Patient satisfaction: Hospitals are not like car dealerships

Recently, I attended what may have been my last quarterly medical staff meeting at my local hospital — ever. (I am retiring from medicine in ten weeks.) I certainly wasn’t there for the food, although the fare was much better than the daily servings in the doctors’ lounge. Part of the night’s agenda was a rousing talk by the hospital’s new chief medical officer (CMO). A retired surgeon, the CMO is supposedly a liaison between the medical staff and the hospital administration, although with a hospital salary he has more allegiance to the hospital then his former peers.

His topic was patient satisfaction  and an argument that the new Holy Grail for a successful hospital was 100% patient satisfaction. He used comparisons of car dealers who ask you to rate their services on surveys as “always.” (Not “usually,” “sometimes,” or “never.”) Ignoring for a moment the fact that I find these disingenuous requests self-serving and annoying, even for a car dealer, I was struck by the analogy. So now the goal is to be perfect on new federal government questionnaires.

In case you missed that last part, patient surveys are mandated by Uncle Sam.  As if ACA, ACOs and medical homes weren’t enough, now part of patient care quality has been reduced to reviews like TripAdvisor or Angie’s List.

HCAHPS (pronounced H-CAPS) stands for Hospital Consumer Assessment of Healthcare Providers and Systems. It is the first national, standardized, publicly reported, survey of patients’ perspectives of hospital care. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient hospital experiences of care that allowed valid comparisons to be made across hospitals locally, regionally, and nationally.

This all sounds good in theory. But what questions are they asking? There are 27 questions sent to random and recently discharged patients. They include communication with nurses and doctors, responsiveness of hospital staff, cleanliness and quietness of the hospital, pain management, overall hospital rating, and whether or not they would recommend the hospital to others.

The whole premise seems a bit flawed and skewed. After all, unlike a car dealership or hotel, one often doesn’t electively choose the hospital. Many admissions are emergencies, or mandated by insurance companies or where a patient’s doctor or surgeon has admitting privileges. From the hospital’s perspective however, this matters little since the same yardstick will eventually compare them all to each other.

Back to Dr. CMO.  He said, “Studies have found that patient’s perceive you have spent more time at the bedside if you are sitting rather than standing.”

“But,” I said, “there are no chairs in the room.”

“We know that, and are working to fix that issue,” he said. “We want all of our patients to answer ‘always’ to all of the questions.”

But many are out of our control. How can I ever effectively manage the pain of a drug addict? How can I control the quietness of the hospital if nurses are laughing, code blue, red, grays blare overhead, and alarms are going off constantly? I realize that a large part of medicine is the service industry, but how about some really important questions?

Here’s what I would like to ask the patients:

  • Did the condition for which you entered the hospital improve or go away?
  • Was the hospital bill clear and accurate and easy to understand?
  • Did a doctor explain procedures to you fully and in enough detail?
  • Was the food hot and edible?

It is essential that patient’s basic needs are met inasmuch as is possible, during the hospital stay. However, I would imagine that all of us, if inpatients, would gladly trade the waterfall in the lobby, or quiet time between 2 to 4pm, for clear nursing and physician communications, and quick response to a call bell.  Increasingly tethered to a computer, much of this becomes quite difficult. I do believe that the addition of computer workstations in the patient’s rooms does help this interaction.

HCAHPS is now mandated by ACA as part of the measures to determine hospital value-based incentive payments. Now I understand why suddenly they are so interested in these survey results. The new equation is better survey results equals more money from the government, at least now for the hospital, and maybe down the road, the doctor.

So as I ride off into the sunset of my career in private practice, I wonder how much more will be heaped upon the shoulders of physicians. After June, I won’t have to worry about HCAHPS,  ACOs, meaningful use, or ICD-10. I will be fishing.

No one will be asking the fish if I am standing or sitting.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.

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  • Dr. Drake Ramoray

    Oh, but our thought leaders disagree.

