Sat Scores Are Helpful & Necessary
by Orion Colfer, MD
Let’s start here: A patient’s satisfaction matters. Being an ED physician is not simply an academic exercise. The human interaction of patient and caregiver provides the foundation to the care we provide. Performed effectively, this interaction requires connection and communication. For all of these reasons, measuring and reporting patient satisfaction is the right thing to do both for patients and physicians.
Patient satisfaction surveys, however, are easy to dislike. Emergency physicians have many negative comments about their value and validity: “The response rate is too low.” “The “n” is too small.” “The curve is too tight.” “There is selection bias.” “Only discharged patients are surveyed.” “Some patients have an ax to grind.” “The survey gives a voice to drug seekers, the unreasonable and the insane.” “No reasonable person would actually take the time to fill out one of those surveys.”
But is that really why we don’t like them? Let’s be honest. Those who don’t want to participate in any program have always looked for reasons to explain their lack of agreement. Are there limitations to the scientific method behind surveys, sure there are. Aren’t there limitations to the scientific data behind much of what we do in medicine? Most importantly, when the data from patient satisfaction surveys is interpreted and applied correctly, the data is valuable and can be used to improve the patient experience. These are the rules of engagement in the patient satisfaction arena. Our dislike, mistrust or lack of understanding of widely accepted survey science is not an effective argument to discredit patient satisfaction surveying. Such arguments appear defensive and self-serving. At worst, it appears arrogant and dismissive. These are not exactly the traits that patients seek in their physicians.
Working from the assumption that patient satisfaction measurements can provide us with feedback from our patients and that we want that feedback, the true importance and value of the process becomes apparent.
What kind of feedback do we solicit? In the case of Press Ganey, patients are asked to provide feedback regarding the physician’s courtesy, ability to listen, ability to inform and concern for comfort. Are these important aspects of the patient care experience? Our patients think so. There’s nothing listed regarding “quality”, making the right diagnosis or choosing the right antibiotic. There are also no questions asking about ordering tests, writing prescriptions for narcotics or even meeting expectations. It’s just courtesy, concern for comfort, informing the patient and listening to them. That’s what it takes to satisfy our patients.
Contrary to what some might think, our patients are not necessarily satisfied when we order unnecessary CT’s, write unneeded prescriptions (the majority of which go unfilled) or simply “give them what they want.” The assumption that successful patient satisfaction hinges on meeting patient expectations with unnecessary testing and treatment, is our baggage. In reality, there is a significant amount of evidence indicating that we are miserably inadequate when it comes to correctly identifying patient expectations.
The overwhelming majority of our patients do not want our tests or drugs. They want our attention. They want us to listen and care. They want us to empathize. They want to form a meaningful connection with us in order to trust that we are acting in their best interest. They want to believe that we will help them with their pain and their worries. It’s not enough to know the medicine. Knowing the medicine is just the start. Being a complete ED physician means connecting with our patients.
It’s not surprising that ED physicians have resisted and refuted the importance of patient satisfaction measures. As residents, we are woefully underexposed to interpersonal communication skills and how to incorporate such skills into practice. We are taught to “move the meat”, not empathize and communicate with it. Despite our desire to be saving lives every day, n reality, we spend most of our time managing the worried well, doing social work and patching together chronically ill patients.
My opinions on patient satisfaction are not based solely on my personal experience but also on the broad experience of many of the physicians with whom I work. One of our groups core values isa “servant’s heart.” After much discussion and debate over the course of years, we have declared patient satisfaction to be a core clinical competency. For nearly a decade, we have used physician specific patient satisfaction scores to determine a portion of our compensation.
It wasn’t easy for our group to get to where we are now. There were intense, sometimes volatile, discussions among the physician partners. Ultimately, we reached a group consensus that we were committed to providing the best experience for our patients – including the best clinical care and the best communication – and we use physician specific patient satisfaction scores as a measurement.
Not surprisingly, our decision to measure, report and compensate our physicians based on patient satisfaction performance had several consequences. High performing physicians continued to do well and they were being recognized and rewarded for their success. A few of the low performing physicians were able to change their behavior in order to improve. However, a large number of physicians struggled to improve and an even larger number could not perform consistently. Aside from the “naturally gifted” patient satisfiers, our physicians felt disempowered, deflated and defeated.
We became acutely aware that we needed to provide our physicians with resources to improve their performance. This started by gathering our best and most consistent performers together in order to gain a better understanding of how they succeed. Led by our best and brightest patient centered physicians, we were able to develop a plan and program to bring to our physicians to give them the tools and resources to improve their performance.
Our approach has been remarkably successful. The mean score for attendees has increased from the 19th percentile prior to the program to the 74th percentile after attending the training. More importantly, the physicians that have attended report improved satisfaction and clarity with their jobs. They report being able to succeed at patient satisfaction by focusing on patient-centered care and communication. They confirm our suspicions that satisfaction is not about doing unnecessary tests and over-prescribing narcotics. They have not found that patient satisfaction negatively impacts the time or quality of care they provide for critically ill patients.
