RESEARCH ARTICLE

Increasing PCP and Hospital MedicinePhysician Verbal Communication DuringHospital AdmissionsMatthew W. Zackoff, MD,a Camille Graham, MD,b,c Denise Warrick, MD, MEd,b Kathleen Pulda, BA,d Craig Gosdin, MD, MSHA,e Blair Simpson, MD,e

Jessica Marischen, BA,f Paul Bunch, MD,b,g Michael Vossmeyer, MD,e Grant M. Mussman, MD, MHSAe

A B S T R A C TOBJECTIVES: During hospital admission, communication between primary care physicians (PCPs)and hospital medicine (HM) physicians provides an opportunity for collaboration. Two-waycommunication facilitates collaboration by allowing the receiver to ask and respond to questions. Atour institution, most HM-to-PCP communication occurred by telephone call after discharge. Ourspecific aim was to increase the percentage of patients for whom a telephone conversation occurredbetween HM and PCPs during hospital admission from 40% to .80%.

METHODS: An improvement team that included PCPs and HM physicians redesigned the process forcommunication with PCPs to emphasize collaboration during hospitalization. Interventions wereused to target key drivers of information transparency, PCP and HM provider buy-in, the value ofearly call initiation, process standardization, accommodating provider availability, and preoccupationwith failure. We used improvement-science methods and run charts to measure our progress andattain our goal.

RESULTS: The median weekly percentage of patients with a phone call completed duringhospitalization increased from 40% to 85% at the satellite campus and 40% to 80% at the maincampus. In addition to the standardized use of a telephone operator system to route calls and follow-up on unplaced calls, critical interventions included feedback on PCP call preferences to providersand the provider script for calls.

CONCLUSIONS: PCPs and HM physicians applied quality-improvement methodology to ensure reliableHM-PCP communication during hospital admission. Interventions to facilitate communication betweenproviders and learners (who may otherwise have limited interaction), such as the scripting of phonecalls and feedback from PCPs to HM physicians, were important for success.

aCritical Care Medicine,Department of Pediatricsand bDivisions of General

and CommunityPediatrics, cMid-City

Pediatrics Inc, Cincinnati,Ohio; and dPhysician

Priority Link, CincinnatiChildren’s Hospital

Medical Center,Cincinnati, Ohio; eHospitalMedicine, and fPhysician

Services, andgSpringdale-Mason

Pediatric Associates Inc,Cincinnati, Ohio

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2017-0119Copyright © 2018 by the American Academy of Pediatrics

Address correspondence to Matthew W. Zackoff, MD, Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’sHospital Medical Center, 3333 Burnet Ave, MLC 2005, Cincinnati, OH 45229. E-mail: matthew.zackoff@cchmc.org

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Drs Zackoff, Graham, Warrick, and Mussman and Ms Pulda conceptualized and designed the study and drafted the initial manuscript;Drs Gosdin, Simpson, Bunch, and Vossmeyer and Ms Marischen conceptualized and designed the study and reviewed and revised themanuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Transitions in and out of the hospital aretimes of increased risk for pediatricpatients. Effective communication betweeninpatient and outpatient providers athospital discharge is often emphasized asan important target for improvement,1,2

but effective communication during thehospitalization provides advantages.Adverse events that are attributable toineffective communication can occur notonly at hospital discharge3 but also athospital admission, when multiple sourcesof information are often needed to elucidatea patient’s complete clinical picture.Examples include medication errors,redundant or unnecessary testing,inadvertent exposure to a food or latexallergy, and exposure of staff to high-riskbehavioral safety situations.4–6

Communication during hospitalizationbetween outpatient and inpatient providersalso provides an important opportunity forcollaboration between primary carephysicians (PCPs) and hospitalists toprovide consistent care across the carecontinuum.7

Two-way communication facilitatescollaboration2,8–11 and offers an opportunityfor the PCP to provide a historicalbackground, ask clarifying questions, anddiscuss follow-up needs.7,11–13 At ourinstitution, we previously improved thereliability of verbal communication betweeninpatient providers and PCPs at hospitaldischarge to .90% for patients who areon the hospital medicine (HM) service.14

Unfortunately, these calls occurredpredominantly after hospital discharge, andmany community physicians expressedfrustration regarding this delay and the lackof an opportunity for collaboration inpatient care; they provided no benefit overother means of communication, such aswritten discharge summaries. As anextension of our previous work, wesought to improve the timeliness of thiscommunication. Our specific aim in thisproject was to increase the percentage ofpatients for whom a telephone conversationoccurred between an HM provider and aPCP during hospital admission (ie, beforepatient discharge) from 40% to 80% for allpatients who were admitted to our HMservice in a 6-month period.

