Thinking the woman should have to “work a little harder” to contact her nurse, Molly moved the call light out of reach. The woman called her on the room phone, asking for another blanket. Molly complied. Three minutes later, the patient rang her again. Molly was wise enough to know that some patients were difficult because they were lonely and scared. But she had four other patients just as lonely and scared as this woman, who was taking up way too much of her time. Nurses flipped coins to avoid patients like her.
Those were the kinds of people who answered the patient satisfaction surveys. Not the man to whom Molly gave her own meal because he missed putting in his dinner order and hadn’t eaten all day. Not the little old lady who had taken her first-ever airplane flight, fallen at the airport, and needed a CT scan that messed up her intricately braided cornrows. She’d had her hair done because she was meeting her great-granddaughter for the first time. Molly spent 45 minutes rebraiding the woman’s hair into its updo. As an out-of-town resident, the grateful woman wouldn’t receive a survey. Instead, Molly got in trouble with the charge nurse for braiding hair.
And no one would hear from the 30-year-old man who was dying of AIDS. He had been estranged from his family, and had just reconciled with his mother when his condition deteriorated. While Molly was triaging him, he begged his mother, “Please don’t leave me. I don’t want to die alone.” Soon afterward, he became unresponsive.
At 2:00 a.m., the patient was admitted to a medical floor for end-of-life care. When Molly wheeled him upstairs, his mother turned to her in tears. “I can’t stay here and watch my child die.”
“I understand this is very painful, but he specifically said he didn’t want to die alone,” Molly said.
When Molly left the man’s room to return to the ER, the mother left, too. At 7:00 a.m., when Molly’s shift ended, she called the floor to ask if the man was still alive. “Yes, but barely,” came the answer.
“Is anyone with him?” Molly asked.
“No. His mother never came back.”
Molly had just finished an exhausting twelve-hour night shift, but she wanted to honor the man’s last wish. She clocked out, took her things to his room, and sat next to him, holding his hand for two hours until he passed away.
“Of course,” Molly said later, “since he was an admitted patient—and dead—he couldn’t be polled about his hospital experience.”
Patient Satisfaction, Tricking Patients, and the Stepford Nurse
When Department of Health and Human Services administrators decided to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores, they likely figured that transparency and accountability would improve healthcare. Centers for Medicare & Medicaid Services (CMS) officials wrote in the Federal Register, rather reasonably, “Delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.” They probably had no idea that their methods could end up indirectly harming patients.
Beginning in October 2012, the Affordable Care Act implemented a policy withholding 1 percent of total Medicare reimbursements—approximately $850 million—from hospitals (that percentage will double in 2017). Each year, only hospitals with high patient satisfaction scores and a measure of certain basic care standards will earn that money back, and the top performers will receive bonus money from the pool. Private health insurance companies, such as Blue Cross Blue Shield of Massachusetts, are reportedly following the lead of what the government calls the Hospital Value-Based Purchasing Program.
Patient satisfaction surveys have their place. But the potential cost of the subjective scores are leading hospitals to steer focus away from patient health, messing with the highest stakes possible: people’s lives.
The questions and the problem
The vast majority of the thirty-two-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” There is no similar question regarding speed of doctors’ or other staff members’ response times.
This question is misleading because it doesn’t specify whether the help was medically necessary. Patients have complained on the survey, which in previous incarnations included comments sections, about everything from “My roommate was dying all night and his breathing was very noisy” to “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.” An Oregon critical care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple bypass surgery). “Many patients have unrealistic expectations for their care and their outcomes,” the nurse said.
What’s more, Medicare calculates scores by tallying only the percentage of patients who rank a hospital a 9 or 10 out of 10 and/or who select “Always” in response to the specific questions. Not “Usually.” Not “Sometimes.” Not an average rating. “Always.” This is a lazy calculation that dismisses a tremendous amount of data. Technically, if a nurse rushes promptly to a patient’s bedside for every request—colder water, warmer blanket, lower shades—except one, then the hospital could lose credit for the question.
Medicare awards bonuses (out of the money withheld from hospitals) to the top-performing hospitals nationwide. Pitting hospitals against each other, the equivalent of grading on a curve, does not necessarily compare like with like. Already, results show that Washington, DC, and New York patients are less likely than other patients to give their hospital a top score. Several experts have pointed out that Midwestern patients complain less than crankier counterparts in the Northeast and California, where hospitals traditionally receive lower ratings.
