Listening Beyond Auscultating: A Quality Initiative to Improve Communication Scores in the Hospital Consumer Assessment of Health Care Practitioners and Systems Survey

Listening Beyond Auscultating: A Quality Initiative to Improve Communication Scores in the Hospital Consumer Assessment  of Health Care Practitioners and Systems Survey


Nardine Saad Riegels, MD; Emily Asher, MD, MS, MPH, MPA;
Joseph R Cartwright, MD, MEd; Jessica L Chow, MD, MPH, MS;
Elaine D Lee, MD; Matthew Nordstrom, MD; Allison N Schneider, MD;
Madeline D Schwarz, MD; Margot Zarin-Pass, MD;
Lindsay A Mazotti, MD

Perm J 2018;22:16-187 [Full Citation]
E-pub: 07/20/2018


Introduction: Physician communication is critical to patient care. However, integration of sound communication practice with clinical workflows has proven difficult. In this quality improvement initiative, medical students used the rapid improvement model to test interventions that could enhance patients’ perception of listening by physicians as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems survey.
Methods: Literature review and process analysis yielded 42 potential interventions, of which 24 were feasible for implementation. Small-scale testing established the 4 most promising interventions; pilot testing was subsequently undertaken on the entire Medicine service. Patient and physician feedback guided further refinement. The final intervention used a structured reminder embedded in the electronic health record to direct physicians to begin interviews by eliciting patient concerns.
Results: Patient concerns elicited after implementation included pain symptoms (28%), disease or treatment course (16%), and discharge planning (10%). In the Hospital Consumer Assessment of Healthcare Providers and Systems survey, physician listening scores rose from a 2014 average of 73.6% to 77% in 2015.
Discussion: Among 24 tested interventions, an open-ended question was most feasible and had the greatest perceived impact by hospitalists and patients. A structured reminder embedded in required electronic medical record documentation facilitated the behavioral change without being overly burdensome to physicians and established a mechanism to enact change in practice.
Conclusion: Medical students used established improvement methods to promote patient-centered care and align patient and physician agendas, providing a strategy to improve hospitalized patients’ perceptions of physician listening.


Physician communication is foundational to patient care and has been shown to impact patient satisfaction, adherence to treatment plans, and health outcomes.1 The Kalamazoo consensus statement, put forth by leaders of major medical organizations and academic institutions on core criteria for effective physician patient communication, emphasized building the physician-patient relationship, active listening, and shared decision making as essential elements of physician communication.2 The significance of physician communication, and in particular these elements, is emphasized in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, the national standard for public reporting of patients’ hospital care experiences. In the HCAHPS survey, patients provide feedback on care received from physicians in the hospital; care comprises how often physicians treated the patient “with courtesy and respect,” “listened carefully” to the patient, and “explained things in a way [the patient] could understand.”3

In 2013-2014, the Oakland Medical Center in CA scored in the 76th percentile for physician communication overall4 and in the 50th percentile for the physician listening subset, falling short of the hospital’s goal to place in the 90th percentile for both measures. To address this gap, 8 third-year medical students in the Kaiser Permanente-University of California, San Francisco Longitudinal Integrated Clerkship (KLIC) developed and implemented an improvement project from July 2014 to May 2015. Prior attempts to increase communication scores at Kaiser Foundation Hospitals-Oakland included communication skills training in the 4 habits model5 and peer-to-peer feedback; the absence of notable improvement is corroborated by the experience of other institutions.6 In contrast, this project aimed to apply quality improvement methods including the Plan-Do-Study-Act approach7 to create and test small-scale interventions that could improve HCAHPS listening subset scores.


The Oakland Medical Center is a 349-bed hospital and tertiary referral center. The hospital medicine service consisted of 64 physicians attending on 4 teaching and 4 nonteaching teams. In 2014, 10 of these hospitalists formed a “Project Bedside” task force to drive patient-centered care initiatives; this group served in an advisory capacity for the project reported here. Conducted as a quality improvement activity, the project was considered exempt from review by the institutional review board.

