Pleasing the patient vs. saying no

The patient in Dr. William P. Sullivan’s emergency room in suburban Chicago asked him to write a note excusing her from work because of an unsightly pimple on her nose. He said no, but later he wondered: Would the refusal, even if it were clinically and ethically appropriate, result in a ding to his department’s patient satisfaction rating?

“People get mad and you think, ‘Great. There goes another bad score,'” he said.

The anecdote is recounted in an American Medical News story that explores what seems to be a source of growing tension between doctors and patients: providing care that’s appropriate vs. pleasing the patient.

This is by no means a new issue. Doctors have always had to deal with patient expectations for care that are not necessarily warranted – antibiotics for a viral infection, for instance, or imaging tests with a low likelihood of yielding any useful information. What’s different these days is that physicians, and the organizations they work for, are increasingly being graded on patient satisfaction and paid accordingly.

From the American Medical News article:

Nearly two-thirds of hospitals, health systems and large physician groups have annual incentive plans for doctors, said an October 2011 report from the Hay Group, a Philadelphia-based management consulting firm. Sixty-two percent of those use patient-satisfaction metrics as a factor, up from 43% in 2010, said the survey of 182 health care organizations covering physicians in 144 medical specialties. Many set base pay lower and require doctors to meet performance metrics to earn hefty incentive pay.

“Bonuses of less than 5% don’t get anybody’s attention. Make it 5% or 10% or 15%, and that’s a sufficient financial opportunity to get your attention,” says Ron Seifert, vice president of the Hay Group. “We’re going to see more of this.”

To add to the motivation to get serious about patient satisfaction, Medicare also has begun paying for and publicly reporting performance measures. Patient satisfaction ratings account for 30 percent of the overall score; hospitals and physicians who fall short will see a percentage of their payments withheld. In other words, if patients are unhappy with the care they’re receiving, the penalty to providers will be a smaller paycheck.

Is patient satisfaction such a bad thing? It’s no secret that health care hasn’t always been well attuned to the patient’s perspective. In many ways, the emphasis on patient satisfaction is a long overdue effort to place the focus of health care where it belongs: on patients themselves. If providers consistently receive low scores from patients, it’s probably a sign that there are some issues in need of addressing. Tying it to financial incentives simply puts more skin in the game.

There’s valid debate, however, over the extent to which patient satisfaction ratings accurately reflect quality of care and how much they should influence the size of the provider’s paycheck. Are patients receiving quality care when the doctor agrees to their request for a CT scan for a headache, even though the imaging study is expensive, exposes the patient to radiation and is probably unnecessary? What about people who are likely to be unhappy regardless of the quality of the care they receive?

The connection between the doctor’s refusal of an inappropriate patient request and the likelihood of a low patient satisfaction score in fact is not entirely clear. That’s why a Wisconsin physician who specializes in addiction medicine is designing a study to examine this relationship more closely.

Dr. Aleksandra Zgierska, an assistant professor with the University of Wisconsin School of Medicine and Public Health, told American Medical News that decisions about prescribing narcotic pain medicine are a “day-to-day conundrum” in her practice. “The challenge is how do we discuss this with the patient so the patient doesn’t leave unhappy… Saying yes is easy. I know from firsthand experience that it’s very tempting,” she said.

Her study will look at the prescription of opioid pain medications and whether it correlates to patient satisfaction ratings.

Of the handful of other studies that have explored this issue, the one that has received the most attention appeared earlier this year in the Archives of Internal Medicine. It found that patients who gave the highest satisfaction ratings also had higher prescription drug costs, were more likely to be hospitalized and had worse outcomes – but the researchers could not definitively establish why this was the case. Although it might be assumed (and this indeed was the conclusion that many people seemed to draw from the study) that these patients were happier because they were receiving lots of prescriptions and hospital care, whether it was warranted or not, this remains just that: an assumption.

Turning down requests for inappropriate care may in fact not be the no-win situation that doctors fear, the American Medical News article suggests:

Experts agree that saying no does not have to mean an unhappy patient. They say that listening with empathy to a patient’s concerns, reviewing options in an evenhanded, nonjudgmental way, emphasizing the undue risks of nonbeneficial interventions, asking the patient to defer a decision, and even sitting down with the patient – instead of standing – can help.

It’s possible that many patients might actually welcome the discussion and ultimately leave the exam room feeling better informed about the decisions that were made.

The real issue seems to be one of balance. How can providers deliver quality care without compromising for the sake of a good patient satisfaction score? How can the patient experience be meaningfully valued without compromising other important measures for how providers ought to be paid? Regardless of the imperfect metrics that currently exist, these are questions that demand some thought.

