Hospitals all across this great country of ours are scrambling to improve their patient satisfaction scores. Why is that you ask? Because the Centers for Medicare & Medicaid Services (also known as CMS, also known as The Medicare National Bank) has decided that patient satisfaction scores should be used in the formula to determine how hospitals get paid by Medicare.
Scores obtained through the survey titled Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) will be used to determine whether hospital systems get paid their full amount by CMS or whether they will have their pay reduced on an annual percentage basis.
Hospitals could lose millions of dollars in funding. These millions of dollars in potential revenue losses will be decided by only 300 random surveys on discharged patients in any given 12 month reporting period. That is shocking. Three hundred patients have the power to determine whether a hospital fails or succeeds at the patient satisfaction game. A small sampling of patients have the power to radically affect the stability of hospital financing. The potential revenue losses to hospital systems could be devastating. Inner city hospitals are going to get decimated. Some folks believe a full one third of all hospitals may close by 2020 under current financing scenarios. Be prepared for geographical and time based rationing of your care.
Like so many government programs, these satisfactions initiatives began with good intentions. However, they always have unintended consequences that are under appreciated and ignored to the detriment of the stated goal. We know that higher patient satisfaction scores are associated with a higher mortality. Who knows, CMS may be covertly using patient satisfaction goals as a way to reduce long term medical expenses. I dead beneficiary costs less than a live one.
Patient satisfaction may be the goal, but at what cost? What are we sacrificing in patient care so our patients are happy? If satisfaction is a stated financial measurement, the right care will most certainly take a back seat to care that makes people happy. Can we have both? Can we have the right care and care that makes people happy? It's possible, but the informed consent process is very time consuming, uncompensated and the margin of error is small. Doctors and hospitals will most certainly error on the side of making patients happy at the expense of making them better because happy patients will pay the bills and bonuses. That has been defined as the marker for quality. This is especially true if just 300 patients have the power to decide a hospital's financial future.
Should hospitals and doctors be providing medical care that guarantees high patient satisfaction scores at the expense outcomes? Of course not. But they will if they are going to get paid for happy patients and they will give them what they want whether it is the right thing or not. For many patients, the care they expect is the care their family expects based on what their neighbor got three years ago at Mayo or what they saw on an episode of House last season.
Grandma was as confused as that one guy who got a spinal tap in TV last week. Doctor, why aren't you doing a spinal top on grandma. Grandma wants a spinal tap? Sure. Why not? If it makes grandma's daughter happy that's what we are here for. Because she's the one filling out the satisfaction survey. That's our goal, right? That's what medical care has become.
By incentivizing patient satisfaction scores as a priority for payment, hospitals are now going to run economic models to determine which programs will be the most economically rewarding. They will sacrifice programs with opposing end points that are less rewarding in favor of higher revenue producing incentives. That means patient satisfaction may trump reduced payments for readmission or length of stay if models predict higher revenue with happier patients.
Are you being given medical care that isn't necessary if it makes you happy? Nonsense. All care meets muster for Medicare medical necessity. Do you want to risk having the daughter give bad marks on your HCAHPS survey because you didn't think grandma was worthy enough to get a lumbar puncture? Are you a community hospitalist who's livelihood is tied to the success or failure of your hospital? Hospitalists can't work in a hospital that goes belly up. We are hospitalists. We are in this together.
The consequences of practicing medicine with the explicit end point of having satisfied patients contradicts all the other quality barometers that have been put into place by CMS. What if a patient does not want to be weighed daily for their heart failure? Shall we sacrifice outcomes and readmissions in the name of satisfied patients? What if diabetics don't want to carbohydrate restrict their diet in the hospital? Should we sacrifice glucose control and higher rates of failed outcomes in the name of patient satisfaction? What if a patient wants their dog in the same room after their bone marrow transplant? Should that be allowed in the name of patient satisfaction? How about patients after knee surgery that complain the physical therapists are working them too hard? I hear that every day. Shall we let them sit around for three days doing nothing, developing an ileus and pneumonia in the name of satisfaction?
How about patients that refuse to be discharged because of their unmanaged expectations? Should they be given special squatter status in room 709 indefinitely. How about smokers who wish to go outside and smoke on hospital property despite hospital smoking ban policies to the contrary. Should we ignore the rules in favor of patient satisfaction and allow our post op CABG patients fem-pop bypass patients to go out for some air and a smoke? Should we allow families to bring in greasy burgers for our pancreatitis patients all in the name of patient satisfaction?