Figure 1 provides an overview of the project design. A literature review on successful physician-patient communication strategies was completed. Given the limited number of studies demonstrating an impact on HCAHPS physician communication scores, the review was expanded to include studies reporting any patient satisfaction measures. Service industry assessments of consumer satisfaction were also included.

The group then turned its attention to detailed observations of patient-physician interactions. The goal was to identify possible elements of the hospital system and physician communication practices that contribute to patients perceiving that their physician was not listening carefully. Observations of communication behaviors and barriers during clinical rounds on inpatient internal medicine teaching and nonteaching teams over a 3-week period were made using time-motion study techniques. Each patient-physician encounter was blocked into 15-second intervals. After each encounter, patients were asked to comment on communication with the physician. Behaviors and patient and physician statements were recorded. Observations were pooled and factors with a negative impact on patients’ perception of listening were extracted. These factors were mapped onto a fishbone diagram8 using 6 predetermined domains of man, materials, methods, machine, measurement, and milieu (Figure 2).

Using the fishbone diagram and communication strategies gleaned from the literature review, 42 interventions that could improve perceptions of physician listening were developed (see Sidebar: Potential Interventions to Enhance Patient Perceptions of Physician Listening). The 8 medical students met with a hospital physician liaison and a systems improvement mentor to make binary assessments for each potential intervention of feasibility (yes/no), potential impact on desired outcome (high/low), and balancing measures (high/low likelihood of having adverse unintended consequences). Group consensus on each parameter was recorded. The 24 interventions deemed to have high feasibility and high impact with low likelihood of having adverse unintended consequences were selected for small-scale testing in phase I.

Listening Beyond Auscultating: A Quality Initiative to Improve Communication Scores in the Hospital Consumer Assessment  of Health Care Practitioners and Systems Survey

The testing phases were informed by the Plan-Do-Study-Act framework. During phase I testing sessions, a student attended one day of bedside rounding with one of three “Project Bedside” hospitalists while attending on a nonteaching service, informing the hospitalist in advance of the specific intervention to be attempted. The hospitalist performed each intervention during three or more patient encounters. After rounds, the student and the hospitalist discussed feasibility, effectiveness, and possible modifications for retesting.

Students used this information to organize the interventions on the basis of feasibility and impact. Fourteen interventions were subsequently rejected on the basis of high effort or low impact. Six interventions, closely related to the domain of etiquette-based medicine,9 were designated as standard practice and not tested further. These were as follows: Closing the door and/or drawing the curtain closed in a room when entering it; introducing oneself and providing a business card; scheduling a return when the patient is in pain, eating, or toileting; using the patient’s preferred name and form of address; turning off the television while talking with the patient; and sitting on a chair during conversations with the patient. The remaining four interventions, described in Table 1,5,10-13 were advanced to phase II. These were as follows: Beginning the patient interview with an open-ended question; giving the patient a hand-held “STOP” sign to signal the need for clarification; managing physicians’ disruptive electronic devices; and involving patients’ families by calling them during rounds.

During phase II, interventions were individually tested by the 4 hospitalists on nonteaching services for 3 days each during 4 consecutive weeks, representing roughly 120 physician-patient encounters for each intervention. Hospitalists were informed of the intervention during physician staff meetings and by Email and reminded through text pages and office flyers. They were asked to exclude patients who did not speak English, were unable to communicate verbally, or had dementia or delirium.

At the end of each three-day intervention period, an online questionnaire was sent to hospitalists soliciting input on adherence, impact, sustainability, and balancing measures. Questionnaires contained multiple-choice questions with five-point Likert scales and space for general comments. Students also approached a convenience sample of patients on the last two days of each testing period to obtain comments about communication with their physicians and entered data on computer tablets. This process adhered to the HCAHPS Quality Assurance Guidelines14 ; responses were voluntary and anonymous and no patient identifiers were recorded.