METHODSContext

This study included all patients who wereadmitted to the HM service at an academicchildren’s hospital’s main campus($500 inpatient beds) and its satellitecampus (42 inpatient beds). At the start ofthe improvement process, the medianlength of stay (LOS) was 27 hours with aninterquartile range of 19 to 43 hours atthe satellite campus, and the median LOSwas 34 hours (interquartile range of21–53 hours) at the main campus. There are4 HM teams at the main campus and 2 HMteams at the satellite campus. Phone callsto PCPs at the main campus are placed byresidents, whereas calls are placed byresidents, attending physicians, or nursepractitioners at the satellite campus.

Interventions

The project was championed by PCP leadersand physicians on the HM service. Teammembers included PCPs from 4 practices,4 HM physicians representing both sites, apediatric chief resident, representativesfrom physician services, and PhysicianPriority Link (PPL) (a 24-hour, institutionaltelephone operator service that is availableat both campuses).

At the onset of the project, the teamreviewed the existing process andconducted a modified failure modes andeffects analysis for failure to complete callsduring hospitalization.15,16 The primaryfailure mode was late initiation of the phonecall process. Other failure modes includedthe absence of an identified PCP, perceivedinconvenience for the PCP, and perceivedlack of value of the communication. Thesefailure modes informed the development ofthe key drivers to achieve the project aim.The theory of improvement, including keydrivers and targeted interventions, isdepicted in Fig 1. Key drivers includedinformation transparency, HM and PCP buy-in, the high value of calls, the early initiationof calls and/or sufficient time to completethe calls, the standardization of the callprocess, the availability of HM providersand PCPs, the identification of the correctPCP, and preoccupation with failure.Interventions targeting key drivers wereinformation dissemination, PCP feedback to

HM providers, the provider script forphone calls, standardizing the call triggerto hospital admission, routing all callsthrough the PPL operator service, and thefollow-up of incomplete calls by the PPLoperator. Resources were not allocated toaddress the failure mode of absence of anidentified PCP, which led to a target callcompletion goal of 80% for this initialwork.

Information Dissemination

Information on the project’s purpose andinterventions was disseminated by usingseveral avenues, targeting our key driversof information transparency and HM andPCP provider buy-in. Information about thepurpose and goals of the project wasshared with PCPs via a monthly staff bulletinnewsletter and to HM physicians at updatesduring weekly team meetings. A member ofthe improvement team conveyed projectupdates and information on plannedinterventions monthly with a preexistinggroup of community PCP leaders andsolicited feedback. Physician servicesrepresentatives incorporated informationvia visits with referring PCPs over a several-month period.

PCP Feedback to HM Providers

Feedback on interventions was solicitedfrom community physicians via e-mail andduring face-to-face visits by physicianservices representatives. Additionally,feedback from community-physicianleaders was requested at monthlycommunity-physician leader meetings byan improvement team member andshared with the improvement team toguide plan-do-study-act cycles. Specificfeedback could be disseminated to HMattending physicians in real time orperiodically at divisional meetings and toresident physicians in real time or duringmonthly orientation sessions. Thisstructure for feedback was vital tomaintaining provider buy-in throughoutthe improvement process.

Provider Script for Phone Calls

Because HM providers may be reluctant tocall PCPs until more of a patient’s clinicalcourse is known, communication with PCPswas scripted to target the key drivers of

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provider buy-in and high call value bystandardizing the interaction. Keycomponents of the script included (1)discussion of the initial treatment plan, (2)the solicitation of additional pertinentinformation from the PCP, and (3) transitionplanning. For most patients on the HMservice, discharge planning couldreasonably begin at hospital admission. Forother patients (ie, those with medicalcomplexity or extended stays), the scriptindicated the need for a follow-up call to thePCP later in the hospitalization. The scriptwas developed by the improvement team,which included PCPs as well as HMproviders.