    I do hope you enjoy your retirement.

  • Ncmedic

    Bravo!!! This “pt satisfaction” nonsense has begun in the 911 ambulance world also…I suddenly feel like I’ve time-warped back to the college days of waiting tables and customer comment cards. Will gratuity be added to the bill when a critical pt arrives at the hospital still alive? Or a larger tip if they’re better off than the condition I found them in ?

    • Dr. Drake Ramoray

      On a scale of 1-5 How satisfied were you with your intubation if any was required?

      Please rate the quality of the CPR if any was performed from 1-5.

      Do I even want to know what kind of questions they are asking about the ambulance experience? All jesting aside. Working for tips is the goal. Some corp med hospitals are already basing physician pay in part on these surveys. That is the ultimate goal.

      • Deceased MD

        That is hilarious but I am sure press ganey is having a field day with it.

    • rtpinfla

      ha nice. Maybe we can start putting a tip jar on the nurses station.

  • Lisa

    As a patient, I hate the surveys I seem to get after every medical visit. They are so stupid – the questions never seem appropriate for the type of visit I had. I can’t say none of the above or doesn’t apply and I can’t write comments.

    So, it sounds like if I like the doctor, I should fill one out and give them all fives. Otherwise throw it in the trash?

    • querywoman

      From fast food to sitdown restaurants to doctors to hospitals, we are oversurveyed.
      If I did all these d@mn surveys, I’d never get anything else done.

    • SarahJ89

      I throw them away. I have no desire to support a bad system.

  • Patient Kit

    Across the board “always” ratings is a ridiculus criteria and unattainable goal. It’s like asking a baseball player to bat a thousand in 162 straight games and then playoffs. Maybe a bad analogy since I do want my docs, especially my surgeons to bat better than .300 (while I’d be happy if all my Yankees did that “always”).

    This all or nothing way for us patients to rate our doctors and hospitals is absurd. We can love our docs and feel we got terrific care but the only way our feedback counts is if we rate them as absolutely perfect in everything “always”?

    I think there is a real role for patient feedback, but this method is unfair to docs and meaningless to patients. It seems designed, not to gather any meaningful patient feedback but, as a way to document a reason to deny docs and hospitals a higher rate of reimbursement, attainable only by being rated absoutely perfect at everything “always” by everyone, even things that are beyond your control.

    As a patient, I’m not happy with this method of “listening” to me. Is there a way for patients to rate how we feel about these surveys?

    • Dr. Drake Ramoray

      You are starting from the premise that these surveys are intended to improve patient care. They are designed to reduce physician reimbursement. Why else would they ask questions that have little or nothing to do with patient care and then require a perfect score to be counted?

      • Patient Kit

        Actually, I just started from the way these ridiculous surveys are presented to us and quickly came to the exact same conclusion — that their sole purpose is to deny $$$ to docs and hospitals, not give patients a voice. I don’t think either docs or patients are dumb enough to buy the spin about these patient satisfaction surveys.

        • Dr. Drake Ramoray

          You are correct. My apologies. We are sayin the same thing. Was reading on my phone and skipped a paragraph.

          • Patient Kit

            No apology necessary. I was posting from my phone (on a crowded bumpy city bus in Brooklyn). I post a lot from my phone when I’m in dead time zones like mass transit and doctors’ waiting rooms. Nothing deters me from being a tad wordy while I get to my point. ;-p

          • DoubtfulGuest

            It was a great post, PK. I think we patients get pulled in by the fantasy that someone cares what we think. Well, I was at first. And I still stand by my statements that many patients have something useful to contribute.

            But the survey questions get increasingly comical. I saw one that I think must have been some sort of “internal validation to see if the patient is some kind of Prima donna” question, but still…was worded like:

            “My provider attended to my personal needs extremely well”.

            Hmm. It made a nice paper airplane, that survey.

