As hospital quality leaders struggle to achieve even small improvements in clinical care results and hope that the effort is rewarded in patient surveys, research suggests comfort amenities like private rooms may be more effective.
That does not mean hospitals should shift focus from improving quality of care in favor of easier-to-achieve improvements in hospitality, says the lead researcher of a recent study. But it might mean the industry focus on measures like the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is misguided, says Cristobal Young, PhD, assistant professor of sociology at Cornell University in Ithaca, NY.
“Improving patient satisfaction is not really about improving medical quality,” Young says. “It comes down to what you mean by quality. Do you mean hotel amenities, or do you mean medical excellence? If medical excellence is still the core mission of hospitals, you probably need to set those patient satisfaction scores aside, or find ways to shift the institutional spotlight away from those satisfaction scores and focus on health and longevity scores.”
Young and a colleague recently published a report casting doubt on whether clinical quality has enough influence on HCAHPS and similar measures.
“With a sample of 3,000 U.S. hospitals, we find that neither medical quality nor patient survival rates have much impact on patient satisfaction with their hospital. In contrast, patients are very sensitive to the ‘room and board’ aspects of care that are highly visible,” the report says. “Quiet rooms have a larger impact on patient satisfaction than medical quality, and communication with nurses affects satisfaction far more than the hospital-level risk of dying. Hospitality experiences create a halo effect of patient goodwill, while medical excellence and patient safety do not.”
An abstract and access to the full study is available here.
Young says patient satisfaction surveys can inadvertently lead patients to put more emphasis on comfort and convenience, when in fact they are not the primary focus. The survey asks them about such issues because they are easier for the patient to assess than clinical care quality. Then, the survey results incorrectly suggest that is the patient’s priority, he says.
“When patients come to the hospital, they appreciate these amenities and customer service aspects, but that’s not what they are there for,” Young says. “I don’t think any patient is going to say they came to the hospital for a good hotel experience. Hospitals are all about getting you the medical care that you need. Hospitals shouldn’t be distracted from that by metrics they happen to be measuring with patients.”
Nevertheless, hospitals are distracted by patient satisfaction scores. Facilities may go along with the misguided idea these scores are true measures of quality and patient satisfaction. Perhaps leaders realize the truth and just play the game as a pragmatic way to receive the high scores that everyone wants.
“This has been a rabbit hole that a lot of people have fallen into. Hospitals are doing the things that raise patient satisfaction scores, and it makes it sound like patients are getting what they wanted,” Young says. “But it’s really troubling when patient satisfaction scores address not what they really value but what they can see about your hospital. Saying you raised patient satisfaction scores doesn’t really mean patients are happy. It just means they’re happy with what they can see.”
The problem is rooted in the difficulty of showing meaningful data to patients, Young notes. It is much easier to provide amenities and ask about them than it is to explain the intricacies of morbidity, mortality, readmission rates, and similarly complex metrics. Providing only the simplest version of that information could be detrimental, Young cautions.
“I still struggle with this, because I’m not sure you want to post your mortality rates on the front door. ‘Seven percent of all patients who come into this hospital die within 30 days, and we’re in the 40th percentile of hospitals on this metric,’” Young says. “That’s being honest with patients, but it’s also pretty scary without knowing how it’s calculated and what it takes into account.”
No restaurant wants to post a notice saying, “We have very low rates of food poisoning,” Young explains. The restaurant does not want to prompt potential customers to even think about food poisoning. Similarly, hospitals do not want to talk about a patient’s chance of dying when they first enter the hospital.
“But hospitals have to be held to a higher standard. They have a fiduciary responsibility to their patients,” Young notes. “They shouldn’t be selling their patients a marketing campaign about high patient satisfaction scores. If they are serious about real medical quality improvement, the satisfaction scores are a real distraction.”
The American Customer Satisfaction Index (ASCI), a data analysis of customer satisfaction across many industries, measures hospital satisfaction. Most recently, the index revealed customer satisfaction with hospitals is down 5.3% from the previous year. The report says that is likely due to shifts from inpatient to outpatient settings.
Patient satisfaction with ambulatory care is steady at a score of 77 of 100 for the fourth year in a row, the report says, but patient satisfaction with hospitals was down 5.3% to 72. “As more hospital care shifts from inpatient to outpatient settings, hospitals overall suffer in customer satisfaction,” the analysis says. “The most significant erosion occurs for emergency room services, retreating 8% to 67 and losing all of the gains made over the past two years. Wait times are a clear issue for emergency departments as incidences of patients leaving ERs without being seen are becoming increasingly more common.” Outpatient satisfaction scores fell 4% to 75, while inpatient care scores were up 1% to 76.
Young says he is hopeful the healthcare community soon will turn its focus from satisfaction scores. “Once people come to recognize the limitations of satisfaction scores, I have no doubt that hospitals will be willing to set them aside and have an honest discussion about measuring what matters to patients,” he says. “It could be a stepping stone to rethinking how we measure what happens to patients in a way that really digs down to the most fundamental things that matter to patients.”
- Cristobal Young, PhD, Assistant Professor of Sociology, Cornell University, Ithaca, NY. Email: firstname.lastname@example.org.