Editor’s Note: Last month, Dr. Michael Jaffe wrote about his personal experience calling patients after each shift. Here’s a bit more depth on the subject, for the hospital CEO who want a follow-up phone call process in place.
Dear Director: My hospital president has asked our group to start a follow up phone call program. This seems like a lot of work, and I’m not sure it’s worth it. What do you think?
When my boss is telling me do something, it often doesn’t matter what I think. While we can sometimes have a discussion or push back, typically what matters in circumstances like this is developing a plan to accomplish the job.
With that said, when my CEO asked me to do this ten years ago, despite all the research suggesting otherwise, I thought it would be a terrible waste of time. While there’s a variety of ways to implement a follow up phone call program, we went with having each nurse make a few phone calls in the morning. To track our impact, we asked our vendor to add one question at the end of the survey–Did you receive a phone call afterwards from a staff member? I was shocked when I looked at the data a few months later and found a huge difference in scores (10 raw score points) when we compared our patients who received a phone call to those who didn’t. Not only do patients appear more satisfied when they’ve received a callback, I think there are opportunities to defuse a negative experience which may have resulted in a very low score being returned. Additionally, since my site (and I suspect your site) only has a 10% return rate on surveys, I believe that patients who are really impressed by the callback are more likely to return a survey.
You can argue the impact and benefit of having highly satisfied patients, but many hospitals continue to push for improving patient satisfaction. Raw scores have been rising nationally, so it’s harder to achieve a particular percentile threshold. For instance, historically, a raw score on overall ranking of 90, would generally put one in the 90th percentile. Now, a 92 is needed to achieve the same percentile rank and those two points are not easy to come by.
The overwhelming majority of ED directors that I’m in contact with tell me that improving patient satisfaction is a big deal for their CEO. This might be because of the publicly reported measures or about improving brand loyalty, but I’ve come across very few directors who say they’re just trying to take care of the sick people and no one cares about their patient sat.
While many variables impact patient sat, for me, your question comes down to two issues. First, I can still remember my shock and disbelief when I looked at the data showing the difference between the patients who got called and those who didn’t, and then I had to go back to my CEO and tell them that there might be something to the follow up phone calls. The second issue is that your boss is asking you to get something done. Those kinds of requests are rarely negotiable. You may be able to go back in a few weeks to discuss the different plans that you considered or tried and what it would take to make them successful ($$), but you have to at least consider some options and implement a plan.
Nurse callbacks aren’t new to medicine. PACU nurses have been doing them for years—calling post-op patients the day after surgery to check on them and make sure they’re satisfied. PACU nurses typically have some time in the morning to do these callbacks, so there tends not to be an associated up tick in cost. From an ED perspective, it seems to me that by 9 a.m., when it would be acceptable to call a patient, most EDs are busy and there aren’t a lot of nurses with extra time to make phone calls. But depending on your ED volume and the number of calls the team is hoping to make a day, this could be a reasonable starting point for a callback program.
There are actually companies that will do follow up phone calls. I have had a very positive experience with one of these companies. But since nothing is free, this is where you have to go back to your CEO and have a conversation about the cost versus benefit of a callback program. My experience is that these companies reach a large percentage of discharged patients (that’s our target audience), telling patients that their doctor wanted to see how they were doing, while obtaining valuable feedback. Sometimes the feedback dictates rapid action. For example, the company contacts our nurse manager directly if a patient is suicidal but simply provides feedback if the patient didn’t understand their discharge instructions.
About six years ago, I started making follow up phone calls myself. I was starting to work in a new ED, and it was a place where patient sat really mattered. I had no idea what my scores would be, and a mentor, Dr H., told me I better do everything possible to not screw up. He was working in another part of the country and had been making calls for about a year. He walked me through the script he used, told me how easy it was, and essentially dared me to do it.
While I’m completely at ease in an ED talking to patients and even calling them to discuss a complaint, calling a discharged patient to see how they were doing felt foreign to me. To improve my comfort level and refine my script, I cherry picked really easy patients for my initial calls. You know the patients—the ones you have the great rapport with or the ones who ask you to be their PMD. Kidney stones, kids with otitis, asthma patients. Easy stuff. And you know what I found? Patients loved it. They couldn’t believe an ER doc was calling to check on them. And positive affirmation from patients is great to hear and something we rarely get. Most people were better and that’s also great to know. Occasionally, they had a question about meds or follow up, and I could easily answer that. On the rare occasion, over the last six years, the calls have led me to send patients back to the ED or to change part of their home care, which I think helps to mitigate the risk of discharging a patient. And part of the beauty of all of this is just how little time calls actually take. Each call took less than a few minutes. When you average out the calls with those where you leave a message, I bet I spend about a minute per call.
