Data aren’t the problem; it’s using data we have
Data aren’t the problem; it’s using data we have
Measurements must facilitate improvements
[Irwin Press’ name has become synonymous with patient satisfaction surveying in the health care field. As co-director of Press, Ganey Associates Inc. in South Bend, IN, he has pioneered the use of satisfaction surveys in quality improvement. In this month’s Quality Talk, he shares with QI/TQM readers his vision of where the health care quality movement is headed, the problems we must overcome, and the leadership that will take us where we wish to go.]
Question: Where do you see the industry headed?
Answer: I see an intensification of the concern for quality and sharper definitions of what quality means. All around the country, there’s talk about outcome measurements. In fact, President Clinton has an advisory commission on consumer protection and quality in health care. The whole commission is devoted to looking at how to ensure quality in health care. There is, in fact, a subcommittee on performance measurement that is directing its attention to developing policies for the establishment of outcome measures and performance measures. All of these are going to force the entire realm of health care to pay attention to improving quality because they’re going to be accountable for it.
Question: What do you mean by sharper definitions of quality?
Answer: There are a lot of different kinds of quality and outcomes measures, but we’re attempting to come up with some that make sense. There are technical issues, but as patient satisfaction becomes more important, there are interpersonal and service issues as well. And there are a number of risk adjustment mechanisms that are being developed and these are going to have to be sharper which means that a lot more focus is going to be on coming up with clear outcome measures that you can tie back to quality in care.
Question: How do patient satisfaction surveys fit into the overall picture?
Answer: I think they are going to be more important as time goes on because it’s still a competitive industry. We’re not going to a single-payer health care system, which means that a number of different institutions will be offering health care. This means it’s competitive, and if it’s competitive, people are really going to want to satisfy the customer.
More and more, health care is becoming a consumer industry. It’s always been a consumer industry, but we never viewed it as that. We always put a big spin on health care that it’s something more special. But now it’s coming to be seen as the consumer industry that it is. HMOs are competing for business; hospitals are competing with one another to get on HMO panels. Physicians are the same way. And as more of this goes on, patient satisfaction is going to become extremely important.
I’m not so sure that the public itself is going to be as interested in seeing the patient satisfaction data. Studies have indicated that the public is far more swayed by the opinions of others, such as their families and friends. But this means that employers are going to be interested in the satisfaction of their employees. HMOs are going to be interested in the satisfaction of people in their plan.
It all comes down to this: Providers are going to be extremely interested in tapping the satisfaction of their patients because that’s the only way they are going to be able to have the information that will allow them to improve services so that they will look good on these report cards that are out there.
Question: What’s the relative importance of the report cards to the patient satisfaction surveys?
Answer: One has to do with accountability, how well are you doing in general. Should you be accredited? Should an HMO get that particular hospital or physician group on board? Those are the report cards. They don’t need to know all kinds of specifics, though. They don’t need to know about nursing units or anything else like that. But the data on them doesn’t help hospitals or physician groups improve their quality because they’re not specific enough.
But there’s not only accountability as measured by the report cards there are quality improvement outcome measures that patient satisfaction surveys target. Hospitals and providers are going to be using the quality improvement outcome measures in order to keep up their quality, improve their quality, and work on it so that whatever report cards are out there, they will look better on their accountability measures. They won’t be able to do well on accountability measures unless they are capable of identifying opportunities for improvement internally.
Question: What do you think about the SF-12 and SF-36 patient satisfaction surveys? Are they good quality measures?
Answer: Only if they are specific enough to be able to be tied back to individual departments, individual physicians, individual shifts, or even individual procedures. If they are not, then it’s really more for accountability. For example, if you find out that a particular hospital doesn’t look good on hip replacements on the SF-36, what can that hospital do about the data? If the data can be broken down by physicians, shifts, areas, and groups that performed the procedures, then you have a quality improvement instrument. If they can’t, then you have an accountability instrument.
Question: What do hospitals need to do to make the data more specific?
Answer: The hospital itself has to constantly be monitoring its own quality. That means it has to be monitoring its own performance. Most hospitals and physicians should have to measure performance on a much broader scale of processes and procedures than any external instruments could possibly measure. In other words, hospitals have to be measuring patient satisfaction down to the units, down to the shifts, and down to individual nurses and doctors if they possibly can, so the data the hospitals find can be used for specific improvement processes. This would allow any provider getting this kind of specific data to be able to improve care throughout the organization at any level, which means, automatically, that providers will be performing better on external accountability measures or report cards.
