Patient Satisfaction and Public Accountability



North Mississippi Medical Center in Tupelo

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.

Sacred Heart Hospital in Eau Claire, WI, makes

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 communication,

which prevents errors and improves

patient outcomes."

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 competitive

position, and more loyal employees. Satisfied

patients are also less likely to sue their hospital.

Thibodaux (LA) Medical Center uses an outside

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

action at Thibodaux. "We are always looking to

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 New Orleans,

140-bed Thibodaux recently lured one of the area's

premier heart surgeons from a competitor and is

attracting newly minted surgeons in other specialties

who have heard of its reputation as a great

place to practice, Stock says. Thibodaux also draws

patients from as far away as New Orleans.

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 complete HCAHPS questionnaires

per year. The resulting database will be the first

publicly available apples-to-apples comparison of

patient satisfaction data among all hospitals.

It is too early to say exactly how HCAHPS will

affect hospitals. An analysis commissioned by CMS

and performed by consulting firm Abt Associates,

Cambridge, MA, showed that data collection will

result in an additional cost to hospitals per year, but

the cost will depend on the method used and

whether the hospital combines it with other patient

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 complete.

Hospitals currently using a mail survey to gather

data may incur only a minimal cost increase since

the HCAHPS questions can be incorporated into

existing surveys.

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 comprehensive surveys

and advice from outside patient-satisfaction

survey vendors.

Chart A

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.

Wright Medical Center, Clarion, IA, a 25-bed

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 completed surveys

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 coming to us for orthopedic

procedures are shopping around, checking how

many we have done, asking about infection rates.

With the Internet, it is the future."

Greg Stock, at Thibodaux Medical Center,

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 comparisons

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:

Thibodaux is scoring well on the HCAHPS survey.

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 Heart Hospital. "Just having

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."

Market Strengthens

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 complex. And for many others,

there is a desire to benchmark themselves against

other hospitals, which can only be accomplished

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

HCAHPS compliance into their offerings and

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).

Wright Medical Center used to handle its

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 recommending our hospital to

patients and potential employees has risen dramatically,

and they're our best marketers."




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