Negative moments of truth

Regardless of what industry you’re in, customer service matters. But if a recent new study is any indication, it especially matters in health care.

The findings by the PwC Health Research Institute are pretty interesting:

– 42 percent of the 6,000 survey participants said personal experience, rather than price, was their most important consideration when choosing a health care provider.

– Personal experience was 2.6 times more important in choosing a doctor or hospital than for other industries, and peer recommendations were twice as important. (Banking, airlines and the retail and hospitality industries were among the industries used for comparison.)

– Six out of 10 health care experiences were defined by the attitude of the staff, making this twice as important in health care than in any other industry.

There are two conclusions to be drawn: Patients value having a good health care experience above all else, and they value it more than a good customer experience at, say, a movie theater or retail store. The report calls it “moments of truth” – the experiences that can cause customers to either love the organization or loathe it.

If I worked in health care, I would sit up and take notice of this survey. For organizations that already place a priority on patient-centered care and the patient experience, it validates that they’re on the right track. And for organizations that aren’t quite there yet, it’s a warning that they’d better start giving more consideration to what matters to their customers.

For what it’s worth, many health care organizations do get it right when it comes to the patient experience. It shows in details such as the receptionist who brings a form to the patient in the waiting room rather than summoning him or her back to the desk. It shows in the hospital housekeeping staff who ask, “Is there anything else I can do for you?” before exiting the room. It shows in the attention being paid nowadays to privacy and dignity, to explaining things to patients before sticking needles into them or subjecting them to a procedure. It shows in more courtesy, more respect and even more interest in what patients think via surveys and feedback.

Although plenty of health care organizations already did this to some extent, it was often hit-or-miss, and it tended to be seen as an added-on nicety rather than essential. This approach doesn’t seem to cut it anymore. The PwC survey found that people were not very forgiving of bad health care experiences – so-called negative moments of truth –  and one-third said they would switch providers if they thought they would have a better experience elsewhere. For those in health care who wonder why public sentiment is sometimes so angry and hostile toward them, this finding helps partially explain why. And as reimbursement increasingly becomes tied to patient satisfaction, the patient’s experience is going to matter whether providers are ready for it or not.

There’s in fact a fair amount of ambivalence in health care about how far the patient satisfaction thing can be carried. Does it mean that the patient’s every whim should be catered to, regardless of whether it’s medically appropriate?

Give health care workers a break, grumbled a registered nurse on the Hospital Impact blog: “It is difficult enough to deal with the increased acuity of illness of the patients but the demands the families are putting on the staff, wanting extra blankets for family, water, food, etc. are taking time away from their loved one. Where does it end?”

Yet is this really what’s meant by “the patient experience”? Or does the patient experience encompass something more?

An article appearing earlier this month in American Medical News tackles this issue by talking to Dr. Mark Friedberg, an internist and researcher at RAND Corp., who says clinicians can deliver good care while also providing a good patient experience. “I don’t think it’s unreasonable to ask clinicians to meet multiple goals,” Dr. Friedberg told American Medical News. “It is possible for highly trained professionals to be excellent in all respects.”

Of many nuggets of information contained in the PwC report, one stands out: Individual attitude is everything. Providing a good patient experience is partly about organizational culture but it also comes down to individual interactions between patient and staff. A handful of people who are caring and competent in their dealings with the patient can help redeem an organization that’s mediocre when it comes to the patient experience. Likewise, one staff person’s abruptness or missteps can undo everything else the organization is doing to improve the patient experience.

It’s not clear how well this lesson has sunk in. Recent new research by HealthLeaders Media suggests that although most hospital executives see the patient experience as a priority, more than half have yet to make a specific investment in bettering the patient experience in their hospital or health care system.

That health care is even talking about the patient experience, let alone making it a priority, is a measure of the progress being made. As recently as 10 years ago, it was only beginning to register on the radar screen in a meaningful way. But expect many more negative moments of truth along the way as health care struggles to change longstanding attitudes and practices in the business of providing patient care.

Rethinking the medical home… again

The medical home model, seen by many as a solution to what ails primary care, continues to receive mixed reviews suggesting it may not be living up to its promise.

The latest dose of reality comes from two new studies which found that primary care medical homes 1) don’t necessarily save money; and 2) don’t increase patient satisfaction.

A little background is in order. The medical home – or, to be more complete, the patient-centered medical home – is a model developed by the National Committee for Quality Assurance to improve the delivery of primary care. Its principles are team-based care that’s coordinated, makes effective use of information technology and tracks how the patient is doing over time.

When correctly implemented, it’s supposed to improve patient care, especially for chronic conditions, by ensuring patients don’t fall through the cracks. The model also is designed to make better use of medical resources by assigning responsibility for patient care to a team that includes nurses and mid-level practitioners as well as physicians. At last count, about 4,000 medical practices in the U.S. have adopted this model.

