Seek patients' experiences on satisfaction surveys

When you see innovations in raising or measuring consumer satisfaction with health care, you'll probably find this month's guest, Susan Edgman-Levitan among the initiators. As president of the nonprofit Picker Institute in Boston, she steers nationally acclaimed efforts to promote quality and better serve consumers' needs. As an instructor in Harvard Medical School's Department of Medicine, she teaches at Beth Israel Deaconess Medical Center.

Edgman-Levitan is a physician assistant by training. At Duke University Medical Center in Durham, NC, she was responsible for the educational curriculum of the Duke Physician Assistant Program. She has also served as technical advisor to the National Committee on Quality Assurance (NCQA) committee to develop the Standardized Member Satisfaction Survey 1.0.

Q. You make a compelling case for monitoring patient satisfaction feedback as a key to upgrading the quality of health care. Why is it so important?

A. There are several very important reasons why providers should look for feedback from their patients. But before I get into that, I'd like to stress how thoughtful providers should be about the kind of feedback they seek from their patients. What a lot of people think are good patient satisfaction questions focus on things that patients could care less about. At Picker Institute, we've found the patient's definition of quality is not that different from a clinician's or another health care expert's definition of care.

I think most patients, unless they are health care professionals themselves, would say that they can't really judge the technical quality of care. But there are many aspects of quality that only the patient can tell you about. That's one of the arguments we make for getting patient feedback.

Q. Will you give us an example of the kind of patient feedback that helps providers make meaningful improvements?

A. Take pain control. It doesn't matter a whit what you've documented in the chart about what you're giving the person to control pain if the patient is still hurting. And, the only way you can find out is by asking.

It doesn't matter how quickly you answer a call light unless the person answering the light can take care of the patient's problem. And the patient is the only one who can tell you that.

All the forms you find in a chart, documenting everything that's been told to patients about their conditions, their cases, or how to take care of themselves, are worthless if the patients don't understand the information. And the only way to find out if they understand is to ask them.

Q. What sorts of questions would capture such information?

A. Our work has taught us to ask people questions such as, "Did someone tell you the danger signals to watch out for when you went home from the hospital?" Or, "Did someone tell you who to call if you had an emergency or a question?" That's very specific. They either understood it or they didn't.

Several studies have also documented that patients' hospital or doctors' office experiences have a very big influence on how they do in the long run, and how well they follow your instructions. If they don't understand your instructions, they are certainly not going to be able to follow them. If they don't understand why they are taking a certain medicine, they are probably not going to take it. Those things really do affect outcomes.

Q. How could we design patient questionnaires to gather the kind of feedback you describe?

A. We have a particular way we design our survey instruments. Not everybody in the world agrees with us, but I think that more people are moving toward asking patients about their experiences as well as their overall satisfaction.

For example, we are one of the teams working on the national standardized consumer assessment of health plans survey (CAHPS) - developed by the Agency for Healthcare Policy and Research. (For contact information or to order a copy of the CAHPS survey and reporting kit, see box, p. 143.) It has been adopted by HCFA (Health Care Finance Administration in Baltimore) for Medicare and Medicaid. It was just recently adopted by NCQA for all the people insured by commercial operations.

The CAHPS survey uses a combination of satisfaction ratings and reports. Some of the questions have "yes" or "no" answers. For others, we use a zero to 10 rating scale. For example, "We want to know your rating of your personal doctor or nurse. Use any number on the scale from zero to 10, where zero is the worst personal doctor or nurse possible, and 10 is the best."

The results will be displayed in groups: Zero to six will be together. Seven, eight, and nine will be another group. Ten will be a separate group. Anything below a seven is not very good.

Q. Among the array of quality measures that we typically use - treatment outcomes, cost per procedure, service utilization rates - how critical is patient satisfaction?

A. I think it's just as important. But if you think patient satisfaction is asking people about parking and food, I am not that interested. I think these kinds of questions are OK, but nobody picks a hospital because it serves gourmet dinners every night.

In fact, we've seen hospitals concentrate on the quality of their amenities without changing the fundamental way they provide care, and it makes the patients angry. We get written comments from patients such as, "Who did they think they were fooling?"

We worked with one hospital that had gone through an unbelievable renovation. The outside and a lot of the hospital people saw when they first arrived looked almost like a hotel. They had valet parking. They had the guys with the brass carts to help you get in. But once you got into the functional part of the hospital, it was business as usual.

Their patient satisfaction plummeted because people expected the whole place to be improved. People were furious because they thought the hospital was fooling them with these external trappings. What they wanted was high quality medical care, not the Ritz Carlton.

Q. Generally speaking, could higher patient satisfaction help contain or lower health care costs?

A. When you ask patients to help you come up with a solution to a problem they are having, their ideas are always extremely inexpensive and very easy to implement compared to what we, as the health care professionals, design if we are left on our own!

I'll give you an example: One of the strongest predictors of overall satisfaction with care is the quality of emotional support that patients get when they are in the hospital. One hospital we worked with had very high problem scores on that dimension. They had put together some quality improvement teams, but they hadn't talked to any patients.

Pinpoint patients' needs

One of their patient satisfaction questions was, "Was there someone available to talk to you about your concerns?" But it never occurred to them to find out what kind of concerns their patients had. So they jumped to the conclusion that they needed more chaplains. They were going to start this big chaplaincy program and bring in a lot of new people.

We knew, though, that most of the time when you sit down and ask people about their concerns, about half of them are things they need to talk to their doctor about. And they need to talk to somebody from the financial office about the other half. They might be worried about how they are going to pay their bill, or what their insurance covers, or about the financial implications of their illness.

This hospital would have spent a lot of money bringing in chaplains who would not have addressed the real issues the patients were concerned about. And their problem scores would have stayed the same.

Another example of how patient satisfaction feedback can lower costs is when you ask people what you can do to help them get ready to go home from the hospital. Again, if you put a group of health care professionals in a room, we come up with about a zillion forms to put in the chart. We'll make all kinds of new procedures and policies to make sure patients go home with the information they need.

But what patients will tell you is, "Give me a notepad by my bed so I can write down all my questions, and my family can write down all their questions. Because whenever you come around, either I am asleep or my family is not there. We just need a way to document our questions so you all can see them, have a chance to think about them, and give us the answers." It's that simple.

Q. Can patient satisfaction and profitability be compatible goals?

A. Yes. If you look at most hospitals these days, they all look pretty much alike in terms of technology. We no longer have just one hospital in the state doing heart surgery, or one doing joint replacements. You can go to your local community hospital and have all sorts of things taken care of, so what hospitals have to compete on is the quality of their caring.

In the 10 years we've been doing patient satisfaction work, we have consistently seen that the top performers in patient satisfaction are amazing places. They take good care of their employees and they're good places for patients. They're very well managed because they've got to have a clear cut mission and culture to address the things that patients care about.

I think we are very much in transition in terms of understanding that health care is a service business. We're changing from a very paternalistic system to one that's much more collaborative. In order to make the transition, places have to be well managed and well run. That does not happen without a lot of focus and intent.