Health care leaders, physicians, nurses, and other hospital personnel understand that maximizing patient satisfaction is an important goal. Health care organizations strive for their patients to be satisfied not only with their health care and its outcomes but also with the non-clinical aspects of their patient experiences. Providers want patients to feel they are being treated with dignity and that hospital personnel are making every safe and medically-advantageous effort to heal them. For these reasons, health care organizations have long sought to understand the perspectives of their patients through patient satisfaction surveys.
Given the significance of patient satisfaction in health care today, it is helpful to define and describe elements of care or patient/provider interactions that influence it. Although, not everyone agrees on exactly what or how to measure it, patient satisfaction has become an integral part of the current health care delivery system.
What Is Patient Satisfaction?
Patient Satisfaction is one performance measure of health care quality. The authors of this Hastings study describe three domains of patient satisfaction: the delivery of essential medical care; treatments sought by patients and their families (which may or may not be favorable to good health); and the provider activities and behaviors that comprise compassionate care and the safeguarding of human dignity. While these categories demonstrate aspects of a patient’s experience that can be evaluated, patient satisfaction is largely subjective and depends on patient perceptions relative to their expectations. Because of the individual quality of patient satisfaction, it’s difficult to define and measure.
Since patient satisfaction is not directly observable, patient satisfaction surveys are commonly used as a measuring device. Patient satisfaction surveys attempt to translate subjective results into meaningful, quantifiable, and actionable data. Measuring patient satisfaction and extracting useful and relevant information involves determining which aspects of patient satisfaction to measure, developing reliable and valid questions, randomly sampling individuals from within a patient population, and using standard techniques such as mail surveys, telephone surveys, or face to face interviews.
Patient satisfaction surveys capture self-reported patient assessments of multiple touchpoints during their medical care experience. Depending on what aspect of patient satisfaction is being measured, examples may include responsiveness of staff, clinician communication, technical skill, and hospital environment. Whether patients are “satisfied” depends on their expectations about these different touchpoints.
Patient satisfaction surveys can be created and administered in-house, but many hospitals rely on third-party providers with experience in developing, administering and interpreting statistically valid patient satisfaction surveys. Some hospitals combine the required HCAHPS questions with additional patient-centered questions to gain a comprehensive overview of patient experience.
The current ubiquity of patient satisfaction surveys stems in part from the development of the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS). HCAHPS is a 27-question survey created by the Centers for Medicare & Medicaid Services (CMS) in partnership with the Agency for Healthcare Research and Quality (AHRQ). It was developed to capture the views of patients (recipients and non-recipients of Medicare) about their health care experiences. By standardizing the data, the HCAHPS survey empowers health care consumer decision-making by enabling individuals to easily compare hospitals. Nationally implemented in 2006, survey results started being published on the CMS Hospital Compare Site in 2008. According to CMS, the HCAHPS survey was created to address three goals:
- Providing health care consumers with “objective and meaningful comparisons of hospitals.”
- Publishing HCAHPS results to incentivize hospitals to advance care quality.
- “Increasing transparency” of care quality by promoting accountability in exchange for the public’s investment.
According to CMS, the survey “is composed of 27 items: 18 substantive items that encompass critical aspects of the hospital experience (communication with doctors, communication with nurses, responsiveness of hospital staff, cleanliness of the hospital environment, quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and recommendation of hospital).” Survey questions are periodically updated to address feedback and research. For example, in response to the opioid crisis, effective January 1, 2018, CMS replaced the pain management questions on the HCAHPS survey with new questions that will provide a composite measure called “Communication About Pain.”
Patient Satisfaction Scores and Reimbursement
In 2012, the ACA tied reimbursement to HCAHPS scores with its Value-Based Purchasing (VBP) policies. This program allows the government to withhold 2 percent of all Medicare payments to create a pool of money to be used to reward hospitals who provide high-quality health care, determined in part by how they perform on the survey. The latest information about the HCAHPS survey and newly released survey scores can be found in CMS’s 2018 HCAHPS Executive Insight Letter.
