QUALITY: The patient satisfaction trap by John Irvine, with rant from Ann Farrell

So in FierceHealthcare today my colleague John Irvine wrote this

Some hospitals have argued for years that patient satisfaction scores can be misleading when it comes to gauging the quality of the healthcare services they receive. After all, patients are only human, aren’t they? And can easily be swayed by factors that have little if anything to do with the true quality of care. A new study out in the Annals of Internal Medicine appears to back this view. RAND Researchers and a team from the University of California Los Angeles surveyed 236 elderly patients, asking them to rate the quality of the care they had received. The average response was 8 out of 10. Follow up on patient records determined that patients received the recommended care 55 percent of the time. Now those numbers may seem relatively unimpressive, but they are evidence of a something that many providers have intuitively believed. It will be interesting to see how this plays out.

That apparently struck a nerve with FH reader Ann Farrell. She wrote to me about this problem, and one senses a little frustration in her voice!

It drives me NUTS when people (smart people and even payors) confuse satisfaction with quality of care  – two things that are NOT THE SAME, and in fact many times not correlated.  In some studies patients getting ongoing excellent care are exposed to the health system more than their healthy counterparts thus have more opportunities for service gaps. People in this study’s satisfaction with plans decreased the more they received treatment, as good as it may be clinically. 

Quality of care has to do with the addressing underlying problems, i.e. getting diagnosed properly then improving status of  medical condition or receiving palliative care if no improvement possible .For example, my diabetes is being treated with best practices leading to optimal outcomes, lack of complications, etc. We know from recent market data that this only happens 55% (if my recall correct) of time. Consumers are by and large clueless about the actual quality of care they are receiving, and many unaware of the patient safety data, i.e. we’re killing close to 100K people a year, which is not only bad quality but introducing medical problems, e.g. nosocomial infections, or actively killing patients, e.g. drug errors. 
Quality of care and patient safety have nothing to do with service or satisfaction, which is often based on parking, food, access/TATs and perception of care providers, “does someone answer my call bell quickly when I need them?” You can have great service and woeful quality, or visa versa. When I worked with benchmarking data University Hospitals has better quality outcomes than community hospitals they competed with so patients tolerated bad service, i.e. waiting for hours in waiting rooms, etc. Now specialty hospitals and some community hospitals are delivering comparable care and differentiating based on improved service. So the fact that people still use the terms interchangeably is baffling. MOST patients haven’t known what the quality of their care is – the Internet is changing that in terms of better access to care standards and evidence.
Sorry, as you can see this struck a huge chord with me, we have to know what problem we’re tackling to solve it.  The industry confuses this.

For some reason the issue of quality, waste, doctors not providing optimal care, etc seems to be a contentious one on THCB. I personally believe that fixing the consumer satisfaction part of health care is easier to do and equally necessary than fixing the care process. But they are separate things (both of which the system deals with very badly). But what do I know? Feel free to have at it in the comments!

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3 replies »

  1. I think part of the problem lies in the difference in penalty and reward variables as it relates to patient sat. I would bet that, for most patients, the quality of care is a penalty variable. “I will be satisfied as long as the quality of care is adequate (it probably doesn’t differ that much from hospital to hospital). The only effect on my overall sat is that I will penalize you if it’s clearly inadequate.” Reward variables are those things in which the patient rewards you in sat the better you do. Reward variables are where you really get a lift in patient sat and, most likely, are the things that make the overall experience easy, pleasant and efficient (e.g. parking, billing, check-in, etc.). I agree: patient sat is not an indicator of the quality of care. But the ancillary is also true: the quality of care is not an indicator of patient satisfaction and loyalty.

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  3. Both patient satisfaction and effective clinical outcomes are important, but it’s a mistake to judge provider performance based on patient satisfaction alone. As I see it, this issue goes to the heart of the transparency problem, i.e., what kinds of information, other than cost, are useful to consumers in deciding which provider to select — what’s the best way to increase consumer knowledge and awareness?
    All else being equal, I would expect a positive correlation between being a satisfied patient and having good outcomes in as much as the satisfaction is related to bedside manner. For example, having good communications with their patients help clinicians evaluate the patients’ problems and understand their preferences, which will likely increase the probably the patients will comply with the plans of care. It is offers the benefits of collaborative decision-making. But failing to give the proper treatment will, obviously, hurt the patient no matter how good the communications are.