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Service Delivery Innovation Profile

Patient Notepad Improves Communication With Physicians, Including Likelihood of Having Questions Answered


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Snapshot

Summary

Select inpatient units and outpatient clinics at the University of Michigan Health System provide patients with a notepad that includes sample questions and informational prompts intended to facilitate communication between patients or family members and physicians. In the inpatient setting, the notepad increased the likelihood of patients writing down notes and having their questions answered by their doctors. The vast majority of those using the notepads felt they improved communication and indicated they would use them again.

Evidence Rating (What is this?)

Strong: The evidence consists primarily of a randomized trial comparing the likelihood of patients taking notes and having their questions answered by doctors on two inpatient units that used the notepad with two similar units that did not; additional evidence includes patient perceptions of the impact of the notepad on the quality of communication with providers and the likelihood of using the notepad if available at future visits.
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Developing Organizations

University of Michigan Health System
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Use By Other Organizations

The University of California at Irvine Medical Center and Northwestern Memorial Hospital have tested similar kinds of notepads. Dr. Farberg has received expressions of interest in the notepad from several organizations, including the University of Minnesota Amplatz Children’s Hospital and Blue Cross Blue Shield of Michigan.

Date First Implemented

2009
The initial trial began in July 2009.

Problem Addressed

Hospitalized patients and their family members often do not understand their diagnoses and treatment. This lack of understanding makes it difficult for them to be actively involved in their ongoing care and recovery, which in turn can have a negative impact on patient satisfaction and outcomes. High-quality conversations between physicians and patients/family members can help, but such communications often do not occur because patients and/or family members are not adequately prepared or are otherwise reluctant to ask questions during the limited time available with the doctor.
  • Failure to understand diagnoses and treatment: Most hospitalized patients do not fully understand their diagnosis or prescribed treatment; a survey conducted at discharge found that only 42 percent could state their diagnosis, only 28 percent could list their medications, and only 37 percent could state the purpose of these medications.1
  • Lack of engagement, leading to lower satisfaction and worse outcomes: Patients who do not understand their diagnoses and treatment find it more difficult to engage in their care and recovery. Such engagement has been associated with better outcomes and with patients feeling more respected and satisfied with their health care experience.2,3 Aware of such findings, the Institute of Medicine has stressed the need for patients and families to become more involved in their care.4
  • Unrealized potential of high-quality communication: Scores on standardized surveys (including the Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS) suggest that communication between physicians and patients remains suboptimal, with substantial opportunity for improvement.5,6 In many cases, communication suffers because patients have not thought about their questions before speaking with the doctor and/or forget to ask them when the doctor arrives. In addition, some patients are hesitant to ask questions that take up the doctor’s time.

What They Did

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Description of the Innovative Activity

Select inpatient units and outpatient clinics at the University of Michigan Health System provide patients with a notepad that includes sample questions and informational prompts intended to facilitate communication between patients/family members and physicians. Key program elements are outlined below:
  • Distribution of notepad to patients: On inpatient units, the notepad is either placed on the patient’s bedside table by housekeeping staff during room turnover or included in the standard packet of materials that patients receive at admission. (Used notepads are subsequently disposed when a patient is discharged.) During the initial randomized trial, housekeeping staff were instructed to place the pads on the bedside tables of patients on units that participated in the program but not to do so for patients on units in the control group. (This approach created some logistical problems that led to suboptimal distribution of the pads to patients on participating units; further discussion of this issue appears in later sections of this profile.)7 After this study ended, the University of Michigan Health System Frankel Cardiovascular Center made the notepads part of the standard inpatient admissions package. In addition, some units within the University of Michigan Medical Center also began using the notepads, relying on housekeeping staff to place them on the bedside table at room turnover. Several outpatient clinics within the health system have also adopted the program (including those affiliated with the cardiovascular center), generally by making the notepads available on tables in the waiting room.
  • An image of the notepad patients and family members use to write down questions

    Figure 1. The notepad prompts patients and family members to write down questions. Click the image to enlarge. Image courtesy of Aaron S. Farberg, MD. Used with permission.

  • Design that facilitates patient notetaking: As shown in Figure 1, the notepad itself contains mostly white space, with a few preprinted words intended to prompt patients and family members to write down questions. Each pad contains 15 identical sheets, thus giving the typical patient plenty of sheets to use throughout the entire inpatient stay. Patients who misplace the pad or run out of sheets can request another one from their nurse or another staff member on the unit. Additional details on the design of the notepad appear below:
    • Preprinted categories: With a banner showing the name of the health system and the words “dear doctor” at the top, the notepad instructs patients and family members to write down any questions they may have. The pad includes a preprinted list of three common areas where questions may arise, with plenty of white space under each category to write down both the questions and the doctor's responses. The three categories are: diagnosis and treatment, tests and procedures, and medications. A sample question appears under each category label; for example, under tests and procedures, the sample question reads: “What tests are planned for today?”
    • Checkbox at bottom to indicate additional questions: At the bottom of the notepad, a checkbox appears next to a prompt that reads “I have a few more questions.” This checkbox encourages the patient to write additional questions on the back of the sheet and reminds the patient to ask these questions when the doctor arrives.
  • Use of notepad before, during, and after physician visits: Patients and family members use the notepad as they see fit. During the initial trial in the inpatient setting, roughly 60 percent of those who received the notepad used it (207 out of 343 patients). Overall, 99 percent of those who used it did so to write down questions in advance of the hospitalist’s visit to the room, and 82 percent used it to keep track of tests and procedures (writing down information given to them by the doctor in response to their questions). For just over half (54 percent) of these patients, friends and/or family members also used the notepad at some point during the inpatient stay.7 For their part, nurses report referring to the notepads regularly when a patient asks a nonurgent question that they cannot answer, suggesting that the patient write down the question and ask the doctor during the following morning’s rounds. Physicians tend to appreciate this approach, as it avoids the need for the nurse to call or page them to ask the question right away.

