Scoring hospitals on physician-staff collaboration could help improve care

“I don't know why the doctor did that.”

“I don't know why they had to draw so much fluid.”

“I don't know why the doctor prescribed this medication.”

Those were three comments I heard from nurses at a hospital in Florida. They were talking about my sister, who had been admitted to an intensive-care unit last year with an unknown infection that was causing organ failure. I was perplexed. And I asked myself, “What can I do?” Not much, since I didn't have enough medical knowledge to question her doctors. Instead, I discussed with a nurse why she didn't ask the doctor herself. She indicated that the physician was not open to her questions or suggestions.

I was taken aback by her response. I decided to talk with the nurses about the collaborative qualities of physicians at other hospitals where they worked. Many of the nurses at this hospital were seasonal because it was during the high season when the population swells. I asked about their experiences working in other states. The nurses told me that at other hospitals, where they worked during the summer months, physicians were much more collaborative—asking their opinions, listening to their comments and incorporating their recommendations.

However, at the hospital where my sister was being treated, they found it a stretch to label the physicians collaborative. During rounding, the hospitalists dictated to the nurses and others in the meeting; however, there was very little discussion from any of the participants, other than answering the doctors' questions.

In the middle of the night before my sister died, I heard her nurse whispering on the phone. After a few minutes she handed me the phone. My sister's doctor told me that “comfort care” was all that they could do for her. After I recovered from the shock, I asked the nurse what she had been whispering to the doctor. She told me that she had expected my sister to die the previous night, which floored me, because I had no idea that her condition had deteriorated so much based on previous conversations with her doctors.

Given she works in a hospital with little collaboration between doctors and other staffers, I applaud this nurse who had the courage to confront the doctor, who then prepared me for the next hours before my sister died.

I've spoken to caregivers around the country about the role of collaboration, the foundation of which is great communication. They know that communication skills are one of the most important drivers of a positive patient experience.

One example is Sound Physicians, based in Tacoma, Wash. The practice, whose 800-plus hospitalists partner with more than 80 hospitals around the country to provide inpatient services, is piloting physician-nurse team rounding that emphasizes communication. According to Dr. Mark Rudolph, vice president of patient experience and physician development, scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey have improved, often by sustained increases of more than 5%, on those floors where the communication and collaboration initiative was implemented. The rounding process also adds to the value of nursing staff surveys, which are conducted annually to provide physicians with feedback about their communication skills.

Research in the U.S. and Europe indicates that when doctors and nurses make a deliberate effort to collaborate, there is better communication, patients are more satisfied and the quality of care improves. A 2010 study at University Hospital Basel in Switzerland, for example, found that a deficiency in collaboration between doctors and nurses had a negative impact on patient outcomes.

Since the experience with my sister, I have believed that a “collaboration score” for all hospitals would be a great idea. It would indicate the effective level of communication and interaction between doctors, nurses and other caregivers. The collaboration scale would be based on objective criteria, such as outcome measures and patient-experience surveys. It also could incorporate subjective components such as the physicians' opinions on their own solicitation of feedback from nurses and nurses' opinions of the doctors' collaboration with them. I want a hospital where the caregivers are a team and where the members value the input of every staff member involved in my care.

A high level of collaboration between nurses and doctors has many ramifications: better patient outcomes through more caregiver interaction; higher nurse retention as their opinions are heard and acted upon; a reduction in medical malpractice litigation; and higher patient-satisfaction scores leading to improved reimbursement under new payment models. That leads to overall savings for the healthcare system.

Collaboration also means nurses and other caregivers won't complain and question doctors' orders with family members, but instead will be empowered to have candid conversations with doctors who value their opinions, encourage their feedback and accept their recommendations when appropriate.

How collaborative is your institution?