Directions:
This assignment is a series of short answer, multiple choice, and fill-in-the-blank questions based on the article, “The Effects of Hospital-Level Factors on Patients' Ratings of Physician Communication” (Al-Amin & Makaremet, 2016). It is worth 150 points.
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[email protected]. The Effects of Hospital-Level Factors on Patients’ Ratings of Physician Communication Mona Al-Amin, PhD, assistant professor, Healthcare Administration Department, Sawyer Business School, Suffolk University, Boston, Massachusetts; and Suzanne C. Makarem, PhD, assistant professor, Marketing Department, Virginia Commonweath University, Richmond E X E C U T I V E S U M M A R Y The quality of physician–patient communication influences patient health outcomes and satisfaction with healthcare delivery. Yet, little is known about contextual factors that influence physicians’ communication with their patients. The main purpose of this article is to examine organizational-level factors that influence patient percep- tions of physician communication in inpatient settings. We used the Hospital Con- sumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and American Hospital Association data to determine patients’ ratings of physician communication at the hospital level, and to collect information about hospital-level factors that can potentially influence physician communication. Our sample con- sisted of 2,756 hospitals. We ran a regression analysis to determine the predictors of poor physician communication, measured as the percentage of patients in a hospital who reported that physicians sometimes or never communicated well. In our sample of hospitals, this percentage ranged between 0% and 21%, with 25% of hospitals receiving poor ratings from more than 6% of patients. Three organizational factors had statistically significant negative associations with physician communication: for-profit owner- ship, hospital size, and hospitalists providing care in the hospital. On the other hand, the number of full-time-equivalent physicians and dentists per 10,000 inpa- tient days, physician ownership of the hospital, Medicare share of inpatient days, and public ownership were positively associated with patients’ ratings of physician communication. Physician staffing levels are an understudied area in healthcare research. Our findings indicate that physician staffing levels affect the quality of physician communication with patients. Moreover, for-profit and larger hospitals should invest more in physician communication given the role that HCAHPS plays in value-based purchasing. 29 PatIents’ ratIngs of PHysIcIan coMMunIcatIon I N T R O D U C T I O N Patient–physician relationships, and communication specifically, influence patient outcomes, patient satisfaction, recall of information, and adherence to treatment regimens (Chang et al., 2006; Roter, 1989; Schneider, Kaplan, Green- field, Li, & Wilson, 2004; Zachariae et al., 2003). Evidence also indicates that physician communication is associated with a shorter length of stay and fewer complications (Trummer, Mueller, Nowak, Stidl, & Pelikan, 2006). As Windish and Olson (2011, p. 44) pointed out, the “patient–physician relationship is the cornerstone for quality of health care.” The U.S. Medical Licensing Examination and Accredita- tion Council for Graduate Medical Education emphasizes the importance of patient–physician communication through the evaluation of residents’ communication skills (Zolnierek & DiMatteo, 2009). The Hospital Con- sumer Assessment of Healthcare Provid- ers and Systems (HCAHPS) survey has provided publicly available data pertain- ing to patients’ hospital experiences. HCAHPS results were first reported publicly in March 2008 (Rothman, Park, Hays, Edwards, & Dudley, 2008). HCAHPS contains measures of interper- sonal communication, specifically quality of communication with physi- cians and nurses. In 2009, 1 year after HCAHPS scores were first released, hospitals witnessed a modest improve- ment in their overall ratings and patient ratings on all dimensions, with the exception of physician communication (Elliott et al., 2010). Clever, Jin, Levinson, and Meltzer (2008) argue that physician commu- nication is significantly associated with patient satisfaction and with patients’ overall ratings of their hospital experi- ence. Therefore, physician communica- tion is not only important for its impact on patient outcomes but also is impor- tant because of its role in influencing overall patient ratings of the hospital (O’Malley et al., 2005). Patient percep- tions and overall ratings of the inpatient experience have emerged as important indicators of hospital performance. Value-based purchasing (VBP) provides financial incentives for hospitals to improve HCAHPS scores and to main- tain good scores (Elliott et al., 2010). Hence, patient ratings of the hospital experience are an aspect of care that can potentially influence the hospital’s livelihood. Among the care dimensions that influence patient perceptions of quality of care, physician communica- tion is one of the most important. In fact, pay-for-performance initiatives will become tied less to technical competen- cies and more to the quality of patient– physician interactions (Safavi, 2006b). While ample literature exists regard- ing the impact of patient–physician communication on patient satisfaction, clinical outcomes, and organizational outcomes (Hammerly, Harmon, & Schwaitzberg, 2014), limited research is available on the organizational factors that shape this communication. Physi- cian behavior, including physician communication, does not occur in a