of the 3 sessions lasted 90 minutes. Instructional materials are available from the authors upon request.

The communication‐skills training program began in August 2011 and extended through January 2012. Participation was strongly encouraged but not mandatory. Sessions were offered multiple times to accommodate clinical schedules. One of the co‐investigators took attendance at each session to assess participation rates.

Survey Instruments and Data

During the study period, NMH used a third‐party vendor, Press Ganey Associates, Inc., to administer the HCAHPS survey to a random sample of 40% of hospitalized patients between 48 hours and 6 weeks after discharge. The HCAHPS survey has 27 total questions, including 3 questions assessing doctor communication as a domain.[3] In addition to the HCAHPS questions, the survey administered to NMH patients included questions developed by Press Ganey. Questions in the surveys used ordinal response scales. Specifically, response options for HCAHPS doctor‐communication questions were never, sometimes, usually, and always. Response options for Press Ganey doctor‐communication questions were very poor, poor, fair, good, and very good. Patients provided an overall hospital rating in the HCAHPS survey using a 010 scale, with 0=worst hospital possible and 10=best hospital possible.

We defined the preintervention period as the 26 weeks prior to implementation of the communication‐skills program (patients admitted on or between January 31, 2011, and July 31, 2011) and the postintervention period as the 22 weeks after implementation (patients admitted on or between January 31, 2012, and June 30, 2012). The postintervention period was 1 month shorter than the preintervention period in an effort to avoid confounding due to a number of new hospitalists starting in July 2012. We defined a discharge attending as highly trained if he/she attended all 3 sessions of the communication‐skills training program. The discharge attending was designated as no/low training if he/she attended fewer than the full 3 sessions.

Data Analysis

Data were obtained from the Northwestern Medicine Enterprise Data Warehouse, a single, integrated database of all clinical and research data from all patients receiving treatment through Northwestern University healthcare affiliates. We used ² and Student t tests to compare patient demographic characteristics preintervention vs postintervention. We used ² tests to compare the percentage of patients giving top‐box ratings to each doctor‐communication question (ie, always for HCAHPS and very good for Press Ganey) and giving an overall hospital rating of 9 or 10. We used top‐box comparisons, rather than comparison of mean or median scores, because patient‐satisfaction data are typically highly skewed toward favorable responses. This approach is consistent with prior HCAHPS research.[4, 5] We calculated composite doctor‐communication scores as the proportion of top‐box responses across items in each survey (ie, HCAHPS and Press Ganey). We first compared all patients during the preintervention and postintervention period. We then identified patients for whom the discharge attending worked as a hospitalist at NMH during both the preintervention and postintervention periods and compared satisfaction for patients discharged by hospitalists who had no/low training and for patients discharged by hospitalists who were highly trained. We performed multivariate logistic regression, using intervention period as the predictor variable and top‐box rating as the outcome variable for each doctor‐communication question and for overall hospital rating of 9 or 10. Covariates included patient age, sex, race, payer, self‐reported education level, and self‐reported health status. Models accounted for clustering of patients within discharge physicians. Similarly, we conducted multivariate logistic regression, using discharge attending category as the predictor variable (no/low training vs highly trained). The various comparisons described were intended to mimic intention to treat and treatment received analyses in light of incomplete participation in the communication‐skills program. All analyses were conducted using Stata version 11.2 (StataCorp, College Station, TX).

Patient Satisfaction With Hospitalist Communication

The HCAHPS and Press Ganey doctor communication domain scores were not significantly different between the preintervention and postintervention periods (75.8 vs 79.2, P=0.42 and 61.4 vs 65.9, P=0.39). Two of the 3 HCAHPS items assessing doctor communication were rated higher during the postintervention period, but no result was statistically significant (Table 3). Similarly, all 5 of the Press Ganey items assessing doctor communication were rated higher during the postintervention period, but no result was statistically significant. The HCAHPS overall rating of hospital care was also not significantly different between the preintervention and postintervention period. Results were similar in multivariate analyses, with no items showing statistically significant differences between the preintervention and postintervention periods.

Pre‐post comparisons based on level of hospitalist participation in the training program are shown in Table 4. For patients discharged by no/low‐training hospitalists, 4 of the 8 total items assessing doctor communication were rated higher during the postintervention period, and 4 were rated lower, but no result was statistically significant. For patients discharged by highly trained hospitalists, all 8 items assessing doctor communication were rated higher during the postintervention period, but no result was statistically significant. Multivariate analyses were similar, with no items showing statistically significant differences between the preintervention and postintervention periods for either group.