Has the focus on patient satisfaction gone too far?

One author says happy patients don't mean healthier patients

Writing in The Atlantic, Alexandra Robbins—author of a recent book on nurses—argues that focusing improvement efforts on the patient experience can ultimately do more harm than good.

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Under the Affordable Care Act's Value-Based Purchasing program, some Medicare payments to hospitals are now tied to patient satisfaction scores from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The problem, Robbins argues, is that improvements in patient satisfaction are not always tied to better health care outcomes.

The link between patient satisfaction and outcomes

Robbins cites a 2012 study by researchers at the University of California-Davis that found high patient experience scores were correlated to higher health care spending, hospitalization rates, and mortality as evidence of the potential harm brought by focusing on patient satisfaction. (Study author Joshua Fenton noted in a Medscape Medical News interview last June that the study was not an examination of the quality of care.)

Higher patient satisfaction scores linked with poorer outcomes

While research has not determined the relationship between patient satisfaction scores and care quality, Robbins argues that patient satisfaction surveys do not incent high-quality care because many of the questions are extraneous to health care outcomes. For instance, she says a question on HCAHPS related to how quickly nurses responded to patient call buttons seems valuable, but is "misleading because it doesn't specify whether the help was medically necessary."

Moreover, Robbins says an emphasis on patient satisfaction can put unwarranted pressure on nursing staff. In one case, Robbins spoke with a nurse who had heard of a colleague who had a negative comment placed in her personnel file because a patient complained about the lack of Splenda at the hospital. An Oregon nurse also complained of the outsized role of patient satisfaction in hospitals. "Many patients have unrealistic expectations for their care and their outcomes," the nurse said.

Moreover, providers may actually harm patients by focusing too much on patient satisfaction, Robbins argues. She spoke with a Missouri clinical instructor who observed, "Sometimes hearing bad news is not going to result in a satisfied patient, yet the patient could be a well-informed, prepared patient." Fenton hypothesized in his 2012 study that doctors may be less tough with patients—even when toughness is medically necessary—to avoid poor patient satisfaction scores. However, he notes that the study did not examine that possibility specifically.

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Curbing providers' autonomy

Robbins argues that efforts to improve scores are reducing the autonomy of nurses. "Perhaps hospitals' most egregious way of skewing care to the survey is the widespread practice of scripting nurses' patient interactions," she writes.  One nurse wrote in The Boston Globe that such efforts were an attempt to turn her into a "Stepford nurse."

Robbins also takes issue with hospitals financially incenting nurses and doctors based on patient satisfaction scores. "These health systems are ignoring the possibility that health providers, like hospitals, could have fantastic patient satisfaction scores yet higher numbers of dead patients, or the opposite," she writes.

A better way to improve patient experiences?

Ultimately, "many hospitals seem to be highly focused on pixie-dusted sleight of hand because they believe they can trick patients into thinking they got better care," Robbins says. In her analysis of patient satisfaction scores and Medicare quality data, Robbins found that two-thirds of hospitals that perform worse than the national average in three or more patient outcome categories also had above average patient satisfaction scores on HCAHPS' "Would you recommend the hospital?" question.

A better way to improve quality and patient satisfaction scores is to improve the working conditions for nurses and maintain appropriate staffing levels, Robbins writes. She cites a Health Affairs study that identified a positive work environment for as one of the largest predictors of patient satisfaction. And, according to Linda Aiken, a professor at the University of Pennsylvania, higher staffing of registered nurses was strongly tied to fewer patient deaths and improved quality.

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Robbins concludes that hospitals should avoid focusing on "smiles over substance," adding, "When hospitals improve nurse working conditions, rather than tricking patients into believing they're getting better care, the quality of care really does get better" (Robbins, The Atlantic, 4/17; Brookes, Medscape Medical News, 6/11/14).

The takeaway: One author argues that the emphasis on patient experience prioritizes style over substance.


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