Customer satisfaction in health care-time for transparency.

You land in your favorite resort town on vacation and you arrive at a Hilton Hotel.

The hotel was not your choice, but the taxi driver who picked you up at the airport decided it would suit your needs. You are asked to sign papers that, essentially, state that staying at the Hilton is inherently risky and that you understand the risks. You are escorted to your room, which, by the way, you will be sharing with a complete stranger who suffers from night terrors and watches television all night.

The meals are mass-produced from a limited menu and the food is of the quality one would expect to find in a penal colony. Oh, and by the way, your hotel bill for a week's stay will be in the neighborhood of $55,000. How difficult would it be for Hilton to attract you back the next time you are in town? How would you score this hotel on a customer service survey?

What if, however, during your stay, the talented personnel of the Hilton Hotel saved your life?

Not really a Hilton

This is the uphill battle that hospitals are asked to fight in the current environment of American health care. The paradox is clear, yet we spend too much money in hospitals measuring the satisfaction of our customers as if they were staying at a resort. Was the food hot? Was the room quiet? Were the nurses attentive?

Satisfaction of the customer in health care is a much more complex entity than it is in the retail world and, in fact, is antithetical to what is now more recently recognized should be the driving force of change in health care, that is, the major emphasis on both clinical outcomes and patient safety.

The tension that exists between patient safety and patient satisfaction is important. Clearly, the nurse who is instructed to accept no interruptions when preparing the medication cart (a standard of patient safety) is at great risk of making a patient wait while ringing the call bell for a drink of water.

That is a setup for poor scores on a patient satisfaction survey but a safe, good outcome. The scale must tip in the direction of patient safety, but given the current emphasis on the hotel-like services in hospitals, how is the public ever going to be educated to the point where less-than-perfect food is an acceptable sacrifice if it means more resources available to make care safe?

If patient satisfaction is thought to be comparable to customer satisfaction in the retail world, then the generally understood definition would be that patient satisfaction is the comparison between the patient's perceived experience vs. what that same patient expected in the first place. A hospital experience that meets expectations would rank high and an experience that falls short would rank low.

There are many vehicles for measuring customer satisfaction in the retail world and, for the most part, the benchmark for success is whether or not you beat the previous quarter in satisfaction. Logically, that would be a marker of constant improvement in the way your customers perceive your institution.

In the retail world, a measurement of whether a shopping experience meets customer expectations can be as simple as whether the item a customer was looking for was on the shelf. There is a certainty of outcome in the retail world. A customer enters a retail environment to make a purchase that either happens or doesn't depending upon whether the store has the item in stock at a price that is acceptable to the consumer.

In the health care environment, the expectation of cure must, more often than not, be tempered with the possible outcome of being "better" and not cured. Sometimes, as in the case of a progressive, chronic illness, the possibility of being clinically worse at the end of a hospital stay must be acceptable to the patient.

Evidence exists that high patient satisfaction scores are an indicator of quality of care. (1), (2) The Joint Commission has recently adopted the requirement that patient satisfaction be measured and reported as part of the accreditation process partly due to the recent call that health care be more patient-centered.

Press Ganey Company has been in the forefront of patient satisfaction measurement and works with approximately 40 percent of the acute care hospitals in the country at this time.

The measurement is reported in the form of both a raw score and a percentile ranking comparing a given hospital to its "peers." The race to improve percentile ranking has always been flawed by the simple fact that your hospital's score could remain the same, or even fall in patient satisfaction, and yet you could celebrate improved percentile ranking as long as the peer group received lower scores, too.

Similarly, you could enjoy a marked increase in patient satisfaction scores due to hard work on everyone's part, yet be rewarded by a decrease in percentile ranking if other hospitals improved more than you did.

Focusing in on percentile ranking at all does a major disservice to those who work hard to improve patient well-being. More than one poor department has been called to task and put through the ringer to bring percentile ranking up in the face of high and improving raw scores.

Manipulation

The manipulation of patient satisfaction survey scores by some hospitals should be discouraged as well. Scripting of employees to "say the right thing" to mirror what patients will be asked about later on in the survey process needs to be discouraged and the practice of signage encouraging "5s" should be frowned upon.

The true value of measuring how happy patients are with the health care you deliver is yet to be realized. The true relationship between quality health care and patient satisfaction should be clearly defined by the governing body.

Patient well-being and safety should generate high patient satisfaction scores; high patient satisfaction scores do not reflect our quality inasmuch as this can be fraught with misperception and deception.

[ILLUSTRATION OMITTED]

One of the pitfalls of using patient satisfaction data naively is that if too many precious resources are spent on hotel services in pursuit of high patient satisfaction scores you could easily end up with a population of highly satisfied patients whose lives are at risk the whole time they are enjoying the expertly prepared meals.

It is of considerable interest that satisfaction with a hospital stay can be assessed using a survey instrument where the following questions are conspicuously absent:

* Do you feel better after your hospital stay than you did when you were admitted?

* How long did you stay in the hospital after you felt well enough to go home?

* Did anyone explain to you what patient safety is and how it might impact on your perception of our attentiveness to your needs?

* Are you happy that everything that was done during your hospital stay was for your benefit?

* Would you recommend that your family seek care here in the future?

To peg the achievement of high scores on answers to questions like these would be risky under circumstances as they exist right now. But they would require that a hospital has taken time to educate the community it serves about what is really important in assessing a hospital stay, the tension that can exist between what seems like inattentiveness but is really attention to safe practice and single-minded pursuit of a quality health outcome for the patient.

To do anything else only serves to perpetuate the myth that quality in health care defies definition and is beyond the capability of patients to truly understand. In this era of publicly reported data and transparency it is time to unmask the patient satisfaction survey process and make it a much more meaningful tool.

[ILLUSTRATION OMITTED]

References

(1.) Clark PA, Drain M, Malone MP, Addressing patients' emotional and spiritual needs. Jt Comm J Qual Safety.29(12);619-70, Dec. 2003.

(2.) Sofaer S and Firminger K. Patient perceptions of the quality of health services. Annual Review of Public Health, 26;513-59, 2005.

By Robert M. Pickoff, MD, MMM 

Robert M. Pickoff, MD, MMM, is chief medical officer of Hunterdon Healthcare System in Flemington, N.J. He can be reached at Pickoff. [e-mail]