          • Patient Kit

            That is the illusion they are trying to sell to patients — that they care what we think and value our input — in order to trick us into answering surveys that will provide them documentation to justify reimbursing our doctors and hospitals less. If I get a survey from a doc I really like, knowing how this really works, I’ll just go ahead and lie and say he is absolutely perfect “always” in all ways. But I’m fairly sure that most patients are clueless about what these patient satisfaction surveys are really about and will innocently rate their doc as all 5s except for one 4, thereby dooming him/her to a lower reimbursement. Sigh. I really wish the peeps who wrote and produced The Wire for five years for HBO would create a new show about our healthcare system. The Wire was one of the best TV shows ever produced. It really nailed how things really work in our various institutions.

          • DoubtfulGuest

            You are right, and I give all perfect scores these days. If I can’t, I throw the survey away. My general policy now if I have a problem with someone is to tell them directly, e.g. “I felt like last time we weren’t on the same page” and why. My example was from a long time ago, before I took the Red Pill.

  • W Joseph Ketcherside, MD

    I’ve seen a fair bit of research indicating that doctors don’t do a very good job of listening to patients. I’ve noticed in my own experience that hospitals don’t always do a very good job of paying attention to things that would improve the patient experience. And by that I don’t mean making sure the drug addict in the ER is happy with their narc prescription – I mean important things like care transitions, communication about conditions, and the like. So I think we could significantly improve our health care system if we did a better job of soliciting, assessing and acting on good feedback from patients.

    That said, surveys are really hard to do well, and I’m not so sure the ones out there now for HCAPS are the answer. All the previous commenters provide ample discussion of that.

    Also, I agree that administrators mis-use the whole process. Very few people around are 5/5 in everything they do, and to make that the standard with penalties for anything less than perfection is ridiculous.

    How do we develop a system that does a better job of gathering and incorporating meaningful feedback and patient engagement, without the bureaucrats and administrators mucking it up? And how do we get some benefit from what we are currently stuck with? Not sure throwing the baby out with the bathwater is the best solution either.

    • Patient Kit

      A good starting point would be to change the underlying ulterior motive for doing patient surveys. Unless that hidden diabolical agenda changes, patient surveys will remain meaningless.

  • EmilyAnon

    I used to think Press Ganey surveys were annonymous, but they’re not. Anyone notice the barcodes? Every form contains a checksum field, two different numeric codes plus the bar code.

    See “Invisible coding of survey questionnaires”

  • T H

    I’ve said this in a different forum, but it bears repeating: I would be very suspicious of any clinician who always had excellent scores from every patient.

    We’re not in the business of doing the nice thing. We’re in the business of doing the RIGHT thing.

  • Edward Leigh, MA

    Two words, “It’s complicated.” We still have a lot of work to do in fine tuning the surveys to gain helpful information. I do believe we get some helpful raw data. It’s a start. It’s not prefect, but it’s a start. Where I believe we get the most valuable data is via focus groups. Hospitals call them, “Patient Advisory Councils.” We need to get a group of patients in a room and ask them their thoughts — as many details as possible! Through this process we will gain the most valuable data. On a survey, a patient may give a 3 out of 5, but what is the reason? A focus group will uncover those reasons.

  • gwen rothberg

    Spot on Dr. Mokotoff – I have often wondered why we are asking these questions of patients, when sometimes the correct response to a patient’s insistence is, “No.” No, you may not take your PCA out to the parking lot to smoke. No, you may not have a cheese-steak sandwich with your Phenergan. No, you may not take that NG out. I want the questions to be indicative of actual good care. When the number one hospital acquired infection is post op pneumonia, then perhaps getting the patient up to cough/deep-breathe and do their IS is the right thing to do, no matter how much it pisses the patient off. When they are obese, they need nutritional education. When they smoke, they need cessation education. These are the issues that make the non-compliant patient the most irate and likely to slag us off in the surveys – and now we are getting paid to side step those issues? It needs a re-do. Quickly.

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