My colleague, Ed Miseta, chief editor of Clinical Leader, recently asked, “Can Better Patient Experiences Lead To Better Medicines?” via an article he developed from an interview with Thomas Goetz, cofounder of Iodine, a digital health company. According to Miseta, Goetz is attempting to turn patient experiences into better medicines and is combining data and design to help patients locate the best treatments based on preferences, demographics, and experiences. But truthfully it wasn’t Goetz’s work that intrigued me (but still worth your reading about), but rather Miseta’s question. If a patient has a better (clinical trial) experience, would that indeed result in a better medicine? Put differently, I pondered, could a patient that was “highly satisfied with their clinical trial experience perceive a medicine as making them feel better?” We see this happen all the time with placebos right? It made me wonder further, if a patient has a better healthcare experience would they have a better healthcare outcome? As I pondered Miseta’s question, I reflected back to a conversation I had this past weekend with William J. Krowinski, Ph.D. The coauthor of the book, Measuring and Managing Patient Satisfaction with Steven Steiber, Ph.D., Krowinski shared how he and his coauthor developed the handbook for designing and administering better patient satisfaction surveys geared toward providing practical information for healthcare institutions. And though Krowinski admits that a well-designed measurement instrument is important, it is what is done with the data that is often most telling.
Are Satisfied Patients A Good Thing?
In April 2015, The Atlantic published The Problem With Satisfied Patients. According to the author, use of patient satisfaction surveys are “a misguided attempt to improve healthcare,” and have led some hospitals to focus on making people happy rather than making them well. Apparently, when the Department of Health and Human Services opted to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores, they believed transparency and accountability would improve healthcare (seems reasonable). Beginning in October 2012, the Affordable Care Act resulted in the implementation of a policy that withheld 1 percent of total Medicare reimbursements (approximately $850 million) from hospitals. The plan was that only hospitals with high patient-satisfaction scores and a measure of certain basic care standards would be able to earn that money back, while the top-performing institutions would receive a bonus.
Interestingly, the vast majority of the subjective, 32-question, patient-satisfaction survey used to determine these “scores” focuses on nursing care. So what happens when a patient presses their call button and a nurse doesn’t arrive as quickly as the patient wanted (an actual survey question)? No matter that the nurse’s help may not have been medically necessary, unrealistic expectations on the part of the patient could result in an unsatisfactory score and end up costing the hospital. So what did some hospitals do? Why naturally, they attempted to satisfy patients. Sure, focusing on giving patients what they want (i.e., a specific test, a certain drug) versus what they need might result in better satisfaction scores, but does it result in better patient outcomes? Survey says — no.
According to a national study conducted by the University of California-Davis, higher patient satisfaction scores were associated with less emergency department use, but with greater inpatient use, higher overall healthcare and prescription drug expenditures, and increased mortality. In other words, a patient could be very satisfied one minute, yet not so happy an hour or so later. But as the goal is to have satisfied patients (that is, after all, what the survey was designed to do and a large component of how hospitals were to be paid) some hospitals began adding additional amenities (e.g., valet parking, live music, flat-screen televisions). In April 2012, Johns Hopkins unveiled a new $1.1 billion “state-of-the-art” facility. Boasting of patient-centered features (e.g., reduced noise, improved natural light, visitor friendly facilities, well-decorated rooms, and hotel-like amenities) the 1.6 million-square-foot facility touted a “new standard of care.” Very smartly, Johns Hopkins monitored (and published) patient satisfaction scores, comparing their levels before and after the upgrades. As you might expect, patients’ satisfaction with the hospital’s amenities did increase. However, this increase didn’t come with a boost in overall patient satisfaction scores or with higher satisfaction when it came to the care they received from doctors or nurses. In other words, patients were able to discriminate their experiences with the hospital environment from those with hospital care staff.
So while facilities make a patient-satisfaction difference, it is the care providers who are the real difference makers. Thus, the obvious solution is to make a difference in how these providers interact with patients, if you really want to be able to boost your patient satisfaction scores.
How To Skew Care To Meet Patient Satisfaction Surveys
As mentioned previously, the patient satisfaction survey (known as HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems]), has a predominant focus on nursing care. According to research conducted by Press Ganey (a healthcare analytics firm ), “Nurse Communication” is the factor with the greatest impact on patients’ overall ratings of their hospital experience. As a result of such “data-driven insight” The Atlantic notes that some administrators ordered nurses to use particular phrases and gush effusively to patients about both their hospital and fellow nurses, even roll playing and rehearsing nursing scripts. The Atlantic cites the “widespread practice of scripting nurses’ patient interactions” as perhaps one of the “most egregious” ways by which hospitals attempted to skew care toward meeting the HCAHPS survey.
Editor’s Note: Ever interact with someone reciting or reading from a script? Let me tell you what happens. Working as a drug rep we were supposed to deliver a core message on every sales call — a practice I abhorred. During one of my ride alongs a newly minted district sales manager wanted to observe me delivering a core message. As I began reciting the message (with the biggest prescriber in my territory) the doctor turned and walked away before I could finish , an action I anticipated would happen (because the doctor told me it would).
But perhaps more disturbing than having nurses function as automatons and treating patients as customers (a dangerous practice, for the patient is not always right), is that some health systems are using patient satisfaction scores as a factor in calculating these healthcare providers’ pay. The real problem (something CMS has failed to address) is that patient surveys won’t drastically and directly improve healthcare. But what can is the hiring of more nurses and treating them well. According to a Health Affairs study comparing patient-satisfaction scores with HCAHPS surveys of almost 100,000 nurses, it showed that a better nurse work environment was associated with higher scores on every patient-satisfaction survey question. Further, U of Penn professor Linda Aiken found that higher staffing of registered nurses was linked to fewer patient deaths and improved quality of health. In other words, if hospitals want to get better patient outcomes, perhaps instead of focusing on the patient satisfaction, they should start treating hospital employees like they are their most loyal customers! Perhaps it is time for hospitals to think longer and harder about employee satisfaction, and the patient satisfaction and outcomes will follow.