Patient Satisfaction in Hospitals—The Impact of HCAHPS
The prominence that the government now places on patient satisfaction survey scores has led hospitals to come up with creative ways to improve patient satisfaction. Unfortunately, some of them have no positive health benefits. For example, some hospitals, influenced by the commercialization of patient satisfaction, are providing patients with designer gowns and valet parking, leaving critics to point out the diversion of resources away from proven measures for improving patient care quality. Another example taken from the previously mentioned Hastings study describes how nurses are being coached by consultants to verbally inform patients they are “closing the door and turning out the lights to keep the hospital quiet at night.” The sole purpose of narrating this activity is to influence patients’ survey responses.
Unintended Consequences of Tying Reimbursement to Patient Satisfaction Surveys
According to a study in the Journal of American Medicine, patients who are more satisfied based on their responses to the Consumer Assessment of Health Plans Survey, are less likely to visit emergency departments, but are more likely to become inpatients. They also have higher health care costs and increased mortality rates. Another study conducted by Dartmouth Hitchcock and the University of Michigan suggests that satisfied patients are more likely to struggle with opioid addiction. Causality was not confirmed in the study, but, as mentioned above, CMS has removed questions about pain management from HCHAPS to address this valid concern. Researchers speculate that physicians whose compensation is tied to patient satisfaction are more likely to give in to patients who request medically-unnecessary treatments that may have adverse effects. It is also purported that physicians may be less inclined to tell patients things they don’t want to hear such as, “You need to lose weight,” or “It’s critical for you to quit smoking.”
Improving Patient Satisfaction
While there have been some less than optimal outcomes from the HCAHPS survey, many institutions are using data from patient satisfaction surveys to guide meaningful and substantive change. One such hospital, St. John’s Regional Medical Center in Oxnard, CA, sought to transform their entire culture around patient-centeredness through initiatives that involve many factors of care, such as better communication, responsiveness, and reducing hospital noise levels. They tackled noise levels by providing patients with “quiet kits” comprised of earplugs, light-blocking masks, “Voices-down, please” cards, lip balm, and Sudoku and crossword puzzles. While these items may not have direct clinical applications, they help patients to sleep better and decrease stress levels—legitimate factors in health and healing.
Rush University Medical Center in Chicago is leveraging data from their patient satisfaction surveys to improve a central aspect of interpersonal skills: communication between hospitalists and their patients. By deploying multiple tools to help patients keep track of medical personnel such as whiteboards for writing the care team’s names, “face cards” with printed images of physicians as well as contact and role information, and communication best practices checklists, they are improving their patient/provider relationships and consequently their patient satisfaction scores. They are also using feedback to guide hospitalists’ education and development and have created yearly training programs on good communication practices.
As indicated by Rush’s focus on communication, patient perspectives on their providers’ interpersonal skills is a key area of patient satisfaction. Certainly, effective treatment is often dependent on the ability of physicians and other health care workers to connect with patients on a personal level. Medical staff who can set patients at ease and communicate with clarity, compassion, and empathy are more likely to elicit critical information from patients as well as gain their compliance with treatment and care directives. In fact, studies have shown that satisfied patients are more likely than unsatisfied patients to take medications, show up for outpatient appointments, and take overall ownership of their health.
Patient Satisfaction Surveys for the Long Haul
Even those that champion measurement of patient satisfaction as a primary driver for improving quality of healthcare, concede it has had unexpected fallout. Valid criticisms, including the inadvertent negative health consequences, deceptive coding practices, and resource-depleting gimmicks, coupled with an understandable resistance to HCAHPS’s highly-visible, consumer-facing Hospital Compare report cards, are legitimate challenges for healthcare administrators.
Yet, there is undeniable value in the broader perspective patient satisfaction survey results have introduced into how care quality is evaluated. By providing insight into their patients’ perceptions, patient satisfaction surveys have informed decision makers efforts to build meaningful patient/provider relationships, establish effective and constructive communication, and develop care journeys that are grounded in empathy and compassion. As Tom Lee, MD, MSc writes, “On balance, we do not need less measurement in health care; we need more wisdom about what to do with the data.” As healthcare leaders continue to gain insights from patient satisfaction survey data, wise responses need to be grounded in evidence-based treatment, patient safety, and the efficient use of resources—not patient appeasement or window dressing that merely creates an illusion of quality.