Hospitals are in constant pursuit of both quality and patient satisfaction, and it is easy to assume that good marks in one will mean good marks in the other. That often is not the case, however, and hospital quality leaders must be careful not to assume correlation.
The importance of patient satisfaction has increased in recent years, particularly with the implementation of Hospital Value-Based Purchasing (HVBP), part of CMS’ effort to link Medicare payment to a value-based system. Under the HVBP, hospitals are paid for inpatient acute care services based on the quality of care rather than just quantity of the services, with poorly performing hospitals receiving less reimbursement. Patient satisfaction is one of the metrics used to determine quality, via the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey, the first national, standardized, and publicly reported survey of patients’ perspectives of hospital care,
There can be some overlap in the measures used to compute scores, such as Medicare’s star ratings and HCAHPS, but the scores must be interpreted correctly, says Emma Mandell Gray, a senior manager at ECG Management Consultants, who specializes in care model transformation and performance improvement.
Research has shown that there often is no correlation between patient satisfaction and hospital quality scores, but Mandell says that may be changing. (See the story in this issue for more on the research.) As the healthcare environment continues to transition toward value and patient satisfaction, and experience measures are being integrated into overall quality scores, additional emphasis is being placed on these areas, Mandell says. That will help to ensure a positive correlation between patient satisfaction and hospital quality scores, she says.
There are good reasons a hospital may have good quality scores and poor patient satisfaction scores, or vice versa, Mandell says.
“Hospitals are, oftentimes, a place where patients go as a last resort, admitted to the ED appropriately or not appropriately, and are a place where providers have to deliver difficult news to patients,” she says. “Those participating in patient satisfaction surveys often only remember the outcomes of the situation, such as a death or a diagnosis of cancer, so the scores become skewed.”
(See the story in this issue for more on the accuracy of patient satisfaction scores.)
Resource Use Can Affect Scores
Hospital quality scores, however, are often focused on improvements in health outcomes, readmissions, mortality, safety, and resource use. With regard to resource use, this may mean that providers are more mindful of prescribing unnecessary medications or conducting unnecessary testing, regardless of the patient’s requestdemand to receive more medications or tests.
“If the provider does not comply because she or he may feel it is not necessary or quality care, then the patients may feel they are not being treated well and will report as such on their patient satisfaction survey,” Mandell says. “Some providers, who may be doing well with patient satisfaction scores, may end up over-prescribing or over-treating, which then could result in negative quality scores.”
In addition, hospitals are a fast-paced environment with staffing models that could be fairly lean, she says. The shift toward value-based care delivery is still fairly new and hospitals are now investing in the additional resources to ensure patients have the best experience while staying in the hospital. Mandell offers the examples of hospitals using care managers to help further explain treatment plans and get patients connected to resources once they are discharged, patient navigators to help patients through the system while in the hospital, and social workers or life coaches to assist with various community resources or social needs while in the hospital.
“The patient does not want to feel a rushed experience; rather, that they were attended to and their needs were met,” Mandell says. “This is difficult in the historical, volume-based environment we have been part of for many years.”
Mandell notes that hospital quality measures and patient satisfaction measures continue to be reassessed and evolve year after year, with the goal of identifying and prioritizing those measures that are most applicable and achievable. That analysis must take into consideration the value-based environment and patient population, she says.
“This conundrum of a negative correlation between the two should hopefully dissolve over the coming years as the healthcare environment continues to transform,” Mandell says.
Subjective vs. Objective
For the time being, though, the two measures should be seen as completely separate tools, each useful in its own way but having no relation to each other, says Shakil Haroon, CEO of MPIRICA Health Analytics in Bellevue, WA. The company analyzes hospital quality by focusing only on outcomes.
Patient reviews on public forums are particularly unreliable, he notes.
“We find absolutely no correlation between actual outcomes and patient satisfaction reviews, or other subjective reviews,” Haroon says. “Using those subjective reviews to assess a hospital or surgeon’s performance is extremely unreliable. We’ve seen numerous instances in which we’ve compared our scores to patient satisfaction scores like those on Yelp or HealthGrades, and the reviews have no correlation with reality.”
Subjective reviews are generally easy to acquire and curate, Haroon says, so they have become useful tools for hospital marketing departments. The marketing campaigns often are misleading and intentionally imply a connection between patient satisfaction and quality that does not exist, he says. Haroon recalls one hospital system’s marketing campaign boasting that 100% of its surgeons had at least a four-star rating, of a possible five, on satisfaction surveys.
“These corporations want to give the impression that their staff and facilities are uniformly excellent, but the facts don’t support that assertion,” he says. “Consumers need to know the difference between marketing and actual performance. If that information is kept from them, you create a situation that is extremely dangerous.”
Quality Overstated by Marketing
Haroon and his colleagues have studied surgeons’ publicly available qualifications, such as patient reviews and their educational background, alongside those surgeons’ outcomes. The results can be surprising, he says.
