Is customer satisfaction in healthcare a gateway to corruption?

Customer satisfaction is quite the rage these days. Many stores and restaurants, many professional offices, hand out surveys, or ask customers to log onto their survey site on the Internet. As a reward, one may win everything from a free sandwich to an iPad.

I’d be interested to know how customer satisfaction played out in my home. “Kids, now you’ve had a week of school-work. Please fill out the attached survey and give your mom and me an idea how we’re doing. Frankly, if you’re not satisfied, your mom is out as teacher!”

How about politics? That would be interesting, wouldn’t it? I know, we vote. But our current system makes it difficult to remove politicians by vote, and even if it’s possible (and between money and media, it can be a stretch), we’re still stuck with them for two to four years. A “citizen satisfaction survey” would be a lot of fun. Unlike a poll, we could give it some real teeth. ‘Senator, it turns out your constituent surveys are really low. So, we’re cutting your salary by half until you bring it up by making people happier!’

Obviously, that technique has problems too, doesn’t it? Politicians can’t always please, or satisfy, everyone. And to do so would be perilous indeed. In the same way that we don’t drop “enemy satisfaction” surveys along with smart bombs. “Did you feel that the destruction of your compound was done in a professional and timely manner? Would you be willing to be bombed by the same pilot again in the future?”

Customer satisfaction has also been around in medicine for a long while, and seems to gain traction every year. Hospitals, struggling for market share, love patient satisfaction surveys and scores. For better or worse, these things often determine funding, raises, even continuation of contracts in the healthcare world. And negative scores can cause significant reprimands. It has some merit here as well. Physicians, and nurses, can’t go around being incompetent, or unprofessional. It makes for a very bad experience. And when we’re sick, or our family members are suffering, that’s the last thing we want.

However, the science isn’t always so good. For one thing, the sample sizes from which the surveys are drawn are often very small. A friend of mine worked in a hospital where the data might be drawn from one survey for a given month. If you made that one patient mad, then it was going to be a tough time!

Next, as in so many settings, happy people tend not to fill out surveys. If you like a product, you tell your friends. You go back and get another. But if you’re upset? Out comes the pen, and the boxes are checked in frustration or anger.

But lately, some physicians have been asking ‘is this really a good idea?’ A study from the Archives of Internal Medicine, published in February, suggested that physicians with very good scores may have patients who do poorly. It’s only one study, but more will likely follow. And it makes sense.

Patient has illness or injury, and desires specific test or drug. Physician feels drug or test aren’t indicated and does not provide them. Patient complains to administrator who pressures physician. Physician begins to do tests and give drugs (especially narcotics) that aren’t appropriate in order to comply with employer. I suspect this is one reason, though certainly not the only one, for the epidemic of narcotic abuse, addiction and narcotic-related deaths in America today.

I believe we should be attentive to customer service. But we have to be careful. In settings in which a high degree of expertise is necessary to make decisions, or in which grave dangers underlie poor decisions, customer service has to be balanced against knowledge and experience.

And more relevant, we often hear citizens and watch-dog groups rail against corporate interests and inappropriate influences. If a business, particularly a hospital, asks professionals to do the wrong thing in order to secure payment from the “customer,” it sure sounds like inappropriate influence to me. Likewise, the companies that push the surveys are, themselves, businesses with financial interests.

We all want to be satisfied customers. But when satisfaction has the appearance of corruption, or results in danger, maybe a little dissatisfaction would be better, and safer, in the end.

Edwin Leap is an emergency physician who blogs at and is the author of The Practice Test.

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  • Homeless

    Healthcare is already corrupt. A few patient surveys don’t make that much difference.

  • PcpMD

    The “customer service fad” is second only to the “railing against customer service” in popularity in my corner of the world. I’m therefore sensitive to both sides of the issue.

    What I’ve learned over the years is that the vast majority of patients leave happy when they feel that they’ve been listened to. They’re not asking to be catered to, just respected and heard. I’ve been fortunate enough to be surrounded by some amazing colleagues over the years. I’ve seen what power empathy, a patient-centric tone and true dialogue can have. I’ve seen these physicians regularly talk patients out of unnecessary antibiotics, inappropriate pain medications, and offer reassurance for the well worried without resorting to unnecessary testing.

