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Patient satisfaction is a primary concern for quality leaders at hospitals, but it should be viewed as only one component in the overall patient experience, experts say. The broader patient experience is directly tied to quality and is far more useful for quality improvement, they say.
Satisfaction has always been only one component measured by tools such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey required by CMS for all hospitals in the United States. But over time, healthcare systems have either focused excessively on that one part or improperly used “satisfaction” to mean the entire patient experience, says Jim Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division.
“I cringe when I hear healthcare organizations say they’re trying to improve patient satisfaction. No, you’re trying to improve care delivery,” Merlino says. “There are nine questions on the HCAHPS about how we communicate with patients, and we’ve seen that when nurses improve how they communicate with patients, falls go down, complications go down, pressure ulcers go down. When physicians communicate better, compliance with treatment goes up. There’s no doubt that when we improve our communication patients are happier, but the bigger point is that we’re touching on quality and safety there, and the overall delivery of patient care.”
Healthcare organizations are coming to that realization more than in years past, Merlino says. Five years ago, hospitals focused on patient satisfaction as an end goal in itself, he says, whereas today more organizations are recognizing that satisfaction is only one metric in the overall assessment of quality of care delivery.
Merlino notes that a 2017 study of Press Ganey data found that when healthcare employees believe the organization prioritizes safety and quality, publicly reported quality of care and patient experience metrics are higher. (That report is available online at: http://bit.ly/2rWkkEE.) Likewise, the study found that when patient experience is rated highly, the hospital tends to have high marks in safety and quality.
“These relationships are absolutely real. Organizations and leaders are getting more sophisticated about how they see these connections, and the research is more supportive of that linkage,” Merlino says.
Hospitals should make improving the patient experience — not solely patient satisfaction — a top priority for the organization, Merlino says — not as part of another initiative, but as a standalone objective. The patient experience also must be defined, he says, so that people don’t assume you’re just looking to get five stars on every survey.
“Make it clear that this is not about making people happy or satisfaction. It’s fundamentally about how we deliver safe, high-quality care in an environment of patient-centeredness,” he says.
Hospitals also must focus their metrics on the patient experience, Merlino says. There are so many metrics available and required these days that the ones truly determining the patient experience can be lost in the shuffle. Focus on the ones that indicate quality and safety when formulating strategies and prioritizing resources.
“As part of your data strategy, make sure you are correctly cascading it from board all the way down to the frontlines,” Merlino says. “Use the scorecard correctly in front of the board and help the frontline staff understand what the performance elements are, how the things they do during the course of a work day impacts the numbers you’re presenting to them.”
One challenge is identifying what actually affects the patient experience, notes Carole Lambert, vice president of practice optimization at Cooperative of American Physicians (CAP). Physician leadership is key, she says, so any effort to improve the experience must prioritize their involvement.
“I often say that if the physician doesn’t want it, it’s not going to happen. The physician needs to say, ‘we’re going to get this right, do things properly, communicate effectively, make sure our patients understand what we’re trying to do to help them and what their responsibility is, and we’re going to follow through,’” Lambert says. “That’s a very important first step in creating the culture that will foster a good patient experience.”
Lambert notes that the patient experience can affect the hospital’s reputation more quickly than ever before. All it takes is one patient who perceives a staff member being inattentive, dismissive, or exasperated (even if it is justified by the patient’s behavior), to walk out of the hospital and immediately post a review on social media.
“In 90 seconds, you have a bad review and you will need to counter it with several good reviews to push it down. At the simplest level, that is the kind of thing that impacts the patient experience and your reputation in the community,” she says. “You have to have staff who understand the bigger picture and that this isn’t just about following an algorithm, and it isn’t just smile training. It is about relentless attention to detail and the meaning of what we do.”
It can be easy for healthcare staff to let their guard down around coworkers and forget that patients may perceive their casualness or familiarity in a negative way, Lambert says.
“We get very used to the environment and the work, becoming so comfortable that we forget what it may look like to people who are not used to it,” she says. “We become informal in our appearance, how we speak to one another, forgetting that this is a business and people are coming in and for whom this is a new environment, and one in which they expect a level of professionalism and decorum.”