Context of the Innovation

The University of Michigan Health System is a large, integrated system made up of hospitals, health centers, and clinics throughout southeast Michigan; the University of Michigan Medical School and its associated faculty group practice; and the University of Michigan School of Nursing. Located in Ann Arbor, the University of Michigan Medical Center is a 610-bed academic medical center that handles 44,000 discharges each year, making it the primary location for inpatient care within the system.

The impetus for this program came from the experiences of two medical school students (Aaron S. Farberg and Andrew M. Lin) in a course known as Family-Centered Experience. As part of the course, each student was paired with a patient who has a chronic disease, spending significant time with the patient observing how he or she experienced the health care system, including accompanying the patient to appointments. As they took the course, the two students noticed that patients who fared the best took an active interest in their own health and health care and that many of these patients regularly took notes about their care, including writing down questions for their doctors prior to seeing them and subsequently jotting down answers when the doctor spoke with them. During a series of discussions about their experiences in this course, the two students came up with the idea of making a simple notepad available to patients to make it easier for them to ask questions and remember the answers.

Did It Work?

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Results

The notepad increased the likelihood of patients writing down notes about their care and having their questions answered by the doctor. The majority of those using the notepad felt it improved communication and indicated they would use it again.
  • More likely to write down notes: Over a 3-month period (July to September 2009), 54 percent of the 440 patients on 2 inpatient units where the notepads were available took notes related to their care, compared with 22 percent of 224 patients on 2 control-group units.7 This difference may underestimate the true impact of the notepads on patient notetaking, given that 22 percent of patients who were supposed to receive them did not (representing 97 patients), primarily because of problems with custodial staff not knowing they were supposed to place the pad on the bedside table during room turnover. Excluding these individuals, approximately 69 percent of those who received the notepad used it.
  • More likely to have questions answered: Patients were asked to rate how often their doctor answered their questions, using a 5-point Likert scale where 5 indicates that the doctor always answered them and 1 indicates that they never did. Overall, patients using the notepads assigned an average score of 4.63, above the 4.45 score given by patients on the two units that did not use the notepads. This difference was statistically significant.7
  • Better communication: While overall satisfaction with the quality of communication did not vary between the two groups, 89 percent of those who used the notepad felt that it led to modest (28 percent), noticeable (35 percent), or significant (26 percent) improvement in the quality of communications with providers.7
  • Strong intent to use in future: Overall, 93 percent of those who used the notepad indicated they would do so again during a future inpatient stay. In addition, a survey of the aforementioned 97 patients on the two implementing units who did not receive a notepad found that 77 percent would use it if made available in the future.7

Evidence Rating (What is this?)

Strong: The evidence consists primarily of a randomized trial comparing the likelihood of patients taking notes and having their questions answered by doctors on two inpatient units that used the notepad with two similar units that did not; additional evidence includes patient perceptions of the impact of the notepad on the quality of communication with providers and the likelihood of using the notepad if available at future visits.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Using notepad informally on a few units: Drs. Farberg and Lin used their personal printing quotas from the medical school to produce quarter-size sheets of paper that they subsequently delivered in packaged bundles to the units on which they most frequently worked. They told nurses on the units that the pads could be given to patients to facilitate notetaking.
  • Meeting with medical school dean: Drs. Farberg and Lin met with the dean of the medical school to share their idea and report on the use of the quarter-sheet pads on the units. The dean strongly supported the idea and encouraged them to apply for internal grant funding to spread it.
  • Developing proposal and gaining approval: With the help of two hospitalists with substantial experience in quality improvement projects, Drs. Farberg and Lin developed a grant proposal to evaluate the impact of the notepad in a more rigorous study. The health system approved the grant, and subsequently the University of Michigan Medical Center’s director of marketing and chief executive officer pledged additional financial support.
  • Gathering patient and clinician input: Drs. Farberg and Lin engaged in a series of one-on-one and small-group discussions with patients and their family members, nurses, physicians, residents, and friends to elicit input on the appropriate design of the pad, including any preprinted language (e.g., categories, sample questions) to include. Opinions varied significantly on these issues, and the two physicians decided to focus primarily on what patients told them, since the notepad was intended to be used by patients and family members.
  • Introducing notepad to hospital-based staff and physicians: Hospitalists, residents, and nurses received a brief introduction to the notepads during regularly scheduled meetings. The notepads were positioned as a tool specifically for patients and their families to use as they see fit.
  • Introducing notepad to custodial and admissions staff: To prepare for the randomized trial, Drs. Farberg and Lin worked closely with the head of the Environmental Services Department to plan the distribution of the notepads to the two units using them, while also making sure that patients on the control-group units did not receive them. As noted earlier, various logistical issues, including the presence of many temporary staff and frequent changes to staffing on the morning and night shifts, prevented all patients who were supposed to receive a notepad from getting one. When the Frankel Cardiovascular Center subsequently adopted the program, center leaders decided not to rely on custodial staff to distribute the pads, instead working with the admissions department to make the notepads part of the standard packet given to all newly admitted patients.