In theory the medical home sounds terrific – the patients win, the staff wins, the practice wins. In reality the picture is less clear.

Take the study that recently appeared in the Journal of the American Medical Association, examining the relationship between quality of care and operating costs at patient-centered medical homes. Researchers at the University of Chicago found that medical homes with higher quality ratings also had higher operating costs – $2.26 more per patient per month, to be exact. This may not sound like much but over the course of a year it could add up to half a million dollars or more.

A couple of caveats are in order. First, this study only involved federally funded health centers, so the results might not apply to a privately owned medical clinic. Second, it focused primarily on cost, hence may not have fully captured the relationship between cost and value.

It provides a glimpse, however, of the fiscal dynamics that may underlie the medical home model once it’s implemented. Among policymakers who support the medical home concept, much of the emphasis has been on the cost savings that will result with fewer visits to the emergency room, fewer hospital admissions and so on. While this may save money for the system as a whole, it might not necessarily save money for the primary care clinics who are doing much of the work.

A bigger issue, at least from the public’s point of view – and one I’ve blogged about before – is whether patients like the primary care medical home.

Some of the early results aren’t encouraging. At the handful of demonstration sites that piloted the medical home model, patient satisfaction actually declined. And a new study, published last month in the Health Services Research journal, reached a similar conclusion: When 1,300 patients were surveyed about their experience at practices that had adopted the medical home model, they weren’t more satisfied.

American Medical News offered this take on the findings: Perhaps the medical home model is more about policy wonkery and behind-the-scenes restructuring than about improving the patient’s actual experience of care.

Most of the process “has been focused on talking with researchers and with academics and with clinic executives, and looking to see what makes a clinic effective, what makes the processes efficient and what makes them better able to track patients,” Dr. Robin Clarke, an assistant clinical professor at the University of California in Los Angeles, told American Medical News. “We haven’t spent a lot of time talking to patients about what they perceive to be patient-centered care and what they want to see in a primary care practice.”


Some months ago I was conversing with a health insurance executive when the topic turned to the medical home model. He was enthusiastic about how wonderful it was for patients. But when I pointed out that some surveys showed a decline in patient satisfaction, his response was, “Oh, people just don’t like seeing someone different,” i.e. a nurse or physician assistant instead of the doctor.

I can think of many reasons why team care might be problematic for patients, not least because of the potential for poor communication or fragmentation of care. Maybe patients instinctively sense this, or maybe they’ve actually experienced it. Either way, why wouldn’t their perspective matter?

Regardless of whether people know or care about the medical home model, their chances of encountering it are growing. Here in Minnesota, there are now 170 medical practices that are certified as medical homes, providing care for two million people.

If some of the early studies suggest the model isn’t all it’s cracked up to be, it doesn’t necessarily mean the concept is fatally flawed. Perhaps it just takes time to learn from mistakes and allow the model to mature. At the very least, however, we might want to proceed with caution.

Patient satisfaction: Deadly to your health?

Do patients truly benefit when health care providers pay attention to the patient experience?

A rather startling new study suggests otherwise. In fact, researchers found that the patients who were the most satisfied with their care also had higher prescription drug expenditures, were more likely to be hospitalized and more likely to die.

How can this be?

Predictably, many in health care are saying “I told you so.” The increasing emphasis on patient satisfaction as a measure of quality care has never sat well with some clinicians – for instance, the anonymous doctor who offered this online reaction to the study’s findings: “Now that the ‘patient satisfaction’ industry has taken root, we will continue to waste billions and billions of dollars on this each year, money that could have gone towards providing genuine health care.”

It’s a valid question to ask. Intuitively, you’d think that when patients are happier with the care they receive, they’re more likely to have a good relationship with providers, more likely to be engaged in their care, ask questions, follow directions and have better outcomes. But whether this is actually the case hasn’t really been tested rigorously enough to prove it; it’s gut instinct, not science.

Let’s back up for a minute and see what the study says. It was published this week in the Archives of Internal Medicine and involved data on cost, health care utilization and patient satisfaction scores for 51,946 adult U.S. patients.

Among the key findings:

– Patients who reported the highest satisfaction with their care were more likely to be hospitalized than patients who were less satisfied.

– Higher patient satisfaction was associated with higher prescription drug costs and higher overall use of health care services, but lower use of emergency rooms.

– Patients who were the most satisfied had a 26 percent higher mortality risk, even after the study’s authors excluded patients who had three or more chronic conditions and who had self-rated their health as poor.