When you start doing callbacks, there are lots of potential concerns. We all worry about patients who had a bad outcome and now there are angry family members on the phone or those patients who won’t leave you alone afterwards and keep calling the ED to speak with you.
I give my business card out to essentially every patient I take care of. It has my email address and office number on it. And I tell pretty much every patient I discharge to feel free to reach out to me if they have a question or if there is something I can do for them. Each year, I can count on one hand the number of times I’ve gotten an email or a call from a patient with a question or a request. The truth is once patients are out of the ED and back to their life, it’s uncommon for them to need us again.
One of the calls I received was from a mom whose kid had a concussion, and I didn’t do a CT. As his symptoms didn’t improve over a few days, she needed a lot of reassurance that he would get better. That actually took a couple of phone calls, but that’s the case that stands out the most. I typically call patients from the ED or my office, but for the rare calls I make from my cell phone, I’ve never had a patient call me back to ask more questions. And this includes the couple of patients who I really thought were crazy enough to call me regularly! For those that still have doubts, there’s now an app you can use where you can make your phone appear to be calling form another number. Pretty cool.
Starting a Program
Whether you’re starting a physician callback program because the CEO asked you to or because you recognize it’s an action that high-performing sites take, getting started will mean explaining the why and how to your group. Like any other new initiative, this will involve some education. An honest and open discussion where barriers are identified and discussed and then strategies to overcome the barriers are developed is key.
There are many sites and groups around the country where follow up calls are just part of the culture and job expectation. Part of that typically means that time doing callbacks outside of your clinical hours are uncompensated, though compensation might come in other ways such as a bonus related to achieving certain patient satisfaction scores. Although I typically make my calls before or after a shift or when I’m in the office, because calls are generally so quick, it’s not uncommon for docs to make them during their shift when they are on the clock. In an ideal situation, you’re documenting these calls in the medical record. Because that increases the time and complexity of the process, I generally just document if the patient is experiencing issues or I’m recommending that they return to the ED.
Just like Dr. Jaffe wrote last month, I have a few colleagues who try to call back every patient. I generally try to call three to five discharged patients from each shift, though it may be more or less depending on the acuity. I usually call the parents of most of the kids, particularly if I was a minimalist in testing or didn’t give any prescriptions. I call back most head injured patients, those with kidney stones or weird abdominal pain, and any patient where I’m on the fence about admitting them or they want to be admitted and I discharge them. When I’m running through the home plan with them and particularly when I sense they’re concerned about going home, I tell them I’m going to call them tomorrow (or the next day) to check on them and make sure everything is okay. I then ask for their cell number and tell them when to expect my call. I think calling within a day or two is critical, though recently I told patients I would call them early next week because I was gone for a long weekend. Not knowing that was a few days longer than usual, they were delighted when I called them that Monday.
As Dr. H. told me, if I’m planning around them, it may be hard for me, but when I call on my schedule and interrupt them when they’re on their own time, they usually want to get off of the phone quickly. So unless there’s a real issue, the conversation is usually that they’re feeling better, they’ll call their doc for follow up, they don’t have any questions and “thanks so much for calling.” I feel like once I tell them I’m going to call, then I need to call (and that’s why I’ve sometimes ended up on my cell phone from home and not from the hospital).
As the director, it can be challenging to know if the docs are actually doing their calls. I have talked to physicians in another group who are required to turn in phone call logs to “prove” they’re making callbacks. An electronic solution would be ideal, as I know when I have requested paper logs, I end up with a giant stack of paper on my desk and spend little time analyzing the data. I do think paper monitoring is necessary for the doc who’s doing poorly on patient sat and is taking the step of doing callbacks.
A directive to do something from the CEO is usually non-negotiable, but how you implement the program is often up to you. While there are a variety of ways to do it, many groups are having success with physicians doing patient callbacks. These callbacks are often professionally satisfying for the doc, mitigate risk, and increase patient satisfaction. Not a bad return on a few minutes of time.
Please see: http://www.ficklefinger.net/blog/2013/01/13/ed-patient-follow-up-calls/
Nice article. In our practice, we do this every day as part of the day doc’s chore list. Calls are often for colleagues’ patients (not our own). I was skeptical at first, but quickly established a familiar routine and concur one year into our program that benefits strongly outweigh the costs.
In addition to enhancing the perception of increased quality, I believe the growing practice of EP callbacks represents a true improvement in the quality of EM care. These subtleties may go unrecognized by the general public. Often these improvements are undervalued by our own partners and staff as they observe and (appropriately) bemoan the inflation-beating surge in health care costs.
Though there is little direct evidence, I am also convinced that follow up calls reduce professional malpractice liability significantly through the intervening variables of patient satisfaction (a known independent risk reducer) and by allowing a delayed opportunity to tweak after care instructions by adjusting meds or altering, accelerating, facilitating or expediting follow up plans for the minority of patients who are not improving.