Presently, approximately 60% of the physicians in our company score above the 90th percentile and 85% score above the 50th percentile. This success is in part due to our training But in reality, that is only one part of the plan. Patient satisfaction has become part of our mission. We talk about it in recruiting and physicians are integrated into our culture when they join the group. We talk about it at director’s meetings and staff meetings. We are developing ways to educate our hospital partner’s nurses, and work with administration to improve our performance.
The bottom line is that our physicians believe that they are empowered and accountable for their performance. The results have been increased physician satisfaction, decreased malpractice risk and improved stability of our hospital contracts.
Emergency physicians absolutely need to be educated in order to optimize their patient satisfaction performance. The leaders in Emergency Medicine would better serve our patients and physicians by working to develop programs and methods train ED physicians to succeed in bedside communication. Our managers and leaders must become experts in interpreting and communicating patient satisfaction results with hospital administrators. It is our responsibility to take ownership of this process and these results so that our hospital administrators are not misusing or misinterpreting such results. Unfortunately, the energy spent fear mongering around patient satisfaction is not serving anyone’s best interests.
Ultimately, it’s about the patient. Patient satisfaction measures give our patients a voice. Rather than spend time and energy arguing with, explaining away or ignoring that voice, let’s make an effort to listen. Let’s look for opportunities to understand. Let’s seek to provide our patients with the best experience possible. After all, a patient’s satisfaction matters.
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>>Counter point by William Sullivan, MD, JD Sat Scores Are Harmfully Misleading
by William Sullivan, DO, JD
However, when we attempt to quantify patient satisfaction, the whole concept falls on its face. Even my ten-year-old son knows that you can’t predict the frequency of colors in a three pound bag of M&Ms just by grabbing a handful off the top. Yet satisfaction survey companies routinely make similar assertions every day by performing advanced statistical calculations on the results of 40 surveys from 6000 patient visits. Then they misuse data even further by creating numerical data about specific physicians from 6 or 7 survey responses.
When hospitals or contract management groups then tie our compensation or even our employment to monthly “numbers” that don’t come close to meeting statistical significance, they are misusing the statistics and detracting from the proper practice of medicine . . . and the satisfaction survey companies are laughing all the way to the bank.
It would be great to measure a physician’s quality of care and to reward those who practice high-quality medicine. Unfortunately, the concept of “quality” is a lot like the concept of “justice” – we know it when we see it, but no one can properly define it. Some companies instead take a variable that can be measured and then use “experts” to make everyone believe that the measure reflects something else. In essence, satisfaction survey companies have taken a big pot of “patient satisfaction” and slapped the label “quality” over the front of it. Then, by showing hospital administrators and hospital boards how competitor hospitals are “performing better,” the companies have gotten full scale buy-in from their clients. It’s like a modern day reincarnation of the Emperor’s New Clothes.
Satisfaction survey companies know that hospital boards and hospital administrators want something that sets their hospital apart. There’s this “Top 100” and that “Top 100” plastered on billboards all over town. Patient satisfaction companies give hospitals yet another metric to brag about. We’re in the 95th percentile! That’s great. Funny how we don’t hear about all of the patients in those communities who have developed MRSA due to unnecessary antibiotic prescriptions, who will develop cancer because they have been over-radiated with CT scans, and who make regular treks to emergency departments for their narcotic fix – all in the name of patient satisfaction. Just make sure you give us all “5”s so our numbers are better than our competitor’s numbers next month.
The problem with grading patient satisfaction is that the scores cater to the difficult patients. A vast majority of our patients are reasonable and well-adjusted. With our employment and our compensation hinging on every “5” we can get, doctors are reduced to giving patients whatever they want, regardless of the medical appropriateness.
But the emergency department doesn’t see that many of those types of patients, right? The last shift that I worked, I evaluated five patients with acute exacerbations of chronic low back pain and two patients with chronic toothaches. I treated their pain, but several were unhappy because I would not refill their opiate prescriptions. I made sure I addressed all of the bullet points for the satisfaction surveys and I had a nurse in the room to witness my interactions with the patients.
I review all of the complaints that come to our emergency department. Before Press Ganey, we had an in-house survey system that gave us similar grades, but that could also be correlated with the patient visit. It was interesting to find that patients who didn’t get what they wanted frequently graded physicians low in all categories, not just a few. When I asked nurses if the doctors were “rude” or “insensitive” as the patients had alleged, frequently the response was “no”. The patients were just angry and the survey was the best way to express those feelings.
Is anyone naïve enough to believe that I will receive all “5”s from patients who don’t get what they want? It is a statistical fact that survey distributions are bimodal. Really happy and really unhappy patients are the ones who complete the surveys. Even worse, with a few swipes of a pencil, one really unhappy patient can take a doctor who is in the 100th percentile with four patients and drag that doctor to the first percentile. In other words, turn away the patient who wants a Z-pack for his cough at the risk of your income . . . even your job.
Emergency physicians can always use guidance on how to communicate better. Patient feedback is a tremendous asset in this regard. But using statistically insignificant data to measure an unrelated set of data in order to create some illusion that one hospital or one physician is “better” than another demeans our profession and is harming our patients.