Resources Used and Skills Needed

  • Staffing: The program requires no additional personnel, as patients, nurses, and physicians incorporate use of the notepads into their regular routines.
  • Costs: Program-related expenses tend to be quite small, consisting primarily of the costs of printing the notepads.
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Funding Sources

University of Michigan Health System
The University of Michigan Health System funded this program internally through a Fostering Innovations Grant.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Sell benefits to hospital leaders: As this study demonstrates, the notepad serves as an effective tool for improving patient perceptions of their own care, which in turn should have a positive impact on customer satisfaction. Given the growing importance of patient-centered care (including the movement to tie payment rates to satisfaction scores), these potential benefits should be attractive to institutional leaders.
  • Start small and let program expand naturally: Begin the program on one or a few units or floors, and then after a month or two hold discussions with patients, physicians, residents, nurses, and other staff to get their impressions of the notepads. Over time, use of the pads may spread to other units as nurses and/or others recognize their value.
  • Include a few trigger categories and questions: The page should mostly contain white space, with just a few suggested categories and sample questions. Most people have substantial experience using notepads, so any preprinted information should be brief, serving as a reminder of the kinds of questions that may be important.

Sustaining This Innovation

  • Consider translating into multiple languages: Organizations that cater to an ethnically diverse patient population might need to make the pad available in multiple languages.
  • Support nurses in sustaining and spreading program: As noted earlier, nurses are often the first to recognize the value of the notepads and hence can be effective advocates for expanding their use. To that end, make sure that nurses have access to an ample supply of the notepads on an ongoing basis.
  • Make notepads part of standard protocol: Over time, the goal should be to make the notepads available to all patients in a given unit, department, facility, or institution. Once a decision has been made to adopt the program universally, the best approach is to include the notepad as part of the standard registration and/or admissions packet given to all patients. This strategy reduces the risk that some patients may not receive the notepad due to staffing and/or other logistical issues.

Spreading This Innovation

As noted, use of the notepads began on a few units in the University of Michigan Medical Center. After the randomized trial demonstrated positive results, the Frankel Cardiovascular Center adopted the program for all its inpatient units and outpatient facilities. The program has also spread to several other inpatient units and departments within the medical center. In some cases, those adopting the program have made minor modifications to the notepad.

Use By Other Organizations

The University of California at Irvine Medical Center and Northwestern Memorial Hospital have tested similar kinds of notepads. Dr. Farberg has received expressions of interest in the notepad from several organizations, including the University of Minnesota Amplatz Children’s Hospital and Blue Cross Blue Shield of Michigan.

More Information

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Contact the Innovator

Aaron S. Farberg, MD
Section of Plastic Surgery, Department of Surgery
University of Michigan Health System
Ann Arbor, MI 48109
(847) 721-2725
E-mail: afarberg@med.umich.edu

Andrew M. Lin, MD
Department of Dermatology
University of Michigan Health System
Ann Arbor, MI 48109
E-mail: andrewml@med.umich.edu

Innovator Disclosures

Drs. Farberg and Lin reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

References/Related Articles

Farberg AS, Lin AM, Kuhn L, et al. Dear doctor: a tool to facilitate patient-centered communication. J Hosp Med. 2013;8(10):553-8. [PubMed]

Footnotes

1 Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80(8):991-4. [PubMed]
2 Venetis MK, Robinson JD, Turkiewicz KL, et al. An evidence base for patient-centered cancer care: a meta-analysis of studies of observed communication between cancer specialists and their patients. Patient Educ Couns. 2009;77(3):379-83. [PubMed]
3 Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423-33. [PubMed]
4 Institute of Medicine of the National Academies. Best care at lower cost: the path to continuously learning health care in America. 2012. Available at: http://www.iom.edu/Reports/2012
/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx
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5 Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st Century. Washington, DC:National Academy Press; 2001.
6 Jha AK, Orav EJ, Zheng J, et al. Patients’ perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921-31. [PubMed]
7 Farberg AS, Lin AM, Kuhn L, et al. Dear doctor: a tool to facilitate patient-centered communication. J Hosp Med. 2013;8(10):553-8. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 04, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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