There have been several memorable patient encounters that were anything but satisfying for me or the patients.  I can recall frustrating circumstances as a medical intern on the floors, tending to patients’ medical needs, but not really being aware of their expectations.  What I mean by this is that I wasn’t tuned into each individual patient as to how to maximize their satisfaction or to include some kind of loop closure regarding their impressions of their hospital admission. A patient was upset that they were at times examined and discussed amongst a group of us at the bedside and that later in the day there would only be the resident or intern, and felt that critical information was not being shared with those who were not present.  Conversely, others were dissatisfied with team rounding and had concerns that they were not getting focused attention by the most senior physicians.  These are two generalized patient perspectives of how they observed the methodologies in being cared for in a teaching hospital. This can easily spill over into even more generalized misinterpretations by patients regarding how they perceived the in-hospital experience. These perceptions can result in confounded survey data based on asking too many generalized questions of often not well informed patients or staff, although the survey takes into account the patients’ education and primary language as valuable data points in some arbitrary manner.

Most concerning and backward in rationale, is that an organization offering high quality care at a lower cost option with superior outcomes could have their revenue stream dramatically impacted by having a governing body hold back reimbursements based on poorly crafted generalized patient satisfaction surveys.  Another institution with less success in controlling costs and with real quality concerns, could outperform the other. 

This could occur based on organizations creating a rehearsed hospitality initiative, without adequately addressing core clinical issues, to drive generalized satisfaction surveys to essentially cheat the system in order to get a greater percentage of the shared revenue being held by the feds.  “When healthcare is at its best, hospitals are four-star hotels, and nurses, personal butlers at the ready—at least, that's how many hospitals seem to interpret a government mandate.”[1] After you pushed the call button, how often did you get help as soon as you wanted it? During your hospital stay, how often did the hospital staff do everything they could to help you with your pain? (These are two questions of 32 from HCAHPS patient satisfaction questions.) 

“The Centers for Medicare and Medicaid Services (CMS) officials wrote, rather reasonably, "Delivery of high-quality, patient-centered care requires us to carefully consider the patient's experience in the hospital inpatient setting." They probably had no idea that their methods could end up indirectly harming patients.”1 Rather than really taking time to thoroughly adjust the surveys so that they can serve as well founded performance drivers, more generalized and off target consumer satisfaction surveys are in pace or teed up to go live for other specialties, including emergency departments.

In the emergency department there is often a looming chronic burden of how long patients have to wait for results, potential delays in answering call bells, or sometimes several patients pushing their call bells every few minutes.

Driven by healthcare systems’ trepidation of losing large amounts of withheld revenue by the government, more are willing to create circumstances where the patient is or must always be considered to be right.  This despite it being widely shared and accepted in business and healthcare that the customer or patient is, in fact, not always right, but that there needs to be more detailed understanding and articulation in identifying patient/customer needs, in order to meet those needs, let alone have meaningful surveys that can offer accurate information. “Try to distinguish between an urgent crisis and an urgent request. There are times when customers have issues that need to be resolved right away, and diving in immediately is the right thing to do. But, depending on your business, this is often the exception rather than the norm.”[2]   

Forced attempts to change consumer behavior can backfire.  When creating or offering a scripted or preordained methodology to improve high patient satisfaction surveys, assuring higher returns on shared savings from the government, the fallout can be far worse.  “In fact, a national study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years.”1 “And because almost every question on the survey involves nurses, some hospitals are forcing them to undergo unnecessary nonmedical training and spend extra time on superfluous steps. Perhaps hospitals’ most egregious way of skewing care to the survey is the widespread practice of scripting nurses’ patient interactions.”1  Delivering quality healthcare is a dynamic process, with endless challenges of how to balance utilization and appropriately justify expenses.  The use of generalized patient satisfaction surveys as a means to hold back revenue from healthcare systems has created and will continue to create more pandemonium then purpose.  It undermines the ability of healthcare systems and providers to appropriately make sustainable changes in order to achieve better outcomes for patients.

Lukas Kolm, MD, MPH