Phone Calls to PCPs Triggered atAdmission and Routing of CallsThrough PPL

To address our key drivers of early callinitiation and high call value, the preexistingprocess for provider communication atdischarge14 was reorganized so that phonecalls to providers were routinely triggered

at hospital admission (Fig 2). Callscontinued to be routed through the PPLoperator service to ensure a standardized,measurable process and provideravailability. The call process was modifiedso that HM providers were instructed tocall PPL to initiate contact with PCPs onadmission after attending staffing and theestablishment of an initial plan of care. Asbefore, after receiving the call from the HMprovider, PPL would then contact thepatient’s PCP, who was expected to returnthe call within 1 hour; once the PCPreturned the call, PPL would page the HMprovider with the expectation of a returncall from the HM provider within 2 to4 minutes. For patients who were admittedafter 8 PM, phone calls to PCPs were initiatedby the HM provider the next day to allow forthe staffing of the patient and establishmentof a clear plan of care.

Follow-up on Unplaced Calls

The provider-driven phone call process wasreinforced by an electronic health record

(EHR)–triggered function, which identifiedunplaced calls for mitigation. The previousprocess (triggered by a discharge order)was modified so that when a providerplaced an order to admit a patient to HM,the EHR (EpicCare Inpatient; Epic SystemsCorporation, Verona, WI) generated amessage to the PPL operator in-basket. As inthe previous process, the in-basket waschecked against PPL phone logs by using asimple search function to identify calls thatstill needed completion. If a patient wasidentified as needing a call, the PPLoperator paged the HM provider via textpage. If the HM provider was ready for thecall to be placed, the operator would eitherconnect to the PCP’s office backline numberor the HM provider would be paged backwhen the PCP returned the call per theprocess described above. The process wasadditionally modified to have PPL-initiatedcalls only occur at the batch times of 1 PM,4 PM, and 8 PM, compared with the previousprocess having 2 batch times as well as aperiod during which every discharge order

FIGURE 1 Key driver diagram for increasing HM–PCP telephone calls during hospital admission.

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triggered an immediate call from PPL. HMproviders were still able to initiate callsoutside of batch times by calling PPLdirectly (Fig 2). This process adjustment

allowed time for HM providers to clarifyplans of care and prevented thepremature paging of HM providers byPPL.

Study of the InterventionAll the patients admitted to the HM serviceduring the study period were eligible forinclusion. Improvement work began at the

FIGURE 2 New process for communication between HM providers and PCPs.

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satellite campus because provider teamswere smaller, consisting of either adirect-care attending, direct-care nursepractitioner, or an attending with a singleresident. As the process was spread tothe main campus, some interventionswere implemented simultaneously atboth sites, whereas some were targetedto 1 of the sites. Active improvementcontinued until goal performance wasmet for 6 months followed by periodicchecks for sustainability to 1-yearpostgoal.

Measures and Analysis

The measure used to determineimprovement was the percentage ofpatients admitted to the HM service forwhom a phone call between an HM providerand the PCP was documented as occurringbetween the time of admission anddischarge from the hospital. Each week, arandom sample of 20 patients was selectedfrom an EHR-generated list of weeklyadmissions to the HM service at each site. If,20 patients were admitted to a site duringa week, then all patients were included inthe sample. The medical record numbers,admission times, and discharge times forthese patients were forwarded to PPL andmanually compared with PPL phonerecords; all calls that were routed throughthe PPL operator system were documentedwith a time stamp. A successful call metthe following criteria: (1) the call wasconnected between an HM provider and thePCP, and (2) the time stamp of that callindicated that the call occurred during thepatient’s hospitalization. The measure wasgenerated by dividing the number ofsuccessful calls by the number of calls inthe sample.

