When quality of care becomes customer satisfaction demands

The new healthcare reform law appears to be using the idea of improved quality to justify the enormous expense of changing the way care is delivered in the United States.

As a justification for the need for change is the reporting currently being touted as a great measure of quality.  This information is gathered in many different ways and reported on the internet by various websites.   Two of the most widely used sets of data are HealthGrades and Hospital Compare sponsored by the Department of Health and Human Services.

HealthGrades bases its reports on information received from Medicare.  Medicare receives its data from participating hospitals throughout the country.  Each participating hospital is responsible for reporting certain “core measures” of quality identified by Medicare for a given diagnosis such as pneumonia or congestive heart failure.  The data collected is directly related to the presence or absence of the physician’s documentation in the chart of those core measures.  For example, smoking cessation is listed as a core measure for pneumonia.  If there is no documentation that the physician discussed smoking cessation during the patient’s hospitalization, that core measure was not met, even if the conversation took place but was not documented.  Core measures and HealthGrades significantly reflect documentation as much as any measure of quality.  Placing so much emphasis on the “documentation“ of quality sometimes take precedence over the performance of quality.

Hospital Compare on the other hand, uses the “HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national survey that asks patients about their experiences during a recent hospital stay. Use the results shown here to compare hospitals based on ten important hospital quality topic “.  Many of the questions are similar to what you may see from a major hotel chain: “Patients who reported that their room and bathroom were ‘always’ clean”, and “Patients who reported that the area around their room was ‘always’ quiet at night”.  Questions related to care were most often related to issues of comfort such as pain and communication with staff.  None of which is a direct measure of quality.   The other areas based on specific health conditions rely on the collection of “core measures” with its inherent error because of the need for 100% documentation to actual measure quality.  HealthGrades also offers an award for the hospitals with the best HCAHPS scores.

One area cited in both of these websites is mortality related to treatment for specific conditions, whether or not a patient was discharged alive and if still alive one month and six months after discharge.  Also taken into account is a “risk adjustment” of mortality for a given patient for each of the diagnoses studied.  This means that additional complicating conditions are added into the mix for the patient’s main diagnosis when calculating a person’s risk of death.  In other words, the sicker a patient looks the more likely they are expected to die, regardless of the cause.  If the death is expected, it doesn’t count against a hospital as harshly.

Suppose two patients come in with a diagnosis of myocardial infarction.  One patient has no other medical conditions documented at the time of admission. He or she just came in with chest pain and had a heart attack.  The other patient came in with chest pain, but the history obtained in the emergency department included diagnoses of high blood pressure, high cholesterol, diabetes mellitus, previous heart attack, and a family history of premature death from heart disease.  Which patient do you think would have a higher chance of dying?  From the patient perspective of a patient and family, it appears that the comfort related issues are most important.

Most times patients present to the hospital in an urgent or emergent situation without the chance to review the HealthGrades reports or the Hospital Compare website.  They themselves likely don’t know their own diagnosis to make a comparison, even if they had the time before their trip to the hospital. Unless the admission is an elective one, choice doesn’t come into play. So, once admitted, comfort becomes a key issue.

In my own experience, patients most often complain about pain, lack of sleep, constipation, thirst and knowing when they will be discharged.  Their families seem to have similar concerns, even if the patients can’t state it themselves.  If urgent or emergent admissions are the main entry into the hospital system, are HealthGrades and Hospital Compare merely academic?  With that in mind, it’s no wonder that customer satisfaction has become a mantra for administrators everywhere.

But these customer satisfaction efforts have made patients more demanding and families more obnoxious.  Since their concerns aren’t of a clinical nature, or related to actual care, the time spent responding to families requests take nurses, aides and physicians away from actually caring for their loved ones.  “Quality of care” for them means an empty trash can, a quiet pulse oximeter and let’s see how many times I can make you come with my finger on the call light button.  These measures of “quality” don’t measure anything except customer service demands.

I don’t believe that there is one provider who doesn’t wish for access to healthcare for everyone.  We all want quality, cost effective, efficient care for all of our patients.  What we don’t want is to spend our precious time providing non-clinical service to people who can’t, don’t and will never understand the intricacies of patient care.  Physicians have gone from a position of respect in the eyes of their patients to one of public service.

How do you think your congressman would fare in a customer satisfaction survey?

“Doc B” is a physician who blogs at One Doc’s Opinion.

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