Show me the quality’
Satisfaction report cards vs. QI measures
By Irwin Press, PhD
President
Press, Ganey Associates
South Bend, IN
As more states begin to mandate patient satisfaction report cards, increasingly cost-conscious hospitals may be tempted to save money by relying on report card satisfaction data rather than utilizing a true quality improvement monitoring system. It’s a shortsighted move.
Here’s just one example of what is happening with such state-mandated satisfaction data. In November 1998, a consortium of Massachusetts hospitals, health plans, and business coalitions, plus the state Hospital Association and Medical Society, published a massive report card in which a number of state institutions were rated by patients on satisfaction with care. Participation in the study was voluntary, and close to 50 hospitals participated.
Although the stated goal was individual hospital quality improvement — not competitive comparative rankings — all of these hospitals’ patient satisfaction scores became public property.
Public release of quality performance data isn’t limited to hospitals. The Health Care Association of Michigan will soon be releasing (via paper and Internet) a guide to the quality of all 450 state-licensed nursing homes. Not only will inspection citations be listed, but also family satisfaction results from over 300 nursing homes that had volunteered to be surveyed.
What’s happening is that previously in-house data are now becoming public property. Americans are no longer taking the quality of hospitals, physicians, home care, nursing homes, or other providers for granted. The new rallying cry for those who are shelling out more and more money for their own care, or for their customers’ or members’ or employees’ care is, "show me the quality."
As the new millennium opens, "quality" is the key word. Price is still important but will likely level out among providers competing for HMO and other purchaser contracts (higher-cost institutions will simply have to offer deeper discounts). This leaves quality as the differentiating factor. And patient (customer) satisfaction is a key indicator of quality because of these factors:
readily understandable; comprehensive in its coverage of care; spin proof. Health care providers can’t excuse low satisfaction scores by claiming to have sicker, poorer, older, or dumber patients.All patients deserve the highest quality technical and personal care. Because of these advantages, satisfaction will match or even exceed "harder" clinical or financial data in importance as a key quality indicator.
Any information on quality gathered by payers, agencies, or interest groups external to the provider can be called report cards. These external entities either survey your patients themselves — HMOs sending out the HEDIS survey, for example — or ask providers to send surveys out for them. Either way, external entities, and often the public, get to see and evaluate your performance on the basis of the report cards.
This means that a lot of people outside your organization are going to be looking at your patient satisfaction scores and basing judgments of your quality on them. At present, many such report cards are still voluntary. But peer pressure alone will soon force providers to participate in statewide or systemwide surveys.
Ultimately, some report cards will be mandated. A half dozen different entities may simultaneously be judging your performance, either by requiring you to survey patients or by doing it themselves. (Your patients, after all, are their customers or constituents.)
State-level health care organizations will publish the results. (This kind of action is consistent with their stated mission.)
Managed care organizations and business coalitions will be more than happy to use report card results to:
• contract with one provider rather than another;
• pressure providers into accepting lower reimbursements.
This goes both ways, of course — and that’s the whole point. Providers with superior report cards will be able to compete successfully for contracts and leverage higher reimbursements from payers. An HMO cannot afford to risk credibility by leaving out of its roster a hospital with very high local patient satisfaction.
To stay on top of external evaluations, providers must be collecting patient satisfaction data by means other than report cards. There is a major difference between patient satisfaction surveys for internal vs. external use. External report cards are essentially global measures of performance and satisfaction. Hospital A is performing 41% below expected numbers. Physician practice B is in the top 10% of statewide medical practices. But, for both Hospital A and Practice B, it is essential to have data that help identify what could be called "causal elements."
Causal elements are any departments, services, units, or individuals that have patient contact and some level of responsibility for the patient’s experience of care. This means that you need patient satisfaction measures that can break scores down by nursing unit, department, medical specialty, function, physician, or shift. If you can’t do this, you can’t identify top performers to use as internal benchmarks for recognition and rewards. You also can’t identify units, services, or individuals who are having a negative impact on satisfaction and who need remedial attention.
Report cards, typically, don’t break satisfaction scores down by actionable units of analysis. Moreover, most report cards are "one-shots" or annual surveys. A lot can happen between surveys. You’re caring for patients continually, not once a year. You need quarterly or even monthly data.
Don’t rely on old data
Perhaps most important, report card data tend to be old data. Most such report cards are published (let alone made available to the providers) months after the data are collected. Improvement processes cannot be effective if based on information as much as a year old. You need to be on top of patient satisfaction before you’re slammed with low scores on some report card.
This means that you may have to pay for two patient satisfaction surveys — a sporadic report card (for others) and a continuous quality improvement program (for yourself).
There may be a temptation to avoid double-dipping by relying on the report card alone. The result will be sporadic, incomplete, and outdated information that can’t identify good performers or specific areas for improvement. Neither the quality of care nor external report card grades can be affected.
Providers must not confuse the functions of one-shot report cards and true ongoing quality improvement surveys. One is for outside evaluation. The other is for internal management — a tool that helps you to "show the quality."
[For further information on patient satisfaction measurement, contact Irwin Press, PhD, Press, Ganey Associates. Telephone: (800) 232-8032. World Wide Web: www.pressganey.com.]
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