Data compilation occurred weekly onthe basis of the availability of relevantpersonnel and data were plotted on a runchart. Run chart medians were establishedand adjusted by using the rules for specialcause variation in run charts.17,18 Theimprovement team met biweekly to reviewcurrent performance, analyze failuresthrough a review of calls that were notsuccessfully completed, and conduct plan-do-study-act cycle modifications to theinterventions.

Ethical Considerations

Our project complied with the institutionalreview board (IRB) policy on systemsimprovement. The project was deemed to besystems improvement by the IRB andtherefore was exempt from formal IRBreview.

RESULTS

From August 31, 2015, to March 19, 2017,there were 1797 discharges from the HMservice at the satellite campus. Thepercentage of these patients with a phonecall during hospitalization increased from40% to 85%; our goal was achieved after27 weeks, and performance was maintainedfor 1 year postimprovement (Fig 3).

From November 23, 2015, to March 19, 2017,there were 5527 discharges from the HMservice at the main campus. Interventionsbegan at the main campus on January 24,2017, after initial improvement at thesatellite campus. The median weeklypercentage of main campus patients with aphone call during hospitalization increasedfrom a baseline of 40% to 80%. Our goal wasachieved after 15 weeks, with performancemaintained for 1 year postimprovement(Fig 4).

At both the satellite and main campuses,establishing an expectation for telephone

calls to PCPs during admission, routing callsthrough PPL, and using the PPL service tofollow-up on unplaced calls were alltemporally associated with improvement inbut not the achievement of goal reliability.Variability in call rates for low-acuitypatients (such as patients who wereadmitted to medical beds to awaitpsychiatric placement) initially persisted atthe satellite campus. The dissemination ofPCP feedback, which included the fact thatphone calls were considered valuable forpsychiatric patients in medical beds, tosatellite campus providers was temporallyassociated with improvement to reach thegoal. At the main campus, residents oftendeferred phone calls on the day ofadmission because of discomfort with theprocess of engaging with PCPs fortreatment planning. The implementation ofthe provider script was temporallyassociated with improvement to reach thegoal at the main campus. On the basis ofreal-time feedback from HM providers andPCPs, we conclude that the improvementprocess did not lead to an increase in phonecalls per patient.

DISCUSSION

PCPs and HM physicians collaborated inapplying quality-improvement methodologyto increase the reliability of verbal

FIGURE 3 Weekly percent of patients with HM–PCP calls during hospitalization at the satellitecampus.

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communication between HM providers andPCPs during hospitalization to 85% at thesatellite campus and 80% at the maincampus, with the goal performance beingachieved in a 6-month time span andsustained for 1 year postimprovement. Thetriggering of calls to PCPs at admission,routing calls through PPL, using PPL tofollow-up on unplaced calls, feeding backinformation to providers, and the providerscript for phone calls were criticalinterventions associated with improvement.A strength of our work is the successfulfacilitation of a complex communicationprocess among providers who mayotherwise have limited interaction andlimited knowledge of priorities forcommunication.

As in our previous work, we were able toadapt our PPL operator system and leveragean EHR-triggered system to improve thetimeliness of phone calls between PCPs andHM providers. However, in this case, theseinterventions resulted in a lower level ofreliability when applied at patient admissionrather than at discharge. Althoughdischarge phone calls between HMproviders and PCPs had been occurringreliably for several years at the beginning ofthis project, the fact that PCPs valued phoneconversation was still surprising andsuggests that although many hospitalists

embrace the idea of collaborating withPCPs,7 the benefits of communicating maynot always be intuitive.

Another finding that arose during our rootcause analysis of continued failures at themain campus was that many residents wereuncomfortable engaging with PCPs early ina hospitalization. Because discharge phonecalls had been a constant feature ofresident training, some initial discomfortwith making calls at admission wasexpected, but we did not anticipate that thiswould continue to be a major failure modefor months after the process began at themain campus. Providing a script for thesecalls that emphasized the collaborativepurpose of the call may have changed theperception of the call’s purpose from purelyinformational regarding patient course (inwhich case, early communication may beless desirable) to a 2-way conversation inwhich PCPs and HM providers both sharedinformation that informed treatmentplanning.

