Patient Satisfaction and Public Accountability
PATIENT SATISFACTION AND PUBLIC ACCOUNTABILITY
reinvents its cafeteria menu at least monthly. Its
breast care center, located in a separate building
so that patients don't have to go into the main
hospital for their mammograms, has the calming
atmosphere of a Zen garden. Candidates for new
hips and knees attend "Joint Camp"-they are
admitted to the hospital in groups of ten to twenty
and receive presurgery education and sometimes
even post-op physical therapy together. As a
result, they have support not only from clinicians
and their families, but from peers who know
exactly what they are going through.
All these things and much more are a direct result
of regular patient satisfaction surveys, says John
Heer, president and CEO of North Mississippi
Health Services (NMHS). Heer came to the five-hospital
system three years ago with a mandate from the
board to improve patient satisfaction.
"We make hundreds of small changes each week
based on patient feedback," Heer says.
Measuring Patient Satisfaction:
The Standard Of Performance
Most hospitals survey their patients regularly and
take varying degrees of action on the results. A
recent poll of more than 300 hospital executives,
conducted by HealthLeaders Media, showed that
99% have a system in place to do regular patient
surveys, and 91% use an outside vendor to handle
those surveys (see Chart A). The HealthLeaders
Media poll included senior hospital executives,
patient representatives, and directors and managers
of quality assurance.
Because patients assume that their hospital
will provide high-quality care, their perceptions of
their experience are often shaped much more by
how they are treated as people-whether nurses
are polite, whether their families get the information
they need, or how long they have to wait to
leave on discharge day.
follow-up phone calls to all discharged patients to
check on their condition and make sure they understand
their medication list and discharge instructions.
The 206-bed hospital also has a nurse
specializing in pain management assigned to each
department. And each patient room has a whiteboard
where patients can write what is most important
to them that day, whether it is being wakened
for visitors or having tests done punctually. All of
these policies stem from survey feedback.
"Everyone wants to put things in a box-
quality care in one, patient satisfaction in
another," says administrator Steve Ronstrom.
"But patient satisfaction is related to good
which prevents errors and improves
Measuring patient satisfaction and acting on
the information acquired can benefit hospitals in
a multitude of ways, including improved quality
of care, better financial health, a stronger
position, and more loyal employees. Satisfied
patients are also less likely to sue their hospital.
vendor to administer and analyze its patient
satisfaction surveys, and ranks in the top one percent
among that vendor's client hospitals for its
high patient satisfaction levels. Not coincidentally,
it is growing its market share and has doubledigit
operating margins and no debt, says chief
executive Greg Stock.
Measuring patient satisfaction leads to tangible
wow our patients," Stock says. "Years ago, we had
lots of little kingdoms within our hospital, and
issues were put off and not resolved. Now people
are empowered, and expected, to fix things on the
spot." About seventy miles west of
premier heart surgeons from a
attracting newly minted surgeons in other specialties
who have heard of its reputation as a great
place to practice, Stock says.
patients from as far away as
The Government Steps In
Until recently, the decision to measure patient satisfaction
was the provider's choice. But now, the
federal government is involved as well. Beginning
with July 2007 discharges, the Centers for Medicare
and Medicaid Services (CMS) began requiring hospitals
to submit patient-satisfaction data for inclusion
in a national database that consumers can
use, in conjunction with clinical quality data, to
choose a healthcare provider. The program, called
the Hospital Consumer Assessment of Healthcare
Providers and Systems, or HCAHPS®, has been in
a test phase since 2005, and submitting data has
been voluntary. Although technically it will continue
to be voluntary, hospitals that do not submit
their HCAHPS data will not receive their full federal
reimbursement updates for 2008.
The HCAHPS survey has 27 questions about
the frequency of several standard patient-satisfaction
measures, including how often staff members
were courteous and respectful, how often treatments
and medications were adequately explained,
how often help was available when requested, how
often things were quiet at night, and how often pain
was well controlled.
More than 250 hospitals participated in the test
phase for HCAHPS in 2005, and a total of 2,800
hospitals submitted HCAHPS information in 2006,
the first year that the survey instrument was generally
available. Hospitals will be required to submit
data from 300
per year. The resulting database will be the first
publicly available apples-to-apples
patient satisfaction data among all hospitals.
