Achieving “buy in” from staff and hospital leaders is key to the success of any quality improvement effort, but it is common to meet resistance from those who doubt its value. When it comes to measuring and improving patient satisfaction, that skepticism often comes from physicians.
The common response from physicians, whether they say it out loud to hospital leaders or grumble quietly among their colleagues, is that their job is to practice good medicine and not to grovel for five-star ratings on a patient satisfaction survey. Left unchecked, that attitude can derail the initiative.
The healthcare industry has come to value patient feedback far more than in the past, using everything from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to patient satisfaction surveys from consultants and vendors and online reviews. The focus on satisfaction may be reaching a level that prompts some physicians to rebel, says Anthony D. Cox, chairperson of graduate business programs in medicine and professor of marketing at the Indiana University Kelley School of Business in Indianapolis.
He has long advocated for paying attention to patient satisfaction and other feedback, but Cox acknowledges that physicians can sometimes feel like “enough is enough.”
“I still support the use of patient feedback to improve quality of care, but there is a lot of resistance among physicians to the increasing prominence given to patient satisfaction in evaluating what they do. It is important to address those concerns in order to get the potential benefits from that patient feedback,” Cox says.
If any initiative within a healthcare organization has a lot of resistance from physicians, it’s going to be hard to make it successful, Cox says. Excessive or insensitive campaigns about patient satisfaction will only exacerbate tensions between hospital leadership and physicians, he says.
“They didn’t get into this business to be a salesperson, and an excessive focus on patient reviews trivializes what they do,” he says. “There often is a lot of distrust between physicians and hospital administrators. If they’re battling, it’s usually the patient who loses, so you don’t want this to be another battlefield.”
Reviews Tend to Extremes
Cox currently is researching physician resistance to patient satisfaction measurements and what factors most influence patients’ perception of quality and satisfaction. Part of that research involves looking at online reviews, and Cox is finding that they tend to be bimodal, with a lot of one-star and five-star reviews.
“We’re looking in particular at what drives a person to be so dissatisfied by their experience to go online and write one of those reviews. There are a number of frequently mentioned issues that don’t come up on survey tools like HCAHPS, which is very narrow. It looks at certain aspects of what the patient experiences in their hospital bed, with no mentions of things like billing, which is a commonly mentioned issue in negative reviews.”
Physicians feel pressured to make patients feel satisfied and provide positive feedback, which can create perverse incentives, Cox says. Some doctors may only act subconsciously to give the patient what he or she wants even if it is not the best medical decision, while others are fully aware that they face a choice of making the patient happy or risking a bad review.
“Some physicians have felt pressure to prescribe opioids to patients who don’t necessarily need them. Two HCAHPS questions were specifically about pain management and one of them asked if the hospital staff did everything possible to alleviate your pain. I’ve talked to a number of physicians, particularly emergency physicians, who thought the idea of pain as a vital sign has created an incentive to overprescribe opioids,” Cox says. “Another example is patients who want antibiotics and will go home feeling better and more satisfied if they get that prescription, but the doctor knows they don’t really [need] it. Doctors can find themselves in a dilemma.”
Valid Methodology Concerns
Physicians are trained to be scientific thinkers and often criticize the methodology behind patient satisfaction metrics. Some of that is just sour grapes, with low-scoring physicians looking for a way to invalidate the survey, but Cox says criticism is sometimes valid. Those flaws may involve sample sizes, for example, or population demographics that influence satisfaction scores.
“I have a good friend with a practice that includes serving parolees who have to go in for mandatory drug testing. Those folks do not give many fives on a satisfaction survey, because they are really unhappy to be there,” Cox says.
Those concerns must be addressed because physicians cannot be expected to support a flawed survey tool that threatens their careers and incomes, Cox says.
Physicians also bristle at the idea of focusing more on patient happiness than on patient wellness, Cox says. Hospitals can inadvertently send the message that they are fixated on happiness by focusing too much on surveys, or by emphasizing their importance with ham-handed initiatives.
If there are methodology concerns, show how you’re addressing them and retooling the survey or finding another tool. When there are issues with patient populations that are never going to give you a top score on a survey, you must find an effective way to factor that in to how you assess and use the results, he says.
“When those objections are acknowledged and administration shows that they’re making a good faith effort to deal with them, you’ll get a lot more buy-in. I’ve seen hospitals just tell physicians ‘this is the way it is now and learn to deal with it,’ but that never works,” Cox says. “If all the objections are dismissed as sour grapes from people who can’t get good satisfaction ratings, you’re going to miss legitimate concerns and push physicians away. Acknowledge legitimate concerns even if you don’t have an immediate solution.”
