Shift the focus from patient satisfaction to employee satisfaction


By now, everyone in health care is accustomed to the idea of patient satisfaction data and the multi-million dollar industry ($61 million in annual revenue for Press Ganey alone) which exists thanks to the health care leaders and policy makers who embrace it.  Most physicians believe it is absurd to use it as a marker of quality care, but have accepted it anyway.  We will “play the game” in order to get paid for our work.  Although high patient satisfaction scores have been proven to be a poor indicator of quality care, and in some studies have been proven to increase morbidity and mortality, they are already so entrenched in U.S. health care that it will prove difficult to impossible  to uproot the established practice of satisfaction data collection.  The absurdity of using patient satisfaction data as a clinically helpful metric has been exposed in numerous well done studies and articles.  “Why Rating Your Doctor Is Bad For Your Health” is a fantastic example.

It doesn’t matter that this data is clinically useless.  The fact that it is easily obtained and tabulated has led our policymakers, politicians, and health care administrators to assign it great value.  It would be very difficult to painstakingly comb through individual patient charts and determine true quality, while it is quite easy to send out lots of surveys and make a spreadsheet.  Without a tectonic shift in policy, it will determine reimbursement and compensation levels for years to come.  When it comes to the assumption that satisfaction data is clinically important, we as physicians cannot seem to change perception by shouting that the emperor isn’t wearing any clothes.

Perhaps a shift in our approach is in order.  I was intrigued by a recent article I read about the management  strategy of Southwest Airlines, and I would encourage all of those in health care (especially administrators) to read it.  It is the most elegantly simple, yet effective strategy for high customer satisfaction I have come across.

The bottom line is that Southwest values its employees as its greatest asset.  Employees are provided with a work environment in which they feel safe, supported, comfortable, and respected.  Southwest realizes that a small percentage of their customers will simply never be satisfied.  These bad apples will always complain about something.  Many are surely trying to get something for free, some are just dysthymic, like Eeyore of Winnie the Pooh.  Southwest sides with its employees in these cases.   The customer is not always right.

The same should be true in health care.  Doctors, nurses, ACPs, and other health care staff come to work to help people and make them healthier and happier whenever they can.  Most of the time, the relationship between hospital staff and patient (or family) is a mutually respectful one.  When it is not, morale and employee satisfaction suffer if administration adopts a “customer is always right” approach.  This simply isn’t true, and it leads to resentful and anxious employees.

In the emergency department where I work, there is a crisis of nurse attrition.  I believe it to be due to the work environment, which each day brings increased patient loads and acuity, yet is not met with commensurate increases in support.  This trend is making our department less safe for patients, creating a more toxic work environment, increasing wait times, and defacing the holy grail of patient satisfaction.  It would make the most sense to work toward retention of talented nurses by spending the money to staff up and improve morale by providing a more supportive environment.  If administrators can do that, just sit back and watch as the patient satisfaction scores climb.  Don’t tell us that you don’t have the money — we all see the hospital profits and administrator salaries in the news.

Thomas Paine is an emergency physician.

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