The authors offer several possible explanations for their findings. Patients often expect – and demand – unnecessary drugs and tests, and they’re more satisfied when doctors cave in and give them what they want, even if this amounts to inappropriate or possibly harmful care, the researchers suggested.

Or maybe patients who received more care also were more reliant on their doctors and hence reported higher satisfaction, although the study’s authors note this doesn’t really explain the apparent connection between higher utilization and more patient satisfaction.

I’m not sure what to make of all this. But with all due respect to folks like uberblogger Dr. Kevin Pho, whose headline this week proclaimed, “How patient satisfaction can kill,” I don’t think this study offers proof that efforts by the health care industry to be more customer-centered are bad for patient care.

Patient satisfaction and clinical outcomes are not the same thing. Although there may be a link between the two, this is a far cry from establishing cause and effect.

Perhaps the real issue is that patient satisfaction, at least in some people’s eyes, has somehow become conflated with giving patients whatever they want. Would patients themselves define it this way? I’m not sure they would; they’re often more likely to use words such as “caring,” “compassionate,” “respectful,” “understanding” and “listens to me” when they describe what makes them satisfied.

Perhaps clinicians are judging on the basis of a different scale. Patients can be surprisingly tolerant of a less than stellar outcome – in other words, more satisfied – as long as they feel they’ve been treated like a human being. Clinicians, on the other hand, might be more apt to see a negative outcome as a failure, period.

Maybe we’re simply not very good yet at measuring patient satisfaction, or we’re using indicators that aren’t particularly meaningful. (Who’s selected to fill out those patient satisfaction surveys anyway? I have never, ever been asked to fill one out.)

If health care leaders focus on patient satisfaction to the exclusion of all else, then yes, it has the potential to be detrimental and even harmful. And clinicians who order drugs and procedures in the belief this is what’s needed to make patients happy (and keep their own satisfaction scores high) are not doing any favors for patient care.

But let’s not allow this study to persuade us to throw out the baby with the bathwater. The collective gut feeling of patients like me is that, on some level, caring about patient satisfaction truly does matter.

The satisfaction gap

For all the talk about patient satisfaction and patient-centered care, it seems many clinicians don’t really know what their patients want or expect – and often don’t even ask them.

The British Medical Journal: Quality and Safety recently published the results of a rather intriguing survey that reveals a pervasive blind spot when it comes to understanding and managing patient expectations. Of the 1,004 survey responses from clinicians at four academic hospitals in Denmark, Israel, the U.K. and the United States, nearly 90 percent said it was important to ask patients about their expectations but only 16 percent reported actually doing so. Moreover, four out of five felt they were inadequately trained to manage patient expectations.

I’m not sure how well these findings reflect general attitudes by clinicians toward patient satisfaction; this was a relatively small study, after all. It highlights a persistent disconnect, however, between patients and the health care system – namely, that those who work within the system often don’t really know what patients want and don’t take the time to ask.

Which raises the larger question: Is this because they simply don’t know how, or is it because they don’t buy into the concept of patient satisfaction to begin with?

There’s considerable debate within health care about the extent to which patient satisfaction should matter. Should it determine how much hospitals get paid? Should it determine how much physicians are paid?

For an example, look no further than the testy discussion taking place at Kevin, MD, in response to a guest entry by Steve Wilkins, a consumer health behavior researcher and former hospital executive, about patient-centered care.

Much of health care remains strongly provider-driven, Wilkins points out. Allowing patients more involvement in their care doesn’t mean letting them call all the shots, he writes; “it simply invites them into the party and gives them a place at the table. As providers, we don’t do a good job of listening to patients. We do an even worse job when it comes to acting on what patients tell us they want.”

“What’s missing from medicine is NOT more time spent eliciting patient opinions about their care,” retorted a psychiatrist. “A patient is no more a partner in their care than I am a ‘partner’ of my auto mechanic when he adjusts my timing belt.”

Someone else scoffed, “This is ridiculous and a reflection of our increasingly entitled and whiney society.”

Can you say “doesn’t get it”?

Fortunately, there seems to be a growing number of institutions and clinicians who do get it, or are at least trying. It’s interesting to note that in the British Medical Journal survey, the vast majority of the doctors and nurses who were surveyed believed it was important to know what their patients want. Where they most often fell short was in putting their beliefs into action, suggesting that part of the gap in meeting patient expectations may lie in a lack of skills or confidence to address this.

In fact, the researchers found that when clinicians had both a good level of awareness and the right training, they were much more likely to ask their patients what they wanted. The study also found that the best performance was in Denmark, where national health policy has emphasized patient satisfaction for the past decade.