Question: Where do information systems fit into quality improvement?
Answer: You have to have better information systems so you can begin to feed in information that may not have been fed into the system before not just medical records, but more specific information for identifying individual physicians and nurses who are part of teams and processes that were used. And you’ll probably need computer programs that will be able to analyze this information and look for patterns.
Question: What are some of the big obstacles in these data gathering efforts?
Answer: The big thing is using the data. There’s a lot of data out there, quite frankly. One of the things that we find is a lot of the providers are not using data that are readily available to them right now. That’s the problem. Perhaps one reason is that this whole data push is so new. Ten years ago, hospitals weren’t even monitoring death or infection rates very well. Yes, there was quality assurance; there’s no question about that. But it was generally for internal purposes and the information systems weren’t around.
Ten years ago, many hospitals weren’t even using computers. This is so changed and so different now, they haven’t caught up with the information revolution. So as a result, hospitals are beginning to look at all kinds of programs that are tying information together because they still aren’t capable of doing it very well. I would say it’s going to probably take another ten years before hospitals are going to be able to truly use all of the data that are available to them right now.
There’s a logical close relationship between patient satisfaction and financial health in the hospital. And yet most hospitals are still incapable of simply looking at financial performance of the different parts of the hospital and tying that into patient satisfaction with those same portions of the institution. And one reason is that there are so many things that have to be tied together, that many institutions just don’t see that as a priority. But that’s the kind of information that, once you have it at your fingertips, will justify paying far more attention to quality issues.
For a long time, people have been raising the issue, "You’re either going to have to have quality or profitability. You can’t have both because if you’re going to go for big quality, you’re going to have to go for big expenses to back up that quality." But is that really the issue? Or does it turn out that where you have higher quality as measured by patient satisfaction and outcomes measures, you also have higher profitability? These kinds of tests and correlations will ultimately justify the attention to quality.
Question: Is there a group of facilities that is doing better in terms of quality?
Answer: No. There’s no clear grouping that you can make, such as religious-based or teaching hospitals do better with their patients. There are various demographic factors that seem to affect patient satisfaction. For example, in larger cities, patient satisfaction tends to be lower. In smaller towns, patient satisfaction is higher. But that doesn’t mean that in smaller towns you’re going to get better quality care. It all boils down to the culture of the specific organization and the mission of the leadership. That’s all.
Question: What do you see is the biggest obstacle in achieving quality improvement?
Answer: Without a doubt, it’s not taking the patient’s perspective seriously enough. This means not putting the resources into responding to patient satisfaction information. When we’re talking about patient satisfaction, we’re not talking about which ones are happy campers. We’re talking about actual positive input into quality of care that these patients are getting. And therefore, the biggest challenge nationally is for hospitals to take patient satisfaction seriously.
Other big obstacles are a need to establish procedures for attacking and addressing problems when they occur and lastly, re-engineering the culture of the organization so that all of the members within an organization are on the same page when it comes to taking patient satisfaction seriously and responding to the information.
Clients will call us up after a year of using our data and say "Hey, how come our scores haven’t gone up?" The answer is: You’ll never get the scores up if you don’t do something with the data.
I have a Palestinian student at the University of Notre Dame. He says there’s an old Palestinian proverb, "You can’t fatten the cow by weighing her." That’s a great statement. You can’t raise satisfaction just by measuring it. You have to do something with the data. The biggest challenge we see is actually getting the hospitals to use the data. Those that pay attention to the data and make them a part of their corporate culture are the ones who will succeed.
When corporate culture says "We’re going to continue to improve and view every score that isn’t the highest as a marvelous opportunity to show off and show what we can do," that’s where you’ll see some noticeable gains. The responsibility falls to administrative leadership, not the doctors. Physicians would be the ideal ones to lead the quality revolution, but they are followers, not leaders. And they are still very distrustful. We have hospitals that absolutely refuse to have questions about their physicians on patient satisfaction surveys because physicians are saying "How dare patients think that they can judge us." Believe me, it happens. That’s exactly why physicians aren’t going to take the lead in quality improvement. Go to top administration. We have to get the trustees. Trustees have to look at the hospitals and say "You’ve got to do this. This is important, and we simply will not tolerate it if you don’t do it."
[Contact Irwin Press, PhD, at Press, Ganey Associates Inc., 404 Columbia Place, South Bend, IN 46601. Telephone: (219) 232-3387. Or e-mail, [email protected].]
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.