Use patient satisfaction information to improve care and performance

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Credentialing & Peer Review Legal Insider, April 11, 2007

In response to competitive pressures--as well as Joint Commission directives and state mandates--healthcare facilities are assessing patient experiences, collecting patient satisfaction information, and using the information gleaned from these activities in myriad ways.

Patient satisfaction information is important and useful. However, facility leaders must inform the physicians about what it will measure and how it will apply these measurements in order to facilitate physician acceptance of patient satisfaction data. In addition, a hospital may endanger the immunity of its peer review data, the confidentiality of its quality assurance activities, and its relationships with the medical staff if patient satisfaction information is mishandled or misused.

Patient satisfaction data can be a useful tool to establish and maintain high quality care and optimum physician performance, but in order for it to be effective, the facility’s expectations must be clear to the physicians, notes Richard Sheff, MD, chair and executive director of the Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

He suggests that facilities consider what indicators are important and spell out to the physicians how to achieve high ratings for those important indicators. For example, are a physician’s communication skills important? Most institutions and patients would answer in the affirmative. But rather than telling a physician that he or she needs to communicate well, it is more effective to describe the essential communication skills and specific communication events that patient satisfaction surveys may measure.

These measurable events may include the following:

Did the patient enter the hospital knowing what to expect?
Were the patient’s expectations realized? If not, why not? Were there unanticipated events, or was communication lacking?
If the patient was admitted on an emergent basis, was the patient—or family, if the patient was not able to communicate—informed promptly and thoroughly about the patient’s status?
Were treatment options clearly explained?
Were questions answered? Were questions anticipated?
Did the patient feel comfortable approaching the physician with questions and concerns?
Did the family feel comfortable approaching the physician with questions and concerns?
How would the patient and the patient’s family characterize the physician’s bedside manner?
Did the patient and the family observe any interactions between the physician and his or her colleagues? How would the patient and family characterize those interactions?
How much time did the physician spend with the patient?
Could the patient and his or her family contact the physician easily?
Was the probable date of discharge clear?
Were discharge instructions clear?

Compare performance, improve care
Once patient satisfaction data has been gathered, this data can illuminate how departments and individual physicians perform compared to their colleagues, Sheff says. But in order for patient satisfaction data to be a useful tool to improve quality, it must get into the hands of the physicians, and the physicians must accept what the data is telling them.

Sheff emphasizes that physician buy-in is easier if physician leaders have laid the groundwork by making clear to the physicians what it expects of them. Physicians who believe they are being measured on clinical performance alone are unlikely to be as receptive to patient satisfaction data as physicians who understood that patient perceptions were part of the yardstick the facility used to evaluate them, he says.

When providing the physician with the results of patient satisfaction surveys, be sure to emphasize the things the physician does well, says Sheff. He notes that it is very important for the physician to appreciate what he or she does well, and to realize that patients appreciate it, too.

But Sheff cautions that “push-back” should be expected if some of the data indicates that there are areas of patient dissatisfaction.

However, “most physicians will self-correct if they know what the problem is,” he says. “Even though they push back, no doctor wants to be an outlier. In the majority of cases they will work on and correct the problem with no further intervention necessary.”

Failure to correct may require intervention
If patient satisfaction data indicates that a particular physician is performing poorly in comparison with his or her peers, then “a series of escalating interventions” may be necessary, says Sheff. These may begin with a meeting between the department head or another colleague to discuss deficiencies, offer strategies for improvement, and set goals to mark progress. Ultimately, a physician who fails to correct a problem may be subject to peer review.

Using patient satisfaction data in peer review activities can be tricky because protected peer review requires that data be collected for the purposes of improving quality of care. A physician with poor patient satisfaction data, subject to peer review as a result, could argue that the information was collected for purposes of marketing the facility, rather than improving quality at the facility, says Jay Silverman, an attorney with Ruskin Moscou & Faltischek, PC, in Long Island, NY.

To avoid these consequences, hospitals should be clear about why they are collecting patient satisfaction information and what it will be used for. That is a further reason why it is crucial to design the patient satisfaction survey with quality care issues foremost, and to involve the medical staff at every step in the process. Information that is used to market the institution must be handled differently than information used to improve patient care and service quality.

For example, some facilities include patient satisfaction survey data--or even the surveys themselves--in physician credentialing files. This is inappropriate and even dangerous for the institution and the physicians, Silverman says.

Including such information in a credentialing file indicates that it is not quality improvement data—yet patient satisfaction data should be a tool for quality assurance and improvement. As a practical matter, including such information in a credentialing file makes it subject to subpoena, and not protected from disclosure as peer review and quality data. This could expose the facility to significant liability.

In addition, including it in a credentialing file risks the information becoming public, causing embarrassment to the institution and the physician.

Sheff notes that patient satisfaction data has no role in credentialing, unless the data would persuade the facility not to renew the physician’s privileges. If that were to happen, the facility would need to initiate a peer review proceeding. That being the case, the data should stay in the facility’s quality assurance and peer review files, and has no place in the credentialing office, Sheff says.

Patient satisfaction ratings as indicators
Hospitals attempt to measure patient satisfaction at least in part to quantify the perception the public has about the quality of the services the institution offers. Insurers and large self-insured companies will consider a facility’s reputation for quality when deciding whether to include the facility on their lists of preferred providers.

Physicians may consider the facility’s reputation for quality care when deciding whether to seek privileges and even when deciding whether to locate a practice in the area the facility serves.

Patients are likewise influenced by a facility’s reputation when seeking care.

But it is critical to distinguish information that is gathered for marketing purposes--that is, information about the perception of quality--from information that is gathered for quality assurance and improvement purposes, Silverman says.

Although the same vehicle may be used to collect the information (e.g., a survey that patients complete on discharge) the data must be analyzed and handled differently when they are used to assess actual quality of care, as opposed to when they are used to quantify the perception of quality, Silverman says.

Maureen Coler is the editor of Credentialing and Peer Review Legal Insider. She may be reached at mcoler@hcpro.com. This story first appeared in the April edition of Credentialing and Peer Review Legal Insider, a monthly newsletter by HCPro Inc. For information on all of HCPro’s products, visit www.hcmarketplace.com.

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