Far from being a social nicety, patient expectations and satisfaction seem to matter on measures that really count. When expectations go unfulfilled, they are “associated with poorer satisfaction, low clinical guideline adherence and poor overall health outcomes,” the researchers wrote. “Consequently, a growing body of evidence supports the importance of identifying and addressing patients’ expectations.”

In pursuit of patient satisfaction

If a new report from HealthGrades is any indication, hospitals are making progress on the patient satisfaction front.

Using the federal government’s Hospital Consumer Assessment of Healthcare Providers and Systems survey data, HealthGrades found a 1.8 percent annual increase in the number of positive responses.

Some areas especially stood out. Patients who participated in the survey were most satisfied with the instructions they received when they were sent home from the hospital. They were least satisfied with the explanation of the medications they were being given and with the quietness of their hospital room.

Hospitals who performed among the top 10 percent were more likely to have patients say they’d recommend the hospital to their family and friends.

(A couple of notes about the methodology: The HCAHPS data were obtained from the Centers for Medicare and Medicaid Services and covered the period from April 2009 to March 2010. Patient satisfaction data was analyzed from 3,797 U.S. hospitals.)

What’s interesting about this analysis is how the hospitals stack up in comparison to each other. The HealthGrades report notes that 80 percent of survey participants at the best-performing hospitals would recommend the facility to others, compared to 55 percent of respondents at the worst-performing hospitals. That’s a sizable gap, and it indicates some hospitals clearly do better than others at meeting patients’ expectations – or maybe what it really means is that these hospitals are better than most at creating a culture that fosters positive patient experiences.

You could argue that the high-performing organizations have simply figured out how to game the system, or that their patient population is easier to please The analysis in fact revealed geographic differences in the degree of patient satisfaction. Patients in the Upper Midwest were the most likely to give their hospital a good rating, while those from the urban East Coast were the least likely to be satisfied – a case of Minnesota Nice vs. Noo Yawk aggression, perhaps.

A study by Press Ganey, one of the leading private organizations for conducting and analyzing patient satisfaction data, found that the time of the year can make a difference too. Patient satisfaction scores tend to drop during the winter months, the company found, speculating this may be due to a combination of the weather, higher hospital occupancy during winter and issues with patient flow.

I suspect it isn’t by accident, though, that some hospitals are better at achieving patient satisfaction. Those who study the success stories have found these hospitals usually have several ingredients in common:

– They emphasize patient education and communication.

– They pay attention to details such as room temperature, food service, noise levels and the cleanliness of the hospital environment.

– They consistently track performance metrics to identify and address weaknesses and/or emerging problems.

– They have made patient satisfaction one of the key values of their organization and have embraced it from the top down and the bottom up.

– They view patient satisfaction as an ongoing goal.

– They create a supportive environment that helps staff do their best.

In other words, what it generally comes down to is organizational culture.

Hospitals don’t need to be large or have a ton of resources to achieve this. When the HealthGrades report singled out those whose HCAHPS scores placed them in the 90th or better percentile last year, the list in Minnesota was dominated by non-metro hospitals: Willmar, Alexandria, Faribault, Red Wing, St. Cloud and Waconia, to name a few.

If you looked at each of these hospitals more closely, you’d probably find varying sets of factors that contributed to their high patient satisfaction scores. But what they more than likely have in common is a core philosophy that patient satisfaction matters, and it’s this that seems to set the high-performing hospitals apart from the rest of the pack.

Photo: Wikimedia Commons

Telling the patient’s story

I don’t know very much about Ginny, other than her name. But after seeing her video on You Tube, I certainly know her story: how a seemingly straightforward ankle fracture escalated into a nightmare of complications and ultimately the loss of part of her leg.

Ginny’s story and video were shared by Maureen Bisognano, chief executive of the Institute for Healthcare Improvement, during a visit to Willmar last month to speak to a statewide nurse educators’ conference:

It was impossible for the audience not to react as Ginny described the consequences of a hospital-acquired infection that spread to the bone in her leg. People literally gasped at each new medical disaster that piled onto the patient: 28 surgeries over the course of five years, an amputation that failed to remove enough damaged tissue and bone and required a second surgery during which Ginny went into respiratory arrest.

She’s not angry, or at least doesn’t sound angry. She’s honest, though, when she says on camera that this experience “has altered my life forever.”

Why did she decide to make a video about it? Because, Maureen Bisognano explained, “she felt like nobody understood Ginny’s story.”

Think about that for a couple of seconds. Here’s a patient who has clearly had intensive contact with the health care system – but of all the well-meaning clinicians with whom she dealt, apparently none of them really knew or thought to ask about the entire experience from start to finish, what it was like for the patient or the permanent damage a preventable hospital-acquired infection wrought on her life.

In the drive to make health care safer, better and more efficient, where’s the voice of the patient?

