Qual­ity co­nun­drum

Pa­tient sat­is­fac­tion can­not be judged on just one mea­sure

Modern Healthcare - - OPINIONS COMMENTARY - Ir­win Press

An ar­ti­cle in Modern Health­care’s Aug. 15 is­sue by Rich Daly (“Un­sat­is­fac­tory marks”) raises some trou­bling ob­jec­tions to pa­tient sat­is­fac­tion as a le­git­i­mate qual­ity in­di­ca­tor. The ob­jec­tions are noth­ing new. How­ever, given that the CMS will soon tie re­im­burse­ments to qual­ity scores that in­clude pa­tient sat­is­fac­tion, the doubts need to be laid to rest.

Es­sen­tially, the ar­ti­cle sug­gests that pa­tient sat­is­fac­tion scores are “bi­ased” in that “high marks for per­cep­tions of care may have lit­tle con­nec­tion to high qual­ity clin­i­cal out­comes.” Well-re­spected med­i­cal cen­ters with high “qual­ity” scores and rep­u­ta­tions may have low sat­is­fac­tion rat­ings.

Daly cor­rectly notes that pa­tient sat­is­fac­tion scores vary by hos­pi­tal size and re­gion. Scores for larger hos­pi­tals tend to be lower than those for smaller hos­pi­tals, while North­east­ern hos­pi­tals tend to score lower than those in the South and Midwest. How­ever, some re­searchers dis­miss the rel­e­vance of lower sat­is­fac­tion scores for aca­demic med­i­cal cen­ters in the North by sug­gest­ing that they have a pre­pon­der­ance of pa­tients “with ei­ther de­pres­sion or com­plex and se­ri­ous ill­nesses.” In­ten­tion­ally or not, this comes across as say­ing that pa­tients have to be ei­ther emo­tion­ally dis­turbed or very sick not to rec­og­nize “the high qual­ity of the clin­i­cal care that other mea­sures have found those in­sti­tu­tions pro­vide.” Thus, pa­tient sat­is­fac­tion sur­veys are “bi­ased.”

It is in­deed true that sat­is­fac­tion and clin­i­cal process mea­sures may vary in­de­pen­dently. But this shouldn’t be sur­pris­ing, as they are mea­sur­ing quite dif­fer­ent aspects of care. It is not un­usual for pa­tients to re­ceive high-qual­ity tech­ni­cal care (proper tests and treat­ments with min­i­mum er­rors and mor­tal­ity) while ex­pe­ri­enc­ing low-qual­ity in­ter­ac­tion, em­pa­thy, in­for­ma­tion and lo­gis­ti­cal man­age­ment (such as am­bi­ent noise, de­lays in ap­point­ments, trans­port or pain re­lief). None of these pa­tient ex­pe­ri­ences is in­cluded in the pub­lic process-of-care mea­sures that many view as the only le­git­i­mate proof of qual­ity. Pa­tients, of course, are typ­i­cally un­aware of the many tech­ni­cal pro­cesses and in­di­ca­tors that con­sti­tute these qual­ity scores. They judge hos­pi­tals on the ba­sis of their per­sonal ex­pe­ri­ence. To pa­tients, this ex­pe­ri­ence de­fines “care.”

The full def­i­ni­tion of “care” must nec­es­sar­ily in­clude both the tech­ni­cal in­ter­ven-

It is wrong to de­fine–or re­ward–qual­ity on the ba­sis of ei­ther pa­tient sat­is­fac­tion or tech­ni­cal process mea­sures.

tion and the man­ner in which it is de­liv­ered. In an ideal world, the two mea­sures would vary in tan­dem. This is not such a world. In our world, the pa­tient can have a lousy per­sonal ex­pe­ri­ence while get­ting first-class treat­ment, or vice versa. In nei­ther in­stance is care of high qual­ity. It is wrong to de­fine—or re­ward—qual­ity on the ba­sis of ei­ther pa­tient sat­is­fac­tion or tech­ni­cal process mea­sures alone. To deny a full role in the def­i­ni­tion of “qual­ity” for the pa­tient’s per­sonal ex­pe­ri­ence is es­sen­tially to de­fine “care” as in­volv­ing only the tech­ni­cal treat­ment or di­ag­nos­tic pro­ce­dure.

If the qual­ity of treat­ment and sat­is­fac­tion do not vary in tan­dem, is it le­git­i­mate to riskad­just pa­tient sat­is­fac­tion scores? The ar­ti­cle quotes Dr. James Mer­lino of the Cleve­land Clinic as say­ing that hos­pi­tals should be held re­spon­si­ble only “for things that they can ac­tu­ally im­prove.” This sug­gests that for things over which hos­pi­tals have no con­trol, risk ad­just­ment could be ap­pro­pri­ate.

No one can ar­gue with this. The risk with risk-ad­just­ing, how­ever, is its ad­mis­sion that we can­not con­trol a sit­u­a­tion. Even if we riskad­just the sat­is­fac­tion scores of large North­ern med­i­cal cen­ters, their pa­tients won’t be more sat­is­fied, nor their over­all qual­ity of care bet­ter. Where do we draw the line? We also know that younger pa­tients are less sat­is­fied with care than older. Male and fe­male scores dif­fer, as do the scores of dif­fer­ent eth­nic and eco­nomic groups. There are good rea­sons for these ex­pe­ri­en­tial dif­fer­ences, and many are os­ten­si­bly ad­dress­able and within a hos­pi­tal’s con­trol. For ex­am­ple, if younger pa­tients are less sat­is­fied with care than older, it may be due to the threat of ill­ness to their self-im­age as in­de­struc­tible and their un­fa­mil­iar­ity with hos­pi­tal pro­ce­dures. Per­haps more in­for­ma­tion and em­pa­thy from staff could make their ex­pe­ri­ence eas­ier. Risk ad­just­ment is a cop-out.

Ad­mit­tedly, there may be no fix that could en­able large aca­demic med­i­cal cen­ters to score near the top of pa­tient sat­is­fac­tion. Size, noise, im­per­son­al­ity, a huge and di­verse staff, the pres­ence of in­ex­pe­ri­enced med­i­cal, nurs­ing and tech stu­dents and other fac­tors can make any pa­tient’s ex­pe­ri­ence less than op­ti­mal.

Here’s a sug­ges­tion: Rather than let all of them off the hook by risk-ad­just­ing, the CMS could put aca­demic med­i­cal cen­ters in their own data­base, and use that for judg­ing the pa­tient ex­pe­ri­ence por­tion of their qual­ity equa­tion. This would force those in the lower half of this peer group data­base to take pa­tient sat­is­fac­tion more se­ri­ously. Some aca­demic med­i­cal cen­ters ac­tu­ally do quite well with pa­tient sat­is­fac­tion, mean­ing that im­prove­ment is pos­si­ble. Risk-ad­just­ing sat­is­fac­tion scores for any­thing only makes hos­pi­tals more sat­is­fied—not their pa­tients.

No one (I hope!) would agree that “care” con­sists only of di­ag­no­sis or treat­ment. If care nec­es­sar­ily em­braces both tech­ni­cal in­ter­ven­tions and the man­ner in which pa­tients ex­pe­ri­ence them, then pa­tient sat­is­fac­tion must be taken se­ri­ously and hos­pi­tals must be held ac­count­able for the full mean­ing of “qual­ity care.”

Ir­win Press is pro­fes­sor

emer­i­tus at the Univer­sity of Notre Dame and co-founder of health­care qual­i­ty­con­sult­ing firm Press Ganey As­so­ci­ates,

both based in South Bend, Ind.

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