    So no, I don’t believe customer satisfaction requires compromising professional ethics. It does require keeping an open mind, establishing a trusting relationship, and the engaging people in meaningful dialogue. These things all take more time and energy, but I’ve seen the results, and they are more than worth it.

  • Ruth B Woolcock M. D.

    Having gone through recent large doses of the healthcare system with my mother and my spouse, I have appreciated the increased attention to their comfort during unavoidable long waits and improved scheduling because both lived quite far from their centers of care. On the other hand I see my patients going to urgent care because my hours have had to be reduced, and I have never seen them leave without an antibiotic and very frequently a steroid even when they have been ill less than 48 hours. We all need to cultivate empathy and a listening ear but not give up our sworn oath to first do no harm.

  • cynholt

    Though I don’t have the hard numbers to prove it, I can personally
    attest to the fact that because the Patient Protection and Affordable
    Care Act (PPACA) has mandated that patient satisfaction scores be tied
    to Medicare and Medicaid reimbursement, hospitals are spending an
    enormously amounts of precious healthcare dollars paying outside
    consultants to advise them on how to boost patient satisfaction scores.
    This has resulted in hospitals hiring a large army of full-time and
    fully benefited RNs, along with a very top heavy management team, to
    call up newly discharged patients and ask them what they liked and
    disliked about their hospital stay. They are doing this not because they
    are looking for better ways to satisfy their patients. Nor are they
    doing this to improve patient outcome or reduce hospital readmission
    rates. They are doing this because outside consultants like the Studer
    Group claim that by simply having RNs call up newly discharged patients
    at home to inquire about their recent hospital stay, these patients are
    more likely to give the hospital a higher satisfaction score than they
    otherwise would. Is this total nonsense, or what!

    It’s hard for me to believe that hospital administrators are falling
    for this Studer-ized nonsense given that there is plenty of data out
    there proving that high patient satisfactions scores are strongly
    correlated with higher readmission rates, more costly hospital stays,
    and higher patient mortality rates. As emergency physician ‘WhiteCoat’
    aptly puts it, “High satisfaction with a health care facility means that
    you’re more likely to be admitted, you’re more likely to pay more for
    your care, and you’re more likely to be discharged in a body bag”:

    What I find particularly troubling about this, at least from a
    patient confidentiality standpoint, is that this information from newly
    discharged patients is being emailed to all doctors and nurses who work
    or had worked on the unit where the patient was staying, providing them
    with their medical record and room number. I don’t know about you, but I
    certainly wouldn’t want my medical record and the hospital room number I
    was staying in posted on hundreds of emails throughout the hospital!
    Then again, I’d refuse to talk to any stranger who calls me at home
    asking about my hospital stay. Now if either a doctor or nurse who had
    cared for me called me up to ask how I was doing and to answer any
    questions I had with regards to my discharged medicines and follow-up
    visits, I would be happy to speak with them.

    This emphasis of patient satisfaction scores has caused hospitals to
    waste precious healthcare dollars on providing wildly frivolous and
    inconsequential things like free 30-minute massages for patients and
    dishing out five-star meals to them. Now it is causing them to waste
    precious healthcare dollars on creating an entirely new nursing
    department whose only job it is to find out what patients liked and
    disliked about their hospital stay. Needless to say, this can only lead
    to higher healthcare costs — and higher healthcare costs that play no
    role whatsoever in improving patient outcome or reducing hospital stay.

  • Doug Capra

    There’s merit to some of what you say — but, frankly, you get off to the wrong start when right off you compare patient satisfaction, i.e. the relationships between patients and caregivers to relationships between parents and children. Talk about paternalistic! It’s a false analogy. Patients are not children and any comparison to that effect is troublesome. Emphasis on customer naturally comes along with more competition — and that’s what the medical culture in this country is facing. Competition. The challenge is to deal with it without letting customer service notions get in the way of best practice and intelligent care.

  • buzzkillersmith

    A lot of ER docs essentially work for the hospital, even if they have their own groups. Good and bad. Kowtowing to admin and admin’s insanity is part of the game, sad to say.

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