It is too early to say exactly how HCAHPS will
affect hospitals. An analysis
and performed by consulting firm Abt Associates,
result in an additional cost to hospitals per year, but
the cost will depend on the method used and
whether the hospital
satisfaction measurement efforts. Hospitals that
conduct patient satisfaction surveys by phone,
either internally or through an outside vendor, will
likely find their costs rising substantially more than
those that use a mail survey, because each phone
conversation will take extra time to
Hospitals currently using a mail survey to gather
data may incur only a minimal cost increase since
the HCAHPS questions can be incorporated into
As for the impact of the data itself, respondents
to the HealthLeaders Media survey say the most
likely benefit will be to increase hospitals' motivation
to improve their quality of care (see Chart B).
But HCAHPS on its own will not give hospitals
all the information and direction needed to
improve patient satisfaction. For that, most will
continue to turn to more
and advice from outside patient-satisfaction
North Mississippi Health Services (NMHS) participated
in the HCAHPS pilot test period to see how
HCAHPS varies from the organization's current
patient satisfaction surveys, which are administered
and analyzed by Press Ganey Associates, Inc. The
firm also administered the HCAHPS questionnaires
for NMHS. CEO John Heer believes that although
HCAHPS has potential value in spotlighting patient
satisfaction issues and making hospital information
more transparent to the public, it will not replace his
current patient satisfaction surveys. "It's not as thorough
as the Press Ganey survey," Heer says.
critical access hospital, has been surveying its
patients regularly for the past six years. Annette
Odland, clinical services leader, sees HCAHPS as
"a different way to ask the same questions."
Wright has acted boldly on the information
yielded by its patient satisfaction surveys: rebuilding
its emergency and outpatient departments to
put walls rather than curtains between patient bays
for better privacy and releasing
internally so that employees can see who is
praised-or condemned-by name. Wright has
also tried to "boutique" itself, with massages and
facials for inpatients-to the point where it attracted
a busy orthopedic surgeon to move his practice.
The tiny hospital now performs ten major joint
operations a week and has doubled its gross revenue
in each of the last two years.
"I do believe in data transparency, whether it is
patient satisfaction or quality of care," Odland
says. "Patients looking at
procedures are shopping around, checking how
many we have done, asking about infection rates.
With the Internet, it is the future."
Greg Stock, at
admits to "a little heartburn" when the hospital first
tried out the HCAHPS survey last summer during
the pilot test period. "The questions are different
and not as broad as the survey Press Ganey does
for us, and we were not sure how the
and benchmarks would go. We felt confident in our
ability to do this, but we did not want to be embarrassed
by getting a different result," he says. As it
turned out, the heartburn was for naught:
Stock says HCAHPS could have an impact on
patient perceptions in the marketplace, especially if
the media embrace the information when covering
healthcare issues. He is concerned that hospitals
may selectively advertise their HCAHPS results but
ultimately believes that a hospital's reputation rests
on more than a billboard. "If you exceed their
expectations, patients will tell their friends," he
says. "They have a clear sense who is doing it right.
Word of mouth is still very powerful, and people
are not fooled by billboards."
Unfavorable HCAHPS numbers may inspire
action. "Some hospitals will be influenced by the
public accountability-especially public hospitals
that have board members in the limelight," Stock
says. "If people know you have not been doing a
good job, that creates an urgent platform for change.
In some hospitals, that really needs to happen."
"I think HCAHPS is a great move," says Steve
Ronstrom of Sacred
the information in a standardized format will separate
the 'wheat from the chaff' and show which
hospitals are truly concerned and which are not.
That is going to drive accountability in a way that
has not been measured before."
For Outside Vendors
Fewer hospitals are trying to manage their patient
satisfaction surveying process by relying exclusively
on internal resources. Hospitals are using
outside vendors for a myriad of reasons. For
some, the logistics involved in gathering and analyzing
data is too
there is a desire to benchmark themselves against
other hospitals, which can only be ac
when multiple providers use the same survey and
share their data with a central repository, such as
those managed by outside vendors.
Hospitals are also looking to outside vendors
due to the growing use of patient satisfaction data
used in staff incentive programs. More than 60% of
respondents to the HealthLeaders Media survey
said their hospitals use patient satisfaction data in
setting incentive payments to senior executives, and
more than 40% use the data to set incentive payments
for all other employees (see Chart C).
HCAHPS is likely to increase the outsourcing
of patient surveys even more, as vendors incorporate
seek guidance for their service performance and
improve improvement efforts. Respondents to the
HealthLeaders Media survey were asked to evaluate
the performance of some of the most widely
used patient satisfaction measurement vendors
(see Chart D).
patient satisfaction surveys internally, but
switched to Press Ganey six years ago. "We were
only measuring against ourselves," says Annette
Odland. "When you start measuring nationally,
you can see what you really need to do to
improve. And the employees are proud of our
great scores and take ownership of them. Their
likelihood of re
patients and potential employees has risen dramatically,
and they're our best marketers."
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