After phase II was completed, students led a focus group with participating hospitalists and members of the Project Bedside task force and obtained further qualitative feedback. Of the four interventions tested, the use of the open-ended question was most feasible and had the greatest perceived impact by hospitalists and patients. The specific question was standardized and made more direct: “What is your greatest concern today?” Concerns about sustainability prompted a proposal to modify the standardized hospitalist daily progress note template in the electronic medical record (EMR) from traditional SOAP (Subjective, Objective, Assessment, Plan) format to “ScOAP,” with the “c” designating a header to document patient concerns. Use of a progress note template was already standard practice by hospitalists for documentation; the EMR contained a forcing function such that the “concerns” field had to be addressed or deleted before progress notes could be signed.

During phase III testing, the modified ScOAP template was put in place for three consecutive days on all teaching and nonteaching teams; all hospitalists and residents were informed of the change through Email communication and requested to ask the open-ended question during patient encounters. A medical chart review was performed of every progress note written during the three-day period. Charts that documented a diagnosis of dementia or delirium or nonverbal patient were excluded. Text in the “concerns” field was collected and analyzed for presence or absence of a comment and themes in recorded text. Finally, face-to-face interviews with hospitalists were conducted about their experience with the phase III intervention.

Listening Beyond Auscultating: A Quality Initiative to Improve Communication Scores in the Hospital Consumer Assessment  of Health Care Practitioners and Systems Survey


Listening Beyond Auscultating: A Quality Initiative to Improve Communication Scores in the Hospital Consumer Assessment  of Health Care Practitioners and Systems Survey


Results from phase II are summarized in Table 1. Patient-reported physician adherence served as a tangible process measure, whereas qualitative comments identified themes and likely reasons for relative success or failure of each intervention. Qualitative assessment included comments from patients and physicians. For example, one patient noted his reaction when his practitioner began the interview with an open-ended question: “From the beginning, I felt he wanted to help me to figure out different ways to get down to what’s going on.” One physician comment about the device-silencing pilot reported a greater sense of humanity: “I feel like this helps remind me that I’m not a robotic shift-worker.”

There were several limitations in the data collection process, including time limitations to survey all patients eligible to receive a given intervention and a low response rate among hospitalists to online surveys. Additionally, because HCAHPS quality assurance guidelines prohibit hospitals from asking patients questions with similar phrasing to the HCAHPS survey to avoid response bias, patients could not be directly questioned about physician listening behaviors. These limitations were managed by gathering a convenience sample of patients, allowing for open-ended responses from patients, and gathering additional information from hospitalists through a focus group after phase II and face-to-face interviews after phase III.

Feedback from hospitalists after phase III testing indicated that using the specific open-ended question helped gather relevant information and that the EMR prompt served as a useful reminder. Hospitalists on teaching services noted that residents brought up patient concerns more frequently on rounds during the intervention period. Hospitalists endorsed feeling empowered to address issues meaningful to the patient, and reflected that these concerns may not have been expeditiously addressed otherwise.

Medical chart review of patient concerns documented during phase III revealed the following: Of 150 eligible patient charts, 100 (67%) included physician documentation of patient concerns in the “concerns” field of the ScOAP note. The most common patient concerns included pain symptoms (28%), disease or treatment course (16%), and discharge planning (10%).

In mid-May 2015, two months after the initial three-day pilot, the hospitalist group formally adopted the ScOAP note template following a review of the interventions and implementation experience; its use is ongoing on the medicine hospitalist service.

The Oakland Medical Center’s inpatient medicine service HCAHPS topbox scores, or the percentage of survey respondents indicating that physicians “always” listened carefully, are shown in Figure 3. To calculate a baseline, we used an average score from 2014 of 73.6%. By comparison, the 2015 average was 77%. In calculating an annual average, monthly averages were weighted on the basis number of surveys returned for that month. The trendline confirms a general improvement in scores with time. Notable data points include an improvement during February 2015, corresponding to phase II testing, as well as in June and July 2015, corresponding to the 2 months following full adoption of the ScOAP template. Data are reported in raw HCAHPS scores; in January, the score of 68.2% is below the 25th percentile among hospitals nationally; in June, 74% corresponds to the 50th percentile; in July 82.5% is just below the 90th percentile.

