Edie Brous
Nurse Attorney
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Patient-satisfaction surveys have their place. But the potential cost of the subjective scores are leading hospitals to steer focus away from patient health, messing with the highest stakes possible: people’s lives.
Alexandra Robbins

I just hate it when a waiter or waitress follows a script instead of simply relating to me naturally as a person.  When, instead of asking me if everything is all right or if I need anything else, they recite memorized lines like, “Is everything tasting delicious?” I just want to smack them. If I want a Disney, “Have a Magical Day” experience, I will go to Orlando or Anaheim.  But I don’t.  I didn’t come to a restaurant to watch people playing roles in tightly scripted plays.  I just want a meal and a normal conversation with the server.  Similarly, when patients in hospitals are sick, injured, scared, in pain, nauseated, thirsty, or otherwise uncomfortable, they don’t want nurses with their fake Miss America smiles dutifully reciting, “Hi.  I am Edie & I am here to deliver excellent care!”  They want real people relating to them like real human beings.

Under its Hospital Value-Based Purchasing Program, the Centers for Medicare & Medicaid Services (CMS) began withholding 1% of Medicare reimbursement to hospitals as of October 1, 2012.  (By 2017 it will be 2%.)  It then restores that percentage to institutions that meet quality performance metrics – 30% of which is based upon how hospitals score on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

HCAHPS surveys were thought to represent patient satisfaction. Nursing care is the cardinal experience of hospitalization so it is not surprising that HCAHPS questions are largely related to nursing care. Professional nurses will tell you that the best way to improve patient satisfaction is to improve nursing satisfaction.  As Dr. Hazan notes, “[I]f nurses are dissatisfied at work, patients will inevitably be dissatisfied with their experience.”

Safe staffing levels, adequate equipment, decent working conditions and management support for its front line providers will result in better care, lower morbidity and mortality, and less patient displeasure.  Yet, with $850 million dollars at stake, hospitals seemed to interpret patient satisfaction as meaning patients are to be evaluated in the same manner as hotel guests.  In attempts to raise HCAHPS scores, they have hired overpriced consultants like Press Ganey or others to “transform the patient experience through integrated data, advanced analytics, and strategic advisory services.”

The resultant pressure for nurses to bear this burden causes patients to actually receive less safe care.  Placing the focus on what patients want instead of what they need compromises nursing care and endangers the very patients hospitals are trying to satisfy. “Satisfied” patients have greater costs, higher hospitalization rates, and are more likely to die.  Providers who are concerned about satisfaction scores are less likely to discuss unpleasant topics with their patients. While hospital administrators focus on hotel-like amenities such as loyalty programs, VIP lounges, room service, or valet parking, nurses continue to work in dangerous systems.  Because hospital administrators require nurses to spend unnecessary time and energy being trained in rehearsing scripts for their interactions with the “customers,” their nurses are unable to honestly relate to their patients as actual people. A particularly egregious example of this was recently highlighted by the Illinois Nurses Association (INA). St. Joseph Medical Center responded to poor patient satisfaction scores by forcing their nurses to attend a “boot camp” which was described by the INA:
According to the INA, boot camp activities included requiring nurses to drink water without access to bathrooms, sitting on a patient care bed in a public hallway while wearing goggles to mimic poor vision and headphones to simulate a patient with poor hearing, all while on top of a bedpan for 30 minutes.

This insanity demonstrates how little responsibility organizations take for their poor administrative decisions. If you want the patients to be happy, you have to create an environment in which nurses can find meaning and pride in their work. Nurses are human beings who deserve to be treated with dignity and respect. Demeaning and abusing them because they cannot meet unrealistic or inappropriate metrics that the organization itself makes impossible by its management decisions, only perpetuates the exodus of experienced providers from the workplace. This further endangers patients.  It is impossible to achieve any measure of patient satisfaction if the nursing staff is demoralized and mistreated.  More importantly, it is impossible to achieve patient safety if nurses do not work in supportive systems with appropriate priorities.  How about a NURSES satisfaction survey once in a while?

Nurses are not robots.  They are highly educated and trained professionals who need to be treated as such. Patients are not hotel guests.  They are sick and injured people.  Treating them like business consumers can have grave consequences.

This was Edie -delivering an excellent newsletter & hoping you are having a magical summer.

For additional reading on the topic:

Fenton, Joshua J. et al., The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality, Arch Intern Med. 2012;172(5):405-411

Guadagnino, Christopher, Patient Satisfaction Critical to Hospital Value-Based Purchasing Program, The Hospitalist, October 1, 2012

Hazan, Alberto, Patient Satisfaction Must Start with Nursing Satisfaction, MedPageToday’s KevinMD.com, June 28, 2016

Minemyer, Paige, Illinois Hospital ER Nurses Humiliated By Training To Improve Patient Satisfaction Scores, Fierce Healthcare, June 24, 2016

Rice, Sabriya, Bioethicists Say Patient-Satisfaction Surveys Could Lead to Bad Medicine, Modern Healthcare, June 4, 2015

Robbins, Alexandra, The Problem with Satisfied Patients, The Atlantic, April 17, 2015

Whitcomb, Winthrop, Patient Satisfaction Surveys Not Accurate Measure of Hospitalists’ Performance, The Hospitalist, September 1, 2013
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