Hospitality Trumps Medical Quality in Hospital Patient Satisfaction Scores

Researchers find that amenities such as private rooms have a greater impact on hospital patient satisfaction than quality measures such as mortality rates.

Consumer satisfaction is a weak driver of quality and safety at hospitals, recent research indicates.

Viewing patients as consumers has been a focal point of efforts to reform U.S. healthcare, with the emergence of online reviews and formal instruments to measure patient satisfaction such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient survey. However, hospitals are a challenging setting to have consumer satisfaction impact quality of care because most medical services are provided out of patients' view.

The recent research, which was published in the journal Social Forces, found that amenities such as private rooms have a greater effect on patient satisfaction than the quality of medical services.

"We find that neither medical quality nor patient survival rates have much impact on patient satisfaction with their hospital. In contrast, patients are very sensitive to the 'room and board' aspects of care that are highly visible. Quiet rooms have a larger impact on patient satisfaction than medical quality, and communication with nurses affects satisfaction far more than the hospital-level risk of dying. Hospitality experiences create a halo effect of patient goodwill," the study co-authors wrote.

Research data

The researchers examined Centers for Medicare & Medicaid Services data for 3,000 acute care and critical access hospitals nationwide.

Medical quality was measured based on adherence to standards of care for heart attack, heart failure, general surgical practice, and pneumonia. Patient safety was measured based on hospital mortality rates. Hospitality was measured based on several metrics in the HCAHPS patient survey such as quality of nurse communication, cleanliness of rooms, and room noise levels at night.

The research includes several key data points.

• Hospitals with the highest mortality rates have patient satisfaction scores only 2.0 percentage points lower than hospitals with the lowest mortality rates.
   
• Hospitals posting medical quality scores in the highest decile have patient satisfaction scores only 3.3 percentage points higher than hospitals with medical quality scores in the lowest decile.
   
• Nurse communication has a major impact on patient satisfaction. Hospitals with the lowest decile score for nurse communication have an average patient satisfaction rating of about 50%. Hospitals with the highest decile score for nurse communication have an average patient satisfaction rating of more than 75%.
   
• The noise level in patient rooms has an 86% larger-in-magnitude impact on patient satisfaction than the hospital mortality rate.
   
• The noise level in patient rooms has a 40% larger impact on patient satisfaction than medical quality.
   
• For more than 300 of the hospitals, the researchers examined 18 measures of local competition to determine the association of competitive markets with patient satisfaction and medical quality. For 17 of the measures, competitive markets lowered patient discontent. For 14 of the measures, competitive markets lowered medical quality. "Local competition among hospitals leads to higher patient satisfaction, but lower medical quality. This provides further evidence of decoupling between medical excellence and patient satisfaction," the study co-authors wrote.

The data shows the hospitality halo effect in how patients view their hospitals, the co-authors wrote. "When patients complain about their hospitals, it is primarily due to the room and board aspects of their stay—and especially about the personal interaction with nurses. … Hospitality is the fast track to customer satisfaction in medicine."

Interpretations and solutions

The lead author of the study told HealthLeaders the finding that hospital competition for patients leads to lower medical quality and higher patient satisfaction is troubling.

"I take it as a sign that high pressure incentives to attract and please patients change hospital priorities and investments," said Cristobal Young, PhD, an associate professor in the Department of Sociology at Cornell University in Ithaca, New York.

He said it is highly unlikely that private patient rooms improve medical service quality—even though patients love the privacy of a hotel-like experience, private rooms are an expensive capital expenditure.

"Stanford Health Care spent a whopping $2 billion on a new hospital building with private rooms—largely because the old one had shared rooms and it was hurting their reputation, as one of the vice presidents told me. If you start to think about all the things that could be done with $2 billion, it is hard to believe that building private rooms is the best medical use of those resources," Young said.

Rather than focusing on metrics of customer satisfaction, hospitals should focus more on customer health and longevity, he said. "No one really wants to talk about patient survival rates, but those metrics exist on Medicare's Hospital Compare website. They are available, and informed patients should know about them."

Downgrading the emphasis on customer satisfaction in favor of customer health and longevity would be challenging, he said. "The analogy I use is that no restaurant wants to talk about food poisoning or health and safety standards—even if they are the best and safest restaurant in the city. They don't want the minds of their potential customers drifting into something that is a negative."

Despite the challenge, hospitals have an obligation to elevate the importance of medical quality and safety, Young said. "Hospitals are not supposed to be selling patients a happy, feel-good marketing campaign. They have a responsibility to the best interests of their patients, and that means being honest about medical quality and patient survival."