“The marketing will talk about how the surgeon went to Harvard, is board certified, and has a 4.5-star rating on HealthGrades. You’re presented with this information as if that’s all you need to know about picking a surgeon,” Haroon says. “When you look at the actual data, the number of procedures performed, and the outcomes, you might find that the Harvard guy has consistently delivered a low level of care over four years, whereas the surgeon with the more pedestrian background and a lower HealthGrades review has consistently delivered excellent outcomes.”
Even when considering only patient satisfaction and not overall quality, patient-derived scores usually represent a small fraction of a physician’s patients, Haroon notes. That can be misleading if the score is based on as few as 10% of a physician’s patient population, he says.
Haroon says hospitals should distance themselves from any metric that significantly underrepresents case volume and has no correlation with outcomes, he says. Many hospital leaders know from outcomes data and other objective measurements that their actual level of quality is not as high as patient reviews in their marketing campaigns suggest.
“I’d say they know exactly what they were doing. The use of patient surveys is self-serving and potentially dangerous,” Haroon says. “There are hospitals that are paying fines and losing reimbursement because Medicare penalizes low quality, but they’re still advertising that they have excellent-quality physicians and facilities across the board.”
Scores Can Frustrate Clinicians
Putting too much emphasis on patient satisfaction reviews also can frustrate physicians and staff, says Donald Fry, MD, executive vice president for clinic outcomes management with MPA Healthcare Solutions in Chicago, and adjunct professor of surgery at Northwestern University Feinberg School of Medicine. Patient reviews are influenced by a range of factors, he notes, including many that have nothing to do with the actual medical care.
“Quality metrics actually are examining whether the measures of care and the outcomes of care were appropriate,” Fry says. “Patient satisfaction and quality metrics are two independent variables in the overall scheme of what happens to patients in the hospital.”
Patient satisfaction should not even be the purview of a hospital quality department, Fry says. The scores from patient surveys can be legitimate and useful, he says, but they have little-to-no bearing on the quality of medical care at the facility. They can be helpful in recruiting patients, so satisfaction scores should be the concern of marketing or another business-related department, Fry suggests.
That does not mean patient satisfaction ratings are unimportant, Fry says. Hospitals have a legitimate reason to measure patient satisfaction and act on any problems identified, he says.
“Treating people with respect and kindness, and having the conveniences in the hospital that they expect, will give them a favorable impression that they will pass on to friends and family, and remember when they need care,” Fry says. “If I were a hospital CEO, I would have a great deal of interest in patient satisfaction. But patient satisfaction should not be a metric in measuring the hospital’s quality of care.”
SOURCES
- Donald Fry, MD, Executive Vice President for Clinic Outcomes Management, MPA Healthcare Solutions, Chicago. Telephone: (312) 467-1700. Email: [email protected]
- Shakil Haroon, CEO, MPIRICA Health Analytics, Bellevue, WA. Telephone: (425) 243-9777. Email: [email protected]
- Emma Mandell Gray, Senior Manager, ECG Management Consultants, Boston. Telephone: (617) 849-5195. Email: [email protected]
What Do Satisfaction Scores Really Mean?
Sometimes patient satisfaction scores are not even an accurate measure of how patients perceive the hospital, says William Fletcher, clinical outcomes analyst with Proliance Surgeons, a system of surgical practices based in Seattle. Unlike objective measures, a patient satisfaction score can be influenced easily, and usually in a negative way.
“We have found over and over again that the entire list of 25 questions on a patient satisfaction survey can be ruined if a patient has to wait 45 minutes in the waiting room,” Fletcher says. “To that patient, everything was miserable. The doctor was awful, the front office was awful, the back office was awful. Everything was awful because they had to wait 45 minutes.”
A long wait time is a valid complaint and has a place in measuring satisfaction, Fletcher says, but a problem like that can unreasonably affect the rest of the survey. The hospital needs to know that the patient was unhappy with the wait time, but it will be misled if the patient answered the other questions in a negative way out of anger.
“We have surgeons with the highest satisfaction scores I’ve ever seen, but their outcomes are not better than our other surgeons, at least not to any degree that the score would suggest,” Fletcher says. “And we have other surgeons who, for whatever reason, just bottom out on patient satisfaction scores — they get horrible scores — and yet they’re some of the best surgeons in the country.”
Fletcher also notes that patient satisfaction is different from patient-reported outcomes, in which patients are asked how they fared after surgery. That is a valid measure of quality, though it can be influenced by subjective assessments to a lesser degree than satisfaction surveys, Fletcher says. Proliance uses patient-reported outcomes as a key measure of quality.
Proliance also relies on data on quality outcomes from sources such as MPIRICA and ProPublica, a non-profit news organization that publishes information on hospital quality, mostly derived from Medicare data.
“With those sources, we can get a much more accurate understanding of the quality of our physicians than we could ever get by asking patients if they were satisfied with their wait time and if the nurse explained the medication,” Fletcher says.
SOURCE
- William Fletcher, Clinical Outcomes Analyst, Proliance Surgeons, Seattle, WA. Telephone: (206) 264-8100. Email: [email protected].
Hospitals are in constant pursuit of both quality and patient satisfaction, and it is easy to assume that good marks in one will mean good marks in the other. That often is not the case, however, and hospital quality leaders must be careful not to assume correlation.
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