Quality vs. Specs
Clinician skepticism usually comes from confusing quality with meeting specifications, says Tom Davis, MD, FAAFP, in St. Louis, who has worked with clinicians, organizations, and insurers regarding Medicare Advantage for 20 years, both as a practicing clinician and a consultant. Quality and specifications are not the same thing, he says.
Davis recalls an effort to improve infection control with more hand-washing when he worked in an outpatient setting.
“Without warning, our office was inundated with mandatory training, posters, screen savers about hand-washing, the whole drill. The emphasis was not on good patient care or outcomes. The emphasis was on making sure the patient saw you wash your hands, even verbally noting it to them, with no explanation given as to why it was important,” he says. “Washing before laying hands on patients is polite and not doing so is drop-dead disgusting, but in the outpatient setting, there is no evidence that it affects any medical outcomes in any way. It is, however, a primary mover of patient satisfaction scores.”
The effort failed in the end, Davis says, and even worse, it left physicians and staff feeling disheartened when they realized there was no science underlying it.
“We were not told these facts during the hand-washing promotion and once the educational program petered out less than three months later, we found them out offhand from a junior administrator, significantly undermining the efficacy of any future intervention,” Davis says.
He suggests the lesson for hospital quality professionals is that you should pick your metrics sparingly for maximal effect. Tie them scientifically to patient outcomes and personalize them, because every clinician has been a patient, Davis says.
“Prepare any education promotion with ‘pre-education’ about these benefits before the program begins. Integrate them into grand rounds and noon conference lunches with respected thought leaders,” Davis says. “Any promotion and metric measurement should be at least three years in length to establish its importance. Limit frivolous selection and promote the credibility of the leadership.”
Create a Quality Culture
Physicians will respond more positively to quality initiatives if they are already involved in the organization’s effort to promote a culture that emphasizes the patient experience, says Omar Baker, MD, co-president, chief quality and safety officer and director of performance improvement with Riverside Medical Group, which has 70 locations in northern New Jersey.
Baker focuses on delivering patient-centric care and has created a mandatory monthly seminar called CARES for all 800 staff, physicians, and managers to address that goal.
“It is our ingrained culture to always put the patient first with a focus on evidence-based care delivery and an emphasis on results that leads to the highest patient satisfaction scores. We value the patient perspective so much that we have patient focus groups at several locations, we encourage online surveys and feedback, and we continually monitor online feedback,” Baker says. “We are in a consumer-driven industry, but our physicians must always do what’s best for our patients and at Riverside, our motto is to treat our patients like family.”
Physicians, staff, and patients all are seen as stakeholders in the care delivery model at Riverside, Baker says, and although they consider patient feedback seriously, it is only one component they use to evaluate their performance and methods for quality and performance improvement.
Riverside looks at structure, process, and outcomes continually to ensure it is delivering a superior patient experience. This is what the CARE model stands for in efforts to better serve patients:
- Culture: Riverside started more than 35 years ago and currently has more than 70 locations in Bergen, Hudson, Essex, and Passaic Counties.
- Access and Accountability: The Secaucus, NJ, headquarters is open 365 days a year from 7 a.m. to midnight. A medical provider is on call 24/7. There is one shared electronic medical record system that provides access to hospital, specialty, and primary care records. For accountability, all care team members are accountable for the health of their patients. Documentation must be legible and accurate, and communication is the key for teamwork.
- Results: The medical groups focus on providing value, defined as the highest possible outcome at the lowest possible cost.
- Engagement: Riverside is a strong advocate of education for all patients, caregivers, and community members. It offers free prenatal, breastfeeding, and diabetes education classes to the community.
- Satisfaction and Safety: Riverside strives to keep employees and patients happy and healthy, practicing what it preaches with annual wellness visits, flu vaccines, and other wellness habits. Riverside conducts patient satisfaction surveys and patient focus groups.
“Skepticism is overcome by understanding [that] medical care is evolving through innovation and technology and that patient satisfaction surveys and scores [are] important, but only one aspect of evaluating our model of care delivery,” Baker adds.
- Omar Baker, MD, Co-President, Chief Quality and Safety Officer, Director of Performance Improvement, Riverside Medical Group, New Jersey.
- Anthony D. Cox, Chairperson, Graduate Business Programs in Medicine, Kelley School of Business, Indiana University, Indianapolis. Phone: (317) 274-3831. Email: firstname.lastname@example.org.
- Tom Davis, MD, FAAFP, Principal, Tom Davis Consulting, St. Louis. Phone: (636) 667-6325. Email: email@example.com.