With patient satisfaction under increasing scrutiny, consider patient callbacks

Experts: Calls make sense from a quality standpoint & patients appreciate follow-up

With Medicare's new value-based purchasing (VBP) program set to begin impacting payments to most acute-care hospitals in October 2012, providers have been put on notice that the fee-for-service payment methodology is being gradually replaced by payment formulas that reward quality. Further, under the final rules unveiled for VBP by the Department of Health and Human Services in April, a full 30% of the funding that will be set aside to reward quality will be based on how patients rate the care and experience that they receive while in the hospital.

While ED managers have long been concerned about patient satisfaction, the VBP initiative is certainly upping the stakes considerably. However, one way to gain the upper hand on this issue is to implement a practice of routinely checking back with patients who have been discharged from the ED to make sure their recovery is on track. Experts maintain that not only does this type of follow-up enable you to intervene quickly if there is a clinical problem, but patients also, naturally, appreciate having someone check up on how they are doing.

"From a patient satisfaction perspective, it is a differentiator. Patients love it," stresses Jay Kaplan, MD, FACEP, the director of service and operational excellence for Emeryville, CA-based CEP America, Emergency Physician Partners, and medical director of the Studer Group, a health care consulting firm based in Gulf Breeze, FL.

Consider link between quality and satisfaction

There is, in fact, a correlation between patient satisfaction and quality, observes Kaplan. "Some people think that core clinical quality, such as making the right diagnosis and giving the right medicines, is the real stuff, and that customer service or service excellence is the fluff stuff," he says. "But quality and service are intricately interdependent, and by making that phone call to someone for follow-up, you are confirming the diagnosis, and from a quality-outcome perspective, we know that people who rate the satisfaction of their experience higher are more likely to adhere to instructions and medication regimens that you give to them."

Typically, more than half of all patients discharged from the ED lack a full understanding of their discharge instructions, and a high percentage of these patients are not even aware that they may be doing things incorrectly, adds Kaplan. "From a quality perspective, [follow-up calls] give you the opportunity to insure that people understand their instructions and how to take their medicines," he says.

Moreover, from an education and risk-management perspective, the calls enable providers to confirm their diagnoses. "I worry about my patients sometimes, so this gives me an opportunity to see that it was what I thought it was or, alternatively, if we made a diagnosis and it turned out to be something else, it gives us the opportunity to intervene and recommend some alternative course of action. That can save lives."

For example, Kaplan recalls the case of a 52-year-old man who came into the ED with chest pain. "He had a negative stress test, but when I called him up the next day, he said that he knew it was not his heart, but it felt like he had an elephant sitting on his chest," says Kaplan. "I told him to come back in, and he had angioplasty done."

Start with a modest request

Kaplan recommends that follow-up calls be made to patients between 24 and 48 hours post-discharge from the ED, but he notes that you will still receive positive results even if these calls are made within a week of discharge. Further, while any clinician can make follow-up calls, the impact is more powerful when they are made by the treating physician, adds Kaplan.

Providers may push back on the idea of making follow-up calls, complaining that they don't have the time, but Kaplan says you can usually get the program started by making the modest request that every physician and nurse practitioner call two patients for every shift that they work, and that they document these calls. "If they get their individual patient-satisfaction score, they typically see such an improvement that it gives them the motivation to make many more calls," says Kaplan. (Also, see Management Tip on implementing patient callbacks, below.)

He also encourages any clinicians who make these follow-up calls to share their experiences with colleagues. "I often think it is best if the members of the departments themselves make the calls because then it is a little closer to home when somebody you work with tells you that he called your patient back and this is what he found," says Kaplan. "If you have someone who is on modified work leave because they cannot do heavy lifting or stand on their feet for long hours, [making the follow-up calls] is a great activity for such a person."

Use non-clinicians to retrieve feedback

While there are some advantages to having clinicians make the callbacks, Mark Reiter, MD, MBA, a practicing emergency medicine physician and CEO of Emergency Excellence, a Bethlehem, PA-based consulting firm, says there are other ways to approach the task as well. For example, he prefers to recruit personnel with excellent interpersonal skills, bilingual capabilities, and knowledge of HIPAA [Health Insurance Portability and Accountability Act] regulations to make callbacks to the 150,000 to 200,000 patients per year that his company is engaged to follow-up with.

"I would say that 2% to 3% of patients report their condition has gotten worse, and 2% to 3% report that they don't understand their discharge instructions, and there is a lot of overlap between those two groups, so it usually ends up that less than 5% overall have one of those two issues," explains Reiter. "So we don't feel it is particularly cost-effective to use a clinical person to make those calls when 95% of the time, clinical knowledge is not necessarily needed."

Instead, whenever a clinical issue or a significant patient satisfaction problem is identified by a patient callback representative, he or she will notify the appropriate individuals at the hospital right away by fax or email so that the matter can be dealt with promptly, says Reiter.

"There is a lot of value in using patient callbacks to track patient satisfaction, particularly to get feedback on the emergency department experience overall, as well as on individual physicians and nurses," adds Reiter. "When we identify patients who are dissatisfied after they leave the ED, [and then intervene through service recovery], then that is a good way to reduce malpractice claims, and certainly to improve patient satisfaction scores."

Callbacks are not recommended for every patient who is discharged from the ED, says Reiter. For example, you are much less likely to derive value from calling patients who have been discharged to a psychiatric facility, another ED or hospital, or a skilled nursing facility, and it can be very difficult to reach people who have been discharged to prison, he says.

"We also find that our [phone call] completion rate is much higher on Saturdays and in the evenings," says Reiter, noting that it also helps to let patients know that they may be receiving a follow-up call upon discharge, and to note that in their discharge instructions.

As recently as five years ago, patient callbacks were relatively rare in the ED, but the practice is growing in popularity, stresses Reiter. "ED and hospital leaders are much more cognizant of the need to collect data and to get feedback from their patients than they have in the past," he says. "Hospitals really want to differentiate themselves from their competitors, and patient callbacks are a way to provide service above and beyond what patients expect."

Management Tip

When implementing a program of patient callbacks, start with your top-performers

If you want your clinicians to begin making follow-up calls to patients who have been discharged from the ED, approach a couple of your top-performers with the idea first, advises Jay Kaplan, MD, FACEP, the director of service and operational excellence for Emeryville, CA-based CEP America, Emergency Physician Partners, and medical director of the Studer Group, a health care consulting firm based in Gulf Breeze, FL. "Ask them to do it, and have someone time them when they do it, and then have them share what they have learned," he says. "More often than not, patients will be so excited that someone called, that the physicians will get very positive feedback."

Occasionally, a follow-up call will actually result in a saved life, and that can really connect the dots for people, adds Kaplan. "A lot of times, people want to do the right thing, and it is just a matter of telling them that it is not that difficult, it's not rocket science, and there are all these benefits," he says. "Callbacks don't take that much time, and they're good in terms of quality, risk management, education, and customer service."