Thoughts on Patient Satisfaction Surveying

Two Research Studies

Two recent research studies on patient satisfaction surveying have just been published. One study questions the fairness of the surveys, while the other documents the unintended consequences of how the results are being used. Both are going to reignite the controversy surrounding patient satisfaction surveying.

The First Study: Questioning the Fairness

The first study presents compelling statistical evidence that “…using only 4 demographic and hospital-specific predictors (i.e., hospital beds, percent non–English speaking, percent bachelors’ degrees, percent white), it is possible to utilize a simple formula to predict patient satisfaction with a significant degree of correlation to the reported scores…”

The Second Study: Consequences from Results

The second strongly suggests that efforts by physicians and hospitals to “game” the results of patient satisfaction surveys are increasing the cost of healthcare while reducing the quality of care delivered.

Published Articles

Details of the two studies have been presented in articles published in professional journals.

  1. Demographic Factors and Hospital Size Predict Patient Satisfaction Variance—Implications for Hospital Value-Based Purchasing”, published online in the Journal of Hospital Medicine, May 4, 2015 and reported on by Alexandra Wilson Pecci for HealthLeaders Media, June 3, 2015.
  2. Patient-Satisfaction Surveys on a Scale of 0 to 10: Improving Health Care or Leading It Astray?”, published in The Hastings Center Report on March 6, 2015 and subsequently referenced in the June 8, 2105 edition of Becker’s Infection Control and Clinical Quality.

Raising Questions

Both of these studies raise very troubling questions about patient satisfaction surveys, at a time when the use of the tools and significance of the results is at an all-time high. To emphasize that point, the Journal of Hospital Medicine article notes that “Hospital Value-Based Purchasing (HVBP) incentivizes quality performance-based healthcare by linking payments directly to patient satisfaction scores obtained from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys.” As to why providers may be motivated to “affect” their results, The Hastings Center article states that “more than 59 percent of physicians reported that their pay is linked to patient-satisfaction ratings.”

Hospital Value-Based Purchasing

Hospital Value-Based Purchasing (HVBP) started being phased in for the Centers for Medicare & Medicaid Services (CMS) payments in the 2013 fiscal year. The final step of the staggered implementation is to occur in the 2017 fiscal year, at which time it will affect 2% of all CMS hospital reimbursement. Given the millions of dollars represented by the 2%, it’s easy to see why healthcare executives are eager to boost their institutions’ scores.

My Experience

My familiarity with patient satisfaction surveying comes from many years in past roles as:

  1. Contract manager staffing clinical service departments for hospitals
  2. Practice manager working with multiple hospital-based physicians

Those experiences have been reinforced by my recent roles as:

  1. Advocate representing either hospitals or physicians in the negotiation of employment contracts
  2. Mediator to facilitate their successful conclusion or aid in resolving disputes regarding these agreements

The Development of Patient Satisfaction Surveys

The government and healthcare industries have been eager to identify quantifiable elements of provider performance to help define quality. That led to a pell-mell search for objective tools to do the job. The patient satisfaction surveys that were developed provided both objectivity and transparency, and that appeared to be enough. Now that they’ve become well established, we’ve conveniently forgotten that the survey tools weren’t intended to measure individual provider performance.

The Benefits of Surveys

To be clear, patient satisfaction surveying can be an essential component of any institution’s self-awareness. Even with the concerns raised by these two studies, survey results can offer remarkable insights into the interworking of an organization as a whole. However, it is critical to understand how that’s done and the limitation of the methodology.

Employers Push for Surveys

These two most recent studies merely add to the serious limitations of the available survey tools were already known. However, without other available options, hospital employers continue to insist that the compensation provisions of their employment contract with physicians and other providers include a patient satisfaction component. Healthcare executives quite accurately point out that patient satisfaction measured in the HCAHPS scores is impacting their HVBP payments. As such, why shouldn’t they extend that risk exposure to those directly involved in delivering care to the patients?

Physicians Push Against Surveys

Not surprisingly, most physicians hate the surveys and actively resist the inclusion of contractual provisions that put their compensation at risk based on these measurements. When this issue emerges, the contract negotiations can become quite contentious. I’ve seen several negotiations stalemate over this issue, with the loss of key personnel or the termination of existing relationships.

The Pros and Cons of Compromise

There are ways to make patient satisfaction provisions both acceptable and meaningful, but most negotiations that end in an agreement do so in a simple compromise. Either the patient satisfaction compensation provision stays in the agreement and the dollars put at risk are drastically reduced, or the performance standard is so modest that payment is virtually guaranteed. The doctors can accept the diminished exposure while the hospital’s negotiators can claim that they’re measuring and incenting patient satisfaction. Unfortunately, these accommodations largely defeat the purpose of having the provision in the first place.

Surveys Will Continue

Even with the grave concerns raised by these two research studies, the current surveying method is simply too well established. Creating a more accurate and meaningful patient satisfaction assessment process is possible, but it takes time and effort to construct. For that reason, the use of the existing surveys with all of their inherent shortcomings may be with us for years to come.