I bring this up because the industry is increasingly moving toward payment based on “value.” One such effort is under way with the Medicare program, which is finalizing the details to tie part of its hospital reimbursement formula to patient-satisfaction scores. If routine surveys show patients are dissatisfied with the care they receive, hospitals might not be eligible for reimbursement bonuses.

There’s clearly a place for standardized surveys. They provide useful, consistent information for hospitals, and they help organizations benchmark themselves against their peers.

But I’m not sure any HCAHPS survey or Press Ganey questionnaire could have captured Ginny’s story or the thousands of other stories that expose what the patient experience is really like. For that, you need to leave the world of statistics and consciously seek out and listen to what patients themselves have to say – and not just about the good experiences but also about the bad. Especially the bad, because this is where some of the greatest opportunities for learning often lie.

Here, for instance, is Dr. Ramona Bates, a plastic surgeon from Arkansas and blogger at Suture for a Living, who recently blogged about her husband’s colonoscopy and her frustration with poor communication by a nurse:

When I was called back by the nurse, she mispronounced my name calling me Rhonda (which I forgave easily). She did not introduce herself to me.

As we entered the recovery area, she did not take me to my husband and assure me he was okay. She took me to the desk and abruptly said, “You need to sign this.”

No explanation of what “this” was, so I replied, “What is it I am signing? I don’t sign anything until I have read it.”

She then said, “It’s the discharge instructions. He’s already been given them.”

Note she had not reviewed them with me. I would be the caregiver. Note also that I had no way of knowing if she had reviewed them with my husband (who is not an engaged ePatient Dave) prior to sedation or in his current state of post-sedation fogginess.

She said, “Sign it when you’ve read them then” and quickly moved on to some other task. I felt like a box that was simply being checked off.

Patient handoffs are well known to be a vulnerable point on the continuum of care. Yet without drilling down to the level of patient and family stories, it can be very hard to uncover specific issues that need to be addressed and improved.

Here’s another story, this one from Anthony Cirillo at the Hospital Impact blog, who writes about his mother’s hospitalization. Cirillo has been in the hospital industry for 25 years but he writes that “you truly don’t know what is going on until it happens to you.”

The “defining moment” during his mother’s hospital stay and surgery: when someone from the finance department approached the patient while she lay in her hospital bed, waiting for a high-risk surgery, to discuss how she was going to pay her Medicare deductible.

Cirillo writes:

… Most of us who work in healthcare don’t know “jack” about how it is really delivered. Keep your metrics, those consultants who want to come in and show you how to score better to attract patients, and all the rest of the positioning.

Hospital marketing comes down to word of mouth, and that word of mouth is generated from the experience that people have at the facility. And if any one component breaks down it will affect perception, reuse, and of course impact the ultimate question – will you recommend us to others?

Hospitals and clinics can’t and shouldn’t design their services on the basis of anecdotes. But organizations that are tone-deaf to individual patient stories are missing an important chance to learn about gaps and vulnerabilities in the system – gaps that are frequently masked by standardized metrics such as patient satisfaction surveys and that are allowed to persist because no one is capturing this information.

I’ve blogged here previously about an adverse event I experienced several years ago. Not one single clinician has ever asked to hear the story of what happened. If they had, they might have learned something about the sequence of events and how this situation could have been prevented or at least mitigated. They might have learned something about the patient’s perspective when things go wrong and how to make a negative experience a little less negative.

When organizations rely too much on standardized surveys and data collection to measure their performance, the risk is that they’re not getting the full picture. They’re not seeing health care as the patient experiences it in all its good, bad and sometimes ugly reality. Moreover, they’re failing to make use of one of the richest sources of information available – stories from patients themselves.

Most patients, I suspect, are more than willing to talk about their experiences – not because they want to bash or be critical, but because they see an opportunity to help systems change and become better. What they have to say can be illuminating and motivating – if health care organizations would only recognize the value and take the time to listen.

Those difficult patients

Admit it: Every so often you secretly wonder if your doctor thinks you’re a difficult patient.

Now you can calculate your odds, sort of. The Journal of General Internal Medicine recently published a study that attempts to quantify how many patients are considered difficult and what makes them so.

The researchers surveyed 750 adult patients who visited a primary care walk-in clinic at Walter Reed Army Medical Center in Washington, D.C., from 2005 to 2007. The patients were assessed for issues such as symptoms, expectations, functional status and the presence of any mental disorder. After their visit with the doctor they were surveyed two more times – as they were leaving the clinic and again two weeks after the visit.

Clinicians were surveyed as well to measure their perception of the visit and to rate each of the 38 participating doctors on their psychosocial skills.