Our 2 remaining failure modes included ashort LOS with discharge before thecompletion of morning rounds and the lackof an identified PCP before discharge. Thesefailures occurred most frequently inadmissions after 8 PM. Phone calls to PCPswere not typically placed until after rounds

the following morning because the callswere nonemergent. Additionally, althoughthe identification of a PCP for follow-up isan expectation on the HM service at ourinstitution, an appropriate PCP may not beidentified until the time of discharge, leavingless time for call completion.

Although it is possible that the new processresulted in increased workflowinterruptions for HM providers or PCPs, thisis unlikely because both the previousreliable process14 and the new processrequired only 1 call per patient in mostcircumstances. Specifically, quantifyingworkflow interruptions among so manyproviders would be resource intensive;however, informal feedback from HMproviders, community-physician leaders,and PCP members of the improvement teamseemed to indicate no additional workflowburden. We also did not attempt tosystemically assess the quality ofcommunication between HM providers andPCPs, which represents an important nextstep in improving communication.

This study has several other limitations. Ourprocess was dependent on the existence ofPPL, and similar services may not beavailable at other institutions. We wouldnote that PPL was not originally designedfor the purpose of communication betweenHM physicians and PCPs; however, therouting of calls through PPL has notrequired staffing increases. We were alsounable to account for phone calls placed toPCPs that did not use PPL. However, becausemost calls that were not completed at leasthad a call placed via PPL, it is likely that fewcalls were completed outside the PPLsystem. We also did not measure the effectof our new process on family or PCPsatisfaction. Additionally, we did notspecifically track whether furthercommunication occurred between the HMproviders and PCPs for prolongedadmissions or for patients with medicalcomplexity. Additionally, although EHRs arenow being widely used, not all systems mayhave the same functionality. Of note, weused existing functionality within our EHR,which may aid in the utility of this approachby other institutions given the wide use ofour EHR system.

FIGURE 4 Weekly percent of patients with HM–PCP calls during hospitalization at the maincampus.

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In this project, we focused on facilitatingphone calls during hospital admission toprovide an opportunity for collaborationbetween PCPs and HM physicians. Thequality of this communication likely variesamong providers, and future researcherswill need to define and measure call quality.Additional next steps include continuing toimprove the efficiency of thiscommunication and measuring the impacton patient outcomes, specifically looking atthe changes in management that were theresult of this improved communication.Additionally, we are actively working onmethods to gather real-time PCPsatisfaction with communication to furthersupport our efforts.

CONCLUSIONS

PCPs and HM physicians collaborated inapplying quality-improvement methodologyto increase the percentage of phone callsbetween HM providers and PCPs occurringduring hospitalization from 40% to 85% atour satellite campus and from 40% to 80%at our main campus over a 6-month timespan, with results being sustained for1 year. Interventions to facilitatecommunication between providers andlearners (who may otherwise have littleinteraction) were important components ofthe improvement process. The results ofthis study may be of interest for adoption atany institution seeking to increaseopportunities for collaboration betweenPCPs and HM providers.

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DOI: 10.1542/hpeds.2017-0119 originally published online March 20, 2018; 2018;8;220Hospital Pediatrics 

Grant M. MussmanGosdin, Blair Simpson, Jessica Marischen, Paul Bunch, Michael Vossmeyer and Matthew W. Zackoff, Camille Graham, Denise Warrick, Kathleen Pulda, Craig

Hospital AdmissionsIncreasing PCP and Hospital Medicine Physician Verbal Communication During

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Print ISSN: 1073-0397. Illinois, 60143. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca,publication, it has been published continuously since 1948. Hospital Pediatrics is owned, Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly

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DOI: 10.1542/hpeds.2017-0119 originally published online March 20, 2018; 2018;8;220Hospital Pediatrics 

Grant M. MussmanGosdin, Blair Simpson, Jessica Marischen, Paul Bunch, Michael Vossmeyer and Matthew W. Zackoff, Camille Graham, Denise Warrick, Kathleen Pulda, Craig

Hospital AdmissionsIncreasing PCP and Hospital Medicine Physician Verbal Communication During

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