Listening Beyond Auscultating: A Quality Initiative to Improve Communication Scores in the Hospital Consumer Assessment  of Health Care Practitioners and Systems Survey

Listening Beyond Auscultating: A Quality Initiative to Improve Communication Scores in the Hospital Consumer Assessment  of Health Care Practitioners and Systems Survey


This article describes the process of testing and implementing best practices in physician-patient communication in an inpatient setting. Application of the Plan-Do-Study-Act method allowed for pilot testing of 24 unique interventions to improve patients’ perceptions of physician listening and refinement of one intervention that was universally implemented by a large hospitalist service in an integrated health care system. Soliciting a specific patient concern during daily rounds had the greatest feasibility and impact among the tested interventions. This practice is grounded in literature that has demonstrated increased patient satisfaction with patient-centered approaches15 and no compromise in efficiency with shared agenda setting.10 Furthermore, addressing a specific concern allows the opportunity for a physician to express empathy and can help shift an encounter from being task-oriented to care-oriented16 with explicit interest in the patient’s experience. Postintervention chart review revealed additional targets for patient satisfaction, including pain control and discharge planning.

The results in Figure 3 demonstrate an upward trend in HCAHPS scores over time; because publicly reported HCAHPS score reports did not include standard deviations, statistical analysis using a t-test was not possible. The attention given to listening behaviors during phase II in February 2015 may have contributed to the upward trend in HCAHPS scores during that period followed by a return to baseline scores close to the 50th percentile. This may be explained by the Hawthorne effect, manifested as a change in listening behaviors among physicians knowing that patients were providing input about physician communication during that time period. However, the adoption of the ScOAP note across the Hospitalist Department was associated with another upward trend in scores from June 2015 to July 2015 that did not correspond to observation of behavior and cannot be explained by the Hawthorne effect. We hypothesize that the downtrend starting in September 2015 is likely because physicians less consistently initiated a patient encounter by asking for a specific concern despite the EMR reminder; to sustain an increase in listening scores, other identified system barriers would need to be addressed.

A structured reminder embedded in required EMR documentation may improve patients’ perception of physician listening without being overly burdensome to physicians and establish a concrete mechanism for change in practice. This is consistent with the principle from “lean methodology” of implementing standardized work to establish a new standard practice.17 The EMR has been shown to be indispensable in various applications including population health management and medication safety18; however, because it “organizes encounters around data gathering demands rather than patients’ narratives,” the EMR has had mixed effects in the physician-patient communication domain.19 This hospitalist group’s experience with the ScOAP note template demonstrates that patient input can shape EMR improvement and that an intervention using the EMR has the potential to enhance patient-centered communication.

Generalizability of these interventions to other medical centers is limited because the use of a departmentally mandated standard progress note template may not be translatable to the workflow of other hospital settings. Students participating in this intervention identified a need to create and test workflows to apply this intervention to non-English-speaking patients or with family members of patients unable to respond to the question. Finally, the assessment of feasibility, acceptability, sustainability, and anticipated impact of potential interventions before phases I and II did not use validated numeric criteria; the same process could lead to a different intervention in another health system. To strengthen this process locally, the selection of interventions was informed by conversations with stakeholders and direct knowledge of the care delivery system.


This report describes a trainee-led quality improvement initiative. As medical students and residents become increasingly involved in quality improvement imperatives as a requirement of their training, our experience demonstrates that trainees hold the potential to initiate change in an institution and positively impact patient care practices.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.


The authors would like to acknowledge Rajeeva Ranga, DO, Valerie Colacurcio, MD, and Sarah Parsons, MD, for their participation in this intervention.

Mary Corrado, ELS, provided editorial assistance.