Healthcare leaders must take responsibility for the message patients receive from their organizations and not make excuses, Lambert says. If a patient feels disrespected and poorly treated, it is not enough to point out that the staff were unusually busy that day and the patient just doesn’t understand the pressure they were under at that time. The message sent to that patient was unacceptable, and hospital leadership should seek a solution, she says.
http://bit.ly/2tXxtTO(CAP offers a Risk Management Self-Assessment Kit that addresses patient experience considerations such as facility cleanliness, air and noise quality, availability of engaging and current reading materials, staff training and engagement, and complaint resolution. The kit is available online at: http://bit.ly/2tXxtTO.)
“A great way to start improving the patient experience is to listen for the clues about where you could do better. Be an alert for any phrases such as ‘We always have trouble with…’ or ‘We never get this right...’ or ‘Why are we doing this again?’ If you hear those things, you’ve found a problem to address,” she says.
Thibodaux (LA) Regional Medical Center improved patient satisfaction by creating a culture of patient-centered excellence, starting when CEO Greg Stock joined the hospital in 2000 and wanted to better focus the mission of the hospital on patient-centered excellence.
Thibodaux promised to provide great clinical care, great emotional care, and to invest in great technology and processes.
Fulfilling those promises would require getting everyone at the hospital on board, and Stock knew that would be a challenge. He and the other hospital leaders expected some opposition to a grand plan such as that, partly because people knew it would require changes to how they currently operated, and partly because they doubted the conviction of hospital leadership.
They also knew the community would be skeptical of the plan, seeing it as either a grandiose idea that the small community hospital could not pull off, or just another empty marketing campaign.
The outside criticism could only be addressed with results, so the leadership team at Thibodaux focused internally, starting with its patient experience metrics. They were generally good, but Stock realized that he had been putting too much confidence in metrics that showed the hospital doing as well or slightly better than other health systems.
“That was a big mistake. Once I started to dig into the data, I could see all sorts of opportunities for improvements. The data was a real eye-opener, showing us how much we could improve and where,” Stock says. “We challenged ourselves to perform at the highest level — not just in comparison to similar health systems, but comparing ourselves to organizations with some of the top numbers for satisfaction metrics, like Cleveland Clinic and Scottsdale Healthcare.”
Thibodaux did that with three key strategies:
1. Holding employees accountable for living up to behavioral standards during the workday. Some employees were fired when they could not meet the behavioral expectations that came with the hospital’s new vision. By the same token, senior leaders stress to managers that they must treat employees respectfully and in a way consistent with the hospital’s values.
2. Using data from employee satisfaction surveys to change behaviors. Thibodaux uses satisfaction data with Six Sigma’s process improvement methodology to change employee behaviors, operating on the premise that they won’t change unless they know they need to change. Stock cites the example of one employee who was viewed by hospital administration as a great leader until they looked at his employee satisfaction metrics. The data revealed that his employees were largely dissatisfied with how he treated them, so the hospital showed him those metrics and encouraged him to change how he related to his staff, particularly how he recognized their contributions. The data helped him significantly improve his department’s satisfaction metrics.
3. Using patient satisfaction data as a measurement of the entire organization’s progress. Thibodaux leaders consciously try to avoid putting too much stock in the last set of patient satisfaction scores, always focusing on the next metrics. Stock says patient satisfaction excellence should be a constant stretch goal, rather than relaxing because you’ve achieved the marks you wanted.
Any effort to improving the patient experience and patient satisfaction must start with the implementation of an evidence-based, collaborative care plan that involves both the patient and caregiver, says Lori O’Brien, MSN RN, senior clinical strategist and operations manager with Zynx Healthcare in Los Angeles. By fully engaging the patient and establishing patient-specific health goals and care plans, patients are more motivated to participate in the process and achieve established goals, she says.
Caregivers can guide the process to ensure continuous dialogue that addresses shifting needs, eliminates potential barriers, and provides patients with the specific tools they need to ensure quality and cost-effective outcomes, she says.
