The Institute of Medicine has defined “patient-centered care” as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”¹ The Committee on Quality of Health Care in America in 2001 included patient-centered care as a quality indicator of national health services.² In obstetrics, this is particularly important, as it may be the only time that some women of childbearing age ever encounter the healthcare system. A positive birth experience has been associated with a feeling of empowerment, accomplishment, and easier adaptation to motherhood. A negative experience has been associated with postpartum anxiety, depression, and reduced future reproduction.²

Nationwide, approximately 38% of hospitals use obstetric hospitalists or laborists.³ Hospitalists, by definition, provide care during Labor and Delivery (L&D) and do not participate in prenatal care. This is a model that has evolved over the years to replace the prior model of an obstetrician being available 24/7 to provide care for the patient, regardless of when labor begins. This division of labor creates unique challenges related to the delivery of patient-centered care. It also creates unique demands on obstetric hospitalists to assess patient values and choices, adapt their communication style, and provide continuity in philosophy of care. Hospitals have looked to evaluate how this new staffing model affects patient satisfaction because scores affect hospital reputation, payment, and competitive advantage. Studies to assess patient satisfaction in the hospitalist model do not demonstrate significant differences with the traditional model, but this area has not been rigorously researched.^3–5

Patient-satisfaction surveys have become an integral part of measuring and improving the delivery of patient-centered care.⁶ These surveys measure patients’ perception of communication, respectfulness, and responsiveness by providers and healthcare systems. Improved patient satisfaction is associated with increased patient adherence, increased patient follow-up, lower utilization of services, lower annual charges, and lower mortality rates.^7–9 It is thought to provide important incremental information on quality of care beyond the clinical performance metrics.⁹ In 2005, the Centers for Medicare and Medicaid Services (CMS) developed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey.¹⁰ More than 4500 acute-care hospitals in the United States routinely send this survey to a random subset of their discharged patients. The results are publicly reported and empower patients to make informed choices about selecting providers. Payments to hospitals are now linked to performance on this metric.¹¹ Hospital leaders devote substantial resources to improve their performance in this area. The HCAHPS survey results are publicly available through the CMS on their “Hospital Compare” website.¹²

A hospital’s performance on the HCAHPS affects its payment through Medicare’s Value-Based Purchase (VBP) program, which rewards providers based on their quality of care. The program adjusts payments to the hospital by withholding 2% of the amount under the Inpatient Prospective Payment System (IPPS). HCAHPS performance affects 25% of a hospital’s payments under the VBP program.

Eight dimensions from HCAHPS are used in calculating payments under VBP. These include six composite measures (Communication with Nurses, Communication with Doctors, Staff Responsiveness, Pain Management, Communication About Medicines, and Discharge Information); one combined measure (Cleanliness and Quietness of Hospital Environment); and one global measure (Overall Rating of Hospital). A hospital’s Patient Experience performance metric is based on how much it improved compared to its own baseline performance, how well the hospital compares to other hospitals, and how consistent its scores are across different dimensions.

Achievement Points for a hospital are calculated for each domain by comparing an individual hospital’s rates during the performance period with all hospitals in the country from the baseline period. Similarly, Improvement Points are calculated by comparing a hospital’s rates during the performance period to the same hospital’s rates from the baseline period. The higher of the two is used to calculate the Patient Experience performance score. Additional points are awarded based on consistency in performance across multiple dimensions. Scores calculated from performance on the lowest-performing dimension are added to the overall Improvement or Achievement score to reach the total Patient Experience score for the hospital.¹³

Press Ganey Associates is one of the many CMS-approved third-party vendors who administer the HCAHP surveys. These vendors often develop proprietary patient-satisfaction survey questions. The mandatory HCAHPS items and the optional hospital-selected vendor’s proprietary survey questions are often sent in the same envelope. Because of Press Ganey’s large market presence, the patient-satisfaction surveys are sometimes erroneously called “Press Ganey surveys.” This terminology is likely appropriate to refer to Press Ganey’s proprietary survey items.

The HCAHPS survey contains three items directly related to physicians (Fig. 8-1). As can be seen, these questions mainly focus on patient-physician communication. In addition, physicians likely have influence over satisfaction related to pain, discharge planning, and overall care.

There are many obstacles to improving delivery of patient-centered care, especially related to care by physicians. Many studies have shown that physicians significantly overestimate how well they perform with regard to communication and etiquette.^14,15 For example, physicians report that they introduce themselves 80% of the time and sit down when talking to the patients 54% of the time, when in fact, research volunteers observing the encounters note that the same physicians perform these behaviors in only 40% and 9% of the encounters, respectively (Fig. 8-2).¹⁵ This is complicated further by the fact that the HCAHPS survey captures a single response for physician performance for a patient, despite that patient being seen by multiple physicians during the hospital stay.

Studies have utilized volunteers to obtain physician-specific feedback from patients on performance of best-practice patient-centered communication and etiquette by individual physicians, such as knocking, sitting down, and checking patients’ understanding of the explanations. A significant improvement in performance is observed when physicians are provided feedback on their individual performances with regard to these behaviors.¹⁶ Multiple educational programs, like one offered by the American Academy of Communication in Healthcare, help improve physicians’ communication skills and have anecdotally shown to improve patient-satisfaction scores. It is likely that a multipronged strategy including valid, thoughtful, and individualized feedback, education, incentives, and team-based approaches is likely to succeed.

The key concepts in providing patient-centered care include choice, continuity, communication, and control (Fig. 8-3).^2,17 In addition, patient’s perception of support, low intervention, patient-centered birth environment, and low pain scores are important concerns. Hospitalists can influence many of these issues individually by improving teamwork or by serving as patient advocates to the hospital leadership.

Patient-physician communication is an important concept in patient-centered care. Effective communication promotes patient empowerment, control, shared decision-making, and preparedness for childbirth.^17–19 For example, implementation of team rounds where the patient is allowed to participate, nursing handoffs occurring in the room, and a clear description of the intended plan prior to implementation results in positive ratings. Hospitalists can also improve communication by being knowledgeable about key issues discussed by patients and their primary obstetrics. Improved communication with the primary obstetrician and creating systems-based solutions could help achieve this goal. They can build on this goal by reassessing patients’ choices, values, and preferences about delivery. Checklists may be very useful in such an approach.