Who gets the survey? Hospitals either call or mail the questions randomly to discharged adults, which theoretically could include drug-seeking patients who leave the hospital irate if the staff won’t give them prescriptions. Once, a patient who was in the hospital for chest pain asked Molly to take out her pessary (a small vaginal device), clean it, and reinsert it, not ER duties. When Molly told her she didn’t know how to remove it, the woman shouted, “I’m supposed to get it cleaned once a month and I’m a month overdue! It needs to be done now!” as if it were Molly’s fault she had skipped a doctor’s appointment. The hospital didn’t do it, risking poor scores because the staff rightly refused to meet the woman’s absurd demand. Another man complained to the hospital’s patient liaison because when the ER staff saved his father’s life, they lost his $8 undershirt. “Those are the people who get called for the survey,” Molly said.
While hopefully there aren’t many unreasonable patients who would avenge unwarranted anger on the survey, they do exist. The survey questions and methodology, however, don’t necessarily elicit an accurate portrayal of care quality. The survey doesn’t ask whether the hospital resolved or improved the patient’s medical issue, which one would hope would be the primary determinant of a patient’s satisfaction with the experience.
A national study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years.
UC Davis professor Joshua Fenton, who conducted the study, said these results could reflect that doctors who are reimbursed according to patient satisfaction scores may be less inclined to talk patients out of treatments they request or to raise concerns about smoking, substance abuse, or mental health issues. By attempting to satisfy patients, healthcare providers unintentionally might not be looking out for their best interests. As
the New York Times nurse columnist Theresa Brown observed, “Focusing on what patients want—a certain test, a specific drug—may mean they get less of what they actually need. In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should.”
The surprise
Hospitals, too, can offer poor care and still get high patient satisfaction ratings, and an alarming number of them do. In my research for this book, I examined Medicare’s provider data for thousands of hospitals—the data on every hospital in the country that the agency makes publicly available. I found the hospitals that perform worse than the national average in three or more categories measuring patient outcome. These are hospitals, in other words, where a higher number of patients than average will die, be unexpectedly readmitted to the hospital, or suffer serious complications. And yet two-thirds of those poorly performing hospitals scored higher than the national average on the key HCAHPS question; their patients reported that “YES, they would definitely recommend the hospital.”
As a Missouri clinical instructor said, “Patients can be very satisfied and dead an hour later. Sometimes hearing bad news is not going to result in a satisfied patient, yet the patient could be a well-informed, prepared patient.”
How far will a hospital go to satisfy a patient? In 2012, when the white father of a newborn baby at Hurley Medical Center in Michigan requested that no black nurses care for his child, the hospital complied. Tonya Battle, a neonatal intensive care nurse for twenty-five years, was reassigned to another patient. Battle sued the board of hospital managers and a nurse manager for discrimination. Hurley settled, paying Battle $110,000 and two other black nurses $41,250 each.
Surely, many patients are both honest and savvy enough to perceive and report the quality of their treatment accurately. But patient opinions and emphases vary widely. A 2012 study found that 61 percent of patients at hospitals with low scores on heart failure process measures (whether certain highly recommended treatments are provided to patients) said they would recommend the hospital to family and friends. Furthermore, about 40 percent of the worst-performing hospitals that treat heart failure reached the top half of patient satisfaction ratings, and 40 percent of the best-performing hospitals were in the bottom half. It is clear that the standard national surveys, developed by the Agency for Healthcare Research and Quality at the request of CMS, don’t provide patients the opportunity to appropriately evaluate their care.
Notably, the survey never indicates to patients that hospital funding is tied to its results. The survey’s recommended sample cover letter to patients states vaguely that the survey “is part of an ongoing national effort to understand how patients view their hospital experience.” That’s a major understatement. If patients knew how important the survey was, they might be more conscientious about completing it.
Gaming the system
Much like universities try to influence the U.S. News & World Report Best Colleges rankings by gaming the system and misrepresenting the data, many hospitals are doing whatever they can to beguile patients into giving them higher ratings. Recently, hospitals have rushed to purchase extra amenities such as valet parking, live music, custom-order room- service meals, and flat-screen televisions. Some are offering VIP lounges to patients in their “loyalty programs.”
The University of Toledo Medical Center spent approximately $50 million to renovate its hospital entry area, make all rooms private, change food and valet service vendors, and hire an executive chef. In Michigan, Beaumont Hospital spent $500,000 to install room service and a new menu including made-to-order omelets. As a Michigan consultant said, “One bad meal can mean a bad patient satisfaction score.” It’s probable that private rooms could give patients more rest, and tastier food could tempt patients into better nutrition. But some of that money, as at any hospital, could have been used to hire additional nurses, which would improve patient health more directly.
Because almost every question on the survey involves nurses, some hospitals are forcing them to undergo unnecessary nonmedical training and spend extra time on superfluous steps. Perhaps hospitals’ most egregious way of skewing care to the survey is the widespread practice of scripting nurses’ patient interactions. Some administrators are ordering nurses to use particular phrases and to gush effusively to patients about both their hospital and their fellow nurses, and then evaluating them on how well they comply.