“Clinicians know, based on a large amount of evidence, that the more that patients are engaged in their care the more likely that that costs will be reduced and clinical outcomes will be improved,” O’Brien says. “By fully engaging the patient and establishing patient-specific health goals and developing individualized care plans, patients are more motivated to participate in the process and achieve established goals.”
Some strategies to more fully engage patients include creating an environment that encourages patients to participate in developing their individualized care plan, she says. Clinicians should encourage dialogue on goal-setting and what that goal means to the patient and their health using their own words, she says.
“Clinicians should provide an evidence-based care plan for the patient to review to provide a starting point for discussion. It’s important for the clinician to answer questions but remain neutral to enable patients to identify what steps or interventions will work for them to achieve their identified goals,” she says. “Goals and interventions should be revisited at every encounter to reflect shifting needs.”
Clinicians also must remember to tailor their communication styles, and their delivery of care to some extent, to the individual. Gender can affect patient expectations, for instance. One recent study found that men focused more on pain management, while women focused more on communication and staff responsiveness. (For more on that study, see the story in this issue.)
A typical barrier to patient engagement is providing too much information at one time. For example, identifying all of the self-management strategies and lifestyle changes for a patient newly diagnosed with Type 2 diabetes can be overwhelming, O’Brien notes.
“It may be better to focus on achieving a normal blood glucose level and medication adherence as the first priority and then focus on diet, weight loss, and exercise in subsequent visits to enable better comprehension and goal attainment,” she says.
Another barrier is receiving information in a format that isn’t personalized to a patient’s learning style. All patient-directed information should be free of medical jargon and abbreviations, O’Brien says, and in a format and language that they can comprehend. Learning styles and preferences should be discussed initially and then re-evaluated for effectiveness and comprehension. (See the story in this issue for more on how artificial intelligence may aid in this effort.)
“Younger individuals will be more likely to access and learn information if it’s in an electronic format that they can access at their convenience,” she says. “Elderly individuals may prefer a face-to-face or telephone conversation and written information to reinforce goals and instructions. By facilitating goal-setting that is relevant and has a personal meaning, eliminating common barriers, and keeping the care plan meaningful and updated, patients are likely to stay more fully engaged and have a healthier future.”
Men and women may have different ideas of what constitutes excellent care, according to a recent report from at the 2017 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). Both want good clinical outcomes, of course, but when it comes to rating their experience with the hospital, the study suggests men want optimal pain management while women want good communication with the staff.
Researchers at the Cleveland Clinic analyzed survey results from 692 patients who had undergone total hip arthroplasty (THA) between November 2009 and January 2015, and both men and women had a mean age of 62. (An abstract of the study is available online at: http://bit.ly/2tHahoi.)
The men and women had comparable mean hospital satisfaction scores, and there were no significant differences in the grading of nurse communication, staff responsiveness, doctor communication, hospital environment, pain management, and communication about medication, the report says. However, when patient perception was further analyzed, researchers found a gender bias in the factors that influenced men’s and women’s perceptions of care.
Women’s patient satisfaction was most influenced by staff responsiveness, followed by their communication with nurses and doctors. For men, the way their pain was managed had the strongest effect on their overall satisfaction with care.
“For post-THA patients who are men, the orthopedist should focus on optimizing pain management. For the post-THA patients who are women, orthopedists should optimize staff responsiveness, as well as focus on improving nurse communication and doctor communication,” the study says.
The authors caution that this finding should not interfere with proper pain relief for women, noting that multiple studies have addressed differences in pain perception and management between different genders. One study compared pain management of acute musculoskeletal problems in the ED between women and men and found that treating physicians assessed women’s pain level to be higher than that of men, even though medication administration was similar for both genders.
That study also found higher anxiety levels among women, which could explain the higher level of pain that was assessed. “In addition, other studies have also shown that women a higher prevalence of chronic pain from conditions such as headaches, temporomandibular joint disorder, fibromyalgia, irritable bowel syndrome, and arthritis, as well as experiencing greater postsurgical pain,” the authors write.
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Dana Spector, Nurse Planner Fameka Leonard, AHC Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.