Previous studies have estimated that up to 15 percent of patient encounters are perceived as difficult by clinicians, and this study was no exception. It put 17.8 percent of the patients in this rather undesirable category. If you do the math for a physician who sees, say, 35 patients a day, an average of three to five of those encounters will be considered difficult.

What made these patients difficult? A whole range of things, apparently. They were more likely to have five or more symptoms, more likely to report being stressed, and more likely to have depression or anxiety. They also were less likely to trust the doctor or feel satisfied with the visit, and less likely to report improvement in their symptoms two weeks after the visit. Other behaviors such as disrespect or belligerence can make the encounter difficult too, of course, but what made this study especially interesting was how it sought to identify some of the less obvious contributing factors.

Lest you think this is a one-way street, the researchers analyzed the surveys filled out by the participating physicians and came up with some conclusions about the doctors as well, namely that physicians who viewed certain patients as difficult often had less experience and fewer psychosocial skills.

In a companion article that appeared this week in American Medical News, one of the study’s co-authors, Dr. Jeffrey L. Jackson, suggested that physicians who were older and more experienced probably have a better perspective on dealing with patients whom they perceive as difficult. His advice: Younger doctors need to accept that some patient encounters will be challenging and should learn how to manage these visits more smoothly.

A few thoughts come to mind. First, patients with complex medical needs often are seen as difficult, a finding confirmed by other studies as well as this one. (Is “difficult” even the right word? Or is it more accurate to call these patients “medically challenging”?) It can take a lot of work and repeated visits to sort through and manage all their issues, as this vignette from the American Family Physician journal illustrates all too clearly:

A 45-year-old woman is being treated for depression, chronic daily headaches, type 2 diabetes, hypertension, and hyperlipidemia. She is taking eight prescription medications. Multiple antidepressants have been tried without improvement in her depressive symptoms. Her blood sugar level remains out of target range. She does not exercise and admits to overeating when feeling depressed. She discloses difficulties with her employer and says her headaches are worsening because of stress. Her weight is slowly increasing.

Were I this patient, I’d be frustrated, stressed and unhappy too with the lack of progress – but let’s face it, it’s frustrating for physicians as well, who tend to be programmed for success rather than failure.

It’s not surprising that patient acuity has become one of the issues of contention in the push to assign more primary care to nurse practitioners and physician assistants. Doctors often are reluctant to have mid-level professionals skim off the more straightforward cases, leaving the physician to manage all the patients whose needs are complicated. Even when doctors are up for the challenge, it can become overwhelming and lead to burnout when they’re forced to function at their utmost cognitive capacity all day long – particularly when their patients’ health shows little sign of improvement.

A second observation: Psychology seems to play a role in making some patients more difficult, suggesting there needs to be greater attention to this aspect of the patient’s health.

And third, sometimes it isn’t specifically the patient or the doctor who’s the problem, it’s the health care system itself. Fewer doctors (especially in primary care), more patients and shorter visits make it harder for doctors and patients to develop trust in each other, form a solid relationship and adequately address all the patient’s concerns. These “soft” objectives can be just as important as the concrete goal of improving the patient’s health, but they often take more time than most systems allow. The result? Everyone’s dissatisfied and the situation is that much more likely to become what doctors and patients dread alike: difficult.

The hospital amenity wars

Do private rooms, luxe bedding, massage therapy and WiFi mean you’re getting better hospital care?

Not necessarily. But for a growing number of consumers, hospital amenities (or lack thereof) seem to be an increasingly important factor in their choice of hospital.

An article last week in the New England Journal of Medicine describes this emerging trend, comparing it to the medical technology arms race that predominated in the 1970s and 1980s:

Now, yet another style of competition appears to be emerging, in which hospitals compete for patients directly, on the basis of amenities. Though amenities have long been relevant to hospitals’ competition, they seem to have increased in importance — perhaps because patients now have more say in selecting hospitals. And the hospital market is booming. National spending on hospitals exceeded $700 billion in 2008 and is growing rapidly.

The authors cite an example: the new $829 million Ronald Reagan UCLA Medical Center in Los Angeles, which opened in 2008 and boasts “private and family-friendly rooms, magnificant views, hotel-style room service for meals, massage therapy.” Patients obviously like it, because UCLA Medical Center has seen a 20 percent increase in the number of patients who say they would definitely recommend the facility to their family and friends.

This isn’t necessarily a bad trend. For too long, hospitals paid little attention to the extras that might help make a stay in the hospital more comfortable. If patients disliked sharing their room with a stranger or had a window with a view overlooking a brick wall, well, too bad. They were patients in a hospital, not guests at a luxury hotel. These days the thinking has changed, boosted by a fair amount of research showing that patients and families tend to feel less stressed and are better able to start the healing process when they’re in an environment that’s quieter, soothing and more home-like.