An entire industry has sprouted, encouraging hospitals to waste precious dollars on expensive consultants claiming to boost satisfaction scores. Posters hang in break rooms even in some of the most prestigious hospitals in the country, displaying key words to remind nurses of the specific jargon they must use with patients. Some hospitals have ordered nurses to keep cue cards in their pockets, or, at several Massachusetts hospitals, to wear laminated cards around their necks that remind them to end each interaction with the words: “Is there anything else I can do for you before I leave? I have the time while I am here in your room.’’ And across the country, administrators are telling nurses to use a patient’s name at least three times per shift.
One of the most common scripted interactions is the AIDET, developed by Studer Group, a company that works with more than 800 healthcare organizations worldwide and refers to its services as “coaching.” AIDET stands for Acknowledge, Introduce, Duration, Expectation, Thank. Some managers are telling nurses that they must demonstrate “AIDET competency” or they will have to undergo “remediation” or an “improvement plan.” They are assessed by “AIDET auditors.” Of course, patients can appreciate some of the AIDET information. It’s helpful to know how long a wait will be or what a procedure entails. Certain nurses could use the reminder that their patients don’t know and wish to know what is going on. But good nurses explain those things to patients anyway, and the best nurses explain them in ways most suited to each individual patient. Evaluating—and penalizing—nurses based on how well they stick to a formulaic script implies that nurses need a blueprint for basic human interaction.
More disturbing, several health systems are now using patient satisfaction scores (likely from hospitals’ individual surveys) as a factor in calculating nurses’ and doctors’ pay or annual bonuses. These health systems are ignoring the possibility that health providers, like hospitals, could have fantastic patient satisfaction scores yet higher numbers of dead patients, or the opposite.
While role-playing can be an effective teaching tool, some hospitals have gone too far, auditioning and hiring trained actors to perform patient roles in playacting sessions for nurses to rehearse these scripts, including call-backs. That’s right: Hospitals are spending valuable resources to audition and hire professional actors.
If scripting sounds like teaching to the test, that’s because it is. HCPro, a healthcare consulting company, offers a tip sheet entitled “Quick Ways to Improve Patient Satisfaction Scores.” The company calls the survey “an open-book test” and suggests that nurses “ ‘remind’ patients and/or their families of the ‘right’ answers.”
It’s safe to say that the Centers for Medicare & Medicaid Services, the federal agency that utilizes the surveys, does not approve of these tactics. Survey guidelines specifically state, “Hospitals must not use HCAHPS wording and/or response categories in their communication with patients.” But what did CMS expect? That’s like college admissions officers telling high school seniors they shouldn’t get help with their applications. No hospital wants to be the only kid taking a curved test on his own, when other students use tutors who already know both the questions and the answers.
In Massachusetts, a medical/surgical nurse told The Boston Globe that the scripting made her feel like a “Stepford nurse,” and wondered whether patients would notice that their nurses used identical phrasing. She’s right to be concerned. Great nurses are warm, funny, personal, or genuine. It can be ha
rd for nurses, who are not actors, to appear heartfelt and compassionate when they all recite the same script.
At Indiana University Health, a ten-page laminated guide instructs staff to use precise phrases and manipulative strategies. Employees cannot answer patients with “You’re welcome” or “No problem”; they are told to say, “It’s my pleasure!” They are directed to use strategies including “fogging” agitated patients by telling them, “You’re probably right”; “verbal softeners,” which replace “That never happens” with “It’s possible” or “It’s unlikely,” and, an interesting strategy for customer service: “Nod and hum.” The guide even recommends specific nodding and humming sounds: “Mmmm hum, hmmm?” and “Uh-huh.”
Uh-huh. These scripts and strategies assume nurses are unintelligent, lazy, or lacking people skills. Consultants further demoralize nurses when they are condescending and out of touch. Rebecca Hendren, an HCPro administrator, wrote the following in an industry newsletter: “If you haven’t found a way to drive home the importance of patient experience to direct-care nurses, find it now. You know how much reimbursement is at stake, but the rank and file caregivers still don’t get it. I’ve written before that the term ‘patient experience’ has a way of annoying bedside caregivers. ‘We’re not Disney World’ is a common refrain; people don’t want to be in the hospital. ‘I’m here to save patients’ lives, not entertain them’ is another common complaint.”
Oh, they get it. Make no mistake that nurses “get” the finances that hang in the balance. But they also understand that ultimately, the way that both Medicare and hospitals are interpreting patient experience has less to do with patient health than with the image of the hospital.
The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital Page 26