How to Cite this Article

Riegels NS, Asher E, Cartwright JR, et al. Listening beyond auscultating: A quality initiative to improve communication scores in the hospital consumer assessment of healthcare providers and systems survey. Perm J 2018;22:16-187. DOI:

1.    Christianson JB, Warrick LH, Finch M, Jonas W. Physician communication with patients: Research findings and challenges. Ann Arbor, MI: University of Michigan Press; 2012.
    2.    Makoul G. Essential elements of communication in medical encounters: The Kalamazoo consensus statement. Acad Med 2001 Apr;76(4):390-3. DOI:
    3.    Centers for Medicare & Medicaid Services. HCAHPS Survey Version 13.0 [Internet]. Baltimore, MD: US Centers for Medicare & Medicaid Services; [cited 2018 May 30]. Available from:
    4. Hospital compare. Hospital profile [Internet]. Baltimore, MD: US Centers for Medicare & Medicaid Services; [cited 2015 Apr 11]. Available from:
    5.    Frankel RM, Stein T. Getting the Most out of the Clinical Encounter: The Four Habits Model. Perm J 1999 Fall;3(3):79-88. DOI:
    6.    O’Leary KJ, Darling TA, Rauworth J, Williams MV. Impact of hospitalist communication-skills training on patient-satisfaction scores. J Hosp Med 2013 Jun;8(6):315-20. DOI:
    7.    Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: A practical approach to enhancing organizational performance. 2nd ed. San Francisco, CA: Jossey-Bass; 2009 Apr.
    8.    Ishikawa K. Introduction to quality control. 1st ed. London, UK: Chapman & Hall; 1989.
    9.    Kahn MW. Etiquette-based medicine. N Engl J Med 2008 May 8;358(19):1988-9. DOI:
    10.    Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: Have we improved? JAMA 1999 Jan 20;281(3):283-7. DOI:
    11.    Castro CM, Wilson C, Wang F, Schillinger D. Babel babble: Physicians’ use of unclarified medical jargon with patients. Am J Health Behav 2007 Sep-Oct;31 Suppl 1:S85-95. DOI:
    12.    Jeanmonod R, Boyd M, Loewenthal M, Triner W. The nature of Emergency Department interruptions and their impact on patient satisfaction. Emerg Med J 2010 May;27(5):376-9. DOI:
    13.    Kuo DZ, Sisterhen LL, Sigrest TE, Biazo JM, Aitken ME, Smith CE. Family experiences and pediatric health services use associated with family-centered rounds. Pediatrics 2012 Aug;130(2):299-305. DOI:
    14.    Centers for Medicare & Medicaid Services. CAHPS® Hospital Survey (HCAHPS) Quality Assurance Guidelines Version 8.0. Baltimore, MD: US Centers for Medicare & Medicaid Services; 2013.
    15.    Williams S, Weinman J, Dale J. Doctor-patient communication and patient satisfaction: A review. Fam Pract 1998 Oct;15(5):480-92. DOI:
    16.    Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: A review of the literature. Soc Sci Med 1995 Apr;40(7):903-18. DOI:
    17.    Albanese CT, Aaby DR, Platchek TS. Advanced lean in healthcare. North Charleston, SC: CreateSpace Independent Publishing Platform; 2014.
    18.    Chaudhry B, Wang J, Wu S, et al. Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006 May 16;144(10):742-52. DOI:
    19.    Shachak A, Reis S. The impact of electronic medical records on patient-doctor communication during consultation: A narrative literature review. J Eval Clin Pract 2009 Aug;15(4):641-9. DOI:


The Kaiser Permanente National CME Program designates this journal-based CME activity for 4 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


27,000 print readers per quarter, 15,350 eTOC readers, and in 2018, 2 million page views of TPJ articles in PubMed from a broad international readership.

The Permanente Press

The Permanente Press publishes The Permanente Journal and books related to healthcare. For information about subscriptions, missing issues, billing, subscription renewal, and back issues, Email:

ISSN 1552-5775 Copyright © 2019

All Rights Reserved.