Here’s the question, though: Is the emphasis on amenities going too far, possibly at the expense of clinical quality?

When the authors of the NEJM article examined survey data, they found many patients valued nonclinical extras far more than the actual clinical care. In one survey, patients said they were willing to travel farther to a hospital that offered more amenities, even if the care was no better than at a hospital closer to home.

Hospital amenities seemed to be a factor in physician referrals as well, the study’s authors wrote:

Physicians said that when deciding where to refer patients, they placed considerable weight on the patient experience, in addition to considering the hospital’s technology, clinical facilities, and staff. Almost one third of general practitioners even said they would honor a patient’s request to be treated at a hospital that provided a superior nonclinical experience but care that was clinically inferior to that of other nearby hospitals.

It’s easy to criticize hospitals for investing in fancy amenities that don’t contribute directly to patient care. The fact is, however, that consumers want and even expect amenities. Hospitals that don’t offer these extras can place themselves at a serious competitive disadvantage. On some level, then, amenities and their role in the patient experience do matter.

As the NEJM article’s authors point out, hospital amenities also have implications for how hospitals are paid and how quality of care is measured. If payment becomes more value-based, we need to figure out what amenities are worth and how they should be weighed against cost and clinical excellence.

If the cost is higher and the quality of care is average, is it really a bargain for patients to choose a hospital on the basis of its hotel-style rooms? Or is the consumer better off selecting a hospital that’s perhaps a little less glitzy but consistently scores high on quality measures? Is it possible for hospitals to do well in all three areas – cost, quality and amenities – without being forced to make some tradeoffs?

What do readers think? Would you travel to receive care at a hospital that’s “nicer” even if your hometown hospital offers the same quality of clinical care? Would you choose a hospital with more amenities if you knew it would cost more? Leave your responses in the comment section below.

Image: lobby of the Four Seasons Hotel, downtown Miami. Courtesy of Wikimedia Commons.

The patient experience

Do hospital executives care whether patients have a good experience in the hospital? The answer, according to a recently released HealthLeaders Media survey, is that they do.

But it might not always be evident because efforts to enhance what’s known as “the patient experience” often fall short, the survey found. The subtitle of the report says it all: “When it comes to patient experience, executives are enthusiastic, ambivalent and a little clueless.”


More than 200 top-level hospital executives responded to the survey, which attempts to identify what hospitals are doing to increase patient satisfaction and the obstacles that are getting in their way.

One of the most interesting findings of the survey is the importance that hospital leaders place on giving patients a high-quality experience:

Nearly 90% of the top-level healthcare executives said that patient experience is either their top priority (33.5%) or among their top five priorities (54.5%). And when we asked them about their priorities five years from now, even more made it their No. 1 pick. Forty-five percent predicted that patient experience would be a top priority in five years; another 50.5% said it would be in their top five.

The number of respondents who said patient experience would not be a priority at all in five years? Zero.

One of the most discouraging findings, alas, is that what the executives are saying and what they’re actually doing are two different things.

Consider: The majority have a budget of less than $50,000 this year for initiatives to improve the patient experience. Eleven percent had no budget at all for these initiatives. Many of the respondents seemed unclear on whose responsibility it is to lead patient-experience initiatives; fully one-fifth said no one at their hospital was in charge of this. Other issues that were cited included a lack of buy-in by the employees and a lack of an overall plan.

What’s more, there seemed to be little innovation. Most of the survey participants said they observe and adopt best practices occasionally or focus on sustaining and improving what they’re currently doing for patient satisfaction.

Finally, the survey respondents expressed plain old confusion about what “the patient experience” is supposed to be. Is it the same as patient-centered care? Does it mean consumer-driven care? Or is it just a fancy version of customer satisfaction? Although many of the respondents equated “the patient experience” with “patient-centered care,” others who study this issue say it’s much more than this.

If the written comments submitted by many of the survey participants are any indication, most of them understand why the patient experience should matter. “Patient satisfaction brings the patient back to the organization,” one person wrote. “We know there are choices – we need to be the top choice.” From someone else: “Patients have options for where to go for their care, and they will choose the place that treats them as an individual with respect for them as a person.”

Is it all about money and market share? Well, yes, sort of – but when survey participants were asked what motivated them to improve the patient experience, guess what was at the top of their list? Improving outcomes for patients, followed by better patient satisfaction scores and retention of good employees and physicians.

It wasn’t that long ago when patient satisfaction was almost an afterthought – a nice extra but not essential to the hospital’s mission. These survey results make it clear the game is changing and that it’s no longer going to be the patient experience as usual.

West Central Tribune file photo