These are real life scenarios that doctors will face every day when faced with the prospect of three hundred random patients deciding whether their hospital will lose millions of dollars in funding or not. The easiest road to success is not to spend time we don't have to explain to patients and families multiple times a day why certain tests are not indicated. The path of least resistance is to give patients everything they want, even if it contradicts the stated goals of their medical therapy.
In addition, patients are satisfied by their hospital stay because of things that have no relevance on their medical care. Having the sense of being in control is important. Give the patient what they want and they'll love you. In addition, convenience and amenities will leave a lasting mark on a patient's experience when it comes time to fill out the survey. HCHAPS questions may be specific, but a happy patient is going to give happy answers across the board no matter what the question and upset patients are going to do their best to punish you.
While hospitals may try and use AIDET to improve the experience of patients, invariably, nurses and physicians, consciously or subconsciously, are going to cave to the demands of their patient clients and provide satisfaction driven care that may provide no benefit and might actually increase length of stay, complications and mortality.
But I've got a better answer. Let's stop kidding ourselves and just openly discuss the cheapest, easiest and fastest ways to rapidly improve patient satisfaction scores. It has nothing to do with your care. It has nothing to do with how nice your doctor or nurse was. It has nothing to do with how long you lingered in the emergency room before you got a bed upstairs. It has nothing do with the spelling of your doctor's name. If you are a hospital and you want to rapidly improve your patient satisfaction scores in the quickest and cheapest and easiest way possible, I present to you my top 10 list of ways to improve patient satisfaction scores. This is based on years of personal experience and rigorous randomized controlled trials on the subject. I've named this the Oprah-Ellen Effect.
Happy's hospital has transformed the discharge process into an Every Discharge Day Is Gift Day experience. We now sport an amazing 100% on all our patient satisfaction surveys. Simply implement my top ten list below and you'll have instant success as well.
On discharge, provide patients with the following parting gifts:
#10 Brochures describing your hospitalist group. But not just any brochure. A musical singing brochure that, when opened, sings the tune "I'm Sexy And I Know It" by LMFAO
#9 A free carton of cigarettes** This can be substituted for 8 gourmet burgers from Omaha Steaks for nonsmokers.
#8 A free case of domestic beer**
#7 One free month of cable TV with premium movie channels including HBO, Showtime and Cinemax**
#6 One free month of unlimited cell phone service**
#5 One free month of high speed internet service**
#4 One gas card good for a free tank of gas (up to 20 gallons)**
#3 Four tickets to the next comedy show by Larry the Cable Guy**
#2 One loaf of bread, a gallon of milk, a jar of peanut butter and 4 cans of SpaghettiO's, with a large assortment of coupons to your local grocer**
#1 Four certificates for an all you can eat buffet at the Golden Corral **
**(Restrictions apply to patients with diagnoses related to 30 day readmission rules.)
If you want to win the hearts of your patients and get great scores on your patient satisfaction surveys, stop wasting you time implementing expensive hospital policies that could potentially harm your patients and start branding yourself as the hospital that comes bearing gifts. Happy's top ten list can have immediate impact on your bottom line. It's time hospitals partnered with local business to create this WIN-WIN-WIN collaborative effort. Now please enjoy all these original Happy Hospitalist ecard experiences.
More and more patient satisfaction nonsense explored. Good intentions. Bad policy.
Must. Keep. Everyone. Happy!
PCA patient I once saw:
Nurse: Have you ever had SCDs before?
Patient: Only once in college.
Wife: Is there anything else you've never told me?
Oops... The under appreciated consequences and dangers of explaining everything you do under AIDET exposed!*****
Happy: I understand you came to the ER with 2 weeks of nausea, vomiting and belly pain.
Patient: Yes that's right.
Happy: So... what made you decide to come to the ER at 3am.
Patient: I was dizzy.
Happy: At 3am?
Patient: Yes. Can I get some tomato soup with crackers?
Happy: Yes. Yes you can...
In the interest of patient satisfaction, I discontinued a carbohydrate restricted diet my partner ordered on a poorly controlled diabetic admitted with a blood sugar of 900. It was making her angry.We don't want angry 'round these parts. Instead, I asked the patient's nurse butler to kindly retrieve 6 cookies from the free cookie cart roaming the Halls of Happyness. One more example of happy trumping quality...*****
This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.