vacuum, but is influenced by organiza- tional structure, environment, and culture. Physicians’ attitudes about healthcare organizations may influence their cooperative behavior, and these attitudes are shaped by the degree to 30 Journal of HealtHcare ManageMent 61:1 January/february 2016 which physicians identify with the organization (Dukerich, Golden, & Shortell, 2002). Furthermore, Ham- merly et al. (2014) argue that organiza- tional efforts to improve physician alignment should take into consider- ation physicians’ emotional intelligence, including their communication and interpersonal skills. The main purpose of this study is to examine organizational-level factors that influence physician communication with patients in inpatient settings. Physicians operate in an organizational context and, although communication skills vary at the individual level, organi- zational structure, culture, staffing levels, availability of electronic health records (EHRs), and other organizational-level factors affect physicians and, in turn, the time, commitment, and incentives they have to provide better patient experi- ences. This study contributes to our understanding of how organizational factors may affect physician communi- cation, as measured by HCAHPS scores. Given patient expectations, the potential for financial penalties, and the negative impact that poor physician communica- tion can have on a hospital’s public image, this understanding is crucial for hospital leaders. Physician ownership of hospital shares, defined by the American Hospi- tal Association (AHA) (2009) as a hospital “owned in whole or in part by physicians or a physician group,” is one factor that influences physicians’ align- ment and identification with the hospi- tal and, thus, their attitudes toward hospital performance and success, their subsequent behavior, and its effects on organizational performance (McCarthy, Reeves, & Turner, 2010). The organiza- tional theory literature contains ample research on the role of employee owner- ship and its influence on organizational performance, especially for professional service firms such as hospitals (Klein, 1987; Long, 1980). Physician ownership has also been examined in previous healthcare research about the effects of organizational factors on the quality of physicians’ services (Conrad & Chris- tianson, 2004) and on patients’ satisfac- tion, as evidenced by HCAHPS ratings (Makarem & Al-Amin, 2014). In addition to ownership, which might influence physicians’ attitudes, operational variables (such as physician staffing levels and number of full-time- equivalent [FTE] physicians available for a certain number of inpatient days) are likely to affect quality of care, the amount of time the physician has to take care of patients, and the quality of physician communication. Although the effect of nurse staffing levels on patient satisfaction has received a lot of atten- tion from researchers (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004), the relationship between physician staffing levels and quality and patient experience is understudied. Shanafelt et al. (2012) found a prevalence of burn- out among physicians in the United States, which can have detrimental effects on quality of care, but their study did not take physician staffing levels into account. Given the critical role that physician communication plays in patient out- comes and satisfaction, it is important to explain the variation in patient ratings of physician communication not 31 PatIents’ ratIngs of PHysIcIan coMMunIcatIon just between patients, but also between hospitals. To that end, we take a step back from understanding how to improve physician communication to focus on establishing a clearer picture of the effects of organizational-level factors on patient perceptions of physician communication. C O N C E P T U A L F R A M E W O R K The conceptual framework by Donabe- dian (1980) has been used frequently in health services research on quality. According to this framework, there are three categories for assessing quality: (1) structure—organizational character- istics or attributes, such as staff-to- patient ratio, that influence care delivery; (2) process—protocols, practices, and the actual steps followed in delivering the service; and (3) outcomes—measures such as survival and mortality rates, readmission rates, and patient satisfac- tion and number of complaints (Blies- mer, Smayling, Kane, & Shannon, 1998; Davis, 1991). Both structure and process influence outcomes. Donabedian differentiates between two domains of quality: (1) technical, the medical and clinical dimensions of care such as mortality and survival rates, and (2) interpersonal, the sociopsychological features of physician–patient communi- cation (Cleary & McNeil, 1988). We focus on physician communication, an inter- personal dimension of quality, which also influences technical quality because poor physician–patient communication can result in patients’ not understanding their treatment regimen and in not complying with physicians’ orders and recommendations (Cleary & McNeil, 1988). Our main objective is to determine how structural dimensions influence physician–patient communica- tion. We hypothesize that a higher physician staffing level, a key structural attribute, is associated with higher ratings of physician–patient communication. Using HCAHPS data, Kutney-Lee et al. (2009) found that nurse staffing levels were significantly related to patients’ ratings of nurse communication. We predict a similar relationship between physician staffing levels and patients’ ratings of physician communication. M E T H O D S Data Sources We used two sources