“Improvements in Patient Experience”–Really?

Hospitals improve their communication with patients when  patient survey results are publicly reported, say researchers with the RAND Corporation and the federal Centers for Medicare and Medicaid Services (CMS).

Writing in Health Affairs, the researchers report that hospitals participating in the first two rounds of annual reporting improved overall in eight of nine survey measures.  The measures comprised communication with nurses and doctors, staff responsiveness, communication about medicines, pain management, and discharge information.  The surveys took place in 2008 and 2009.

Hand-lettered sign reading, "Stop complaining"The problem is that none of the average improvements exceed one percent. And, physician communication didn’t improve at all–although, interestingly, it scored first or second both years, with four in five patients reporting positive experiences.

Surveying patients is now de rigueur (I took French but, alas, had to look up how to spell this phrase–I hope my use of it impresses you).  The federal survey program is widespread–the vast majority of hospitals now participate–allowing comparisons to be drawn across hospitals and over time.  Hospitals survey patients for marketing purposes and because CMS penalizes hospitals that fail to participate in the program.

CMS pushes the program to improve quality of care, which, in the view of many advocates of quality (this blogger being one), includes patient satisfaction.

Author Marc N. Elliott and colleagues say the result is “encouraging.”  This is because hospitals that take part in the program are improving.  The title of their article is probably an over-reach: “Hospital Survey Shows Improvements in Patient Experience.”  Elliott is a statistician and sounds a bit more interested in the use of statistical measures than in quality of care.

My problems with the results are:

  1. The reported improvements are so small that it’s way early for CMS to claim victory for this program. Hospitals might even have been able to achieve this modest gain by somehow intervening in the survey process, despite what I’m sure are strong safeguards.
  2. The overall positive scores are misleading. The scores allow hospitals to insist, incorrectly, that they are doing a good job communicating with patients.  In each of the nine measures and in both years, most patients gave positive scores.  But, studies focusing on specific communication practices–such as physicians’ discussion of patients’ anxieties or medication errors–show that general performance is weak and must be drastically improved.
  3. Asking patients to evaluate the hospital’s performance is very useful only when patients are given specific criteria for evaluation. For example, to evaluate discharge information, patients should be informed that proper discharge practices include: a conversation with the attending physician about medication use and next steps; a conversation about self-care with a registered nurse who’s cared for the patient; and a conversation with a social worker about the next setting of care and, if applicable, how to appeal an insurance decision to discharge the patient early–and that each of these conversations should be reinforced with printed, user-friendly material and discussion with a family member if possible.  Without knowing these things, what exactly is the patient evaluating?

In other words, my problems with the program go to the validity and reliability of the scores.

My current cynicism about hospitals is buttressed by another article in the same Health Affairs issue.  There, a pediatrician who headed a general pediatrics department in a major teaching hospital discloses how his hospital and its competitors maneuvered to increase admissions to their neonatal intensive care units (NICUs), because these units are hugely profitable.  At the same time, the hospitals maneuvered to avoid giving high-quality followup care to children after discharge from the NICU, because followup care is highly unprofitable.

In this scenario, it’s hard to stomach the fact that hospitals are treasured and considered “charitable institutions” and so are usually exempt from taxes, while insurance companies, with similar motives, are often taxed and accused of being heartless and greedy.

Go figure.  And take care.

Photo credit:  uncafeliteoalasonceAttribution.

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