Patient Experience - Are we missing the point?

Like many other amazing teams, my team tries to read broadly and regularly. So we often share a "what we're reading" list as we run across a lot of interesting thinking and articles. One recent article we shared really struck a nerve with me.

https://patientengagementhit.com/news/do-patient-satisfaction-scores-truly-portray-quality-care

This is a great article in some ways, but it is also an example of something I find troubling.

The authors begin the article noting an op-ed piece titled "The Importance of Patient Satisfaction: A Blessing, a Curse, or Simply Irrelevant?" From this very leading headline, there is an outline of points which appear truly alarming about the state of patient experience metrics and the results they've had in the industry. In the end, they offer a conciliatory notion that patient experience is important, but just broken.

What I find troubling is that the article, while seeming to be balanced also introduces some thought-processes which I feel are misleading. Let me provide four examples of what I mean along with some counter-balancing thoughts:

Issue #1: Asking the wrong question (quality or satisfaction?)

As hospital and practice administrators focus on obtaining high reimbursement rates, they promote often conflicting agendas: delivering outcomes-based care while keeping the patient happy. Some providers have trouble reconciling the two priorities, the authors stated.

For example, some emergency doctors may prescribe an antibiotic without running tests to determine a diagnosis simply to satisfy the patient and get her through the ER more quickly. 

I think this looks at the issue from the wrong angle. Or maybe it's that it addresses the wrong issue. It sets up the dilemma as one that seems to be either "don't do tests so we can make people happy" or "do tests because this is right regardless of making people miserable."

From what I've seen, the real issue is about the inefficiency of hospital operations and ineffectiveness of provider communications. Instead of setting up a false dichotomy, work on improving how well the operations are run and you can do the necessary work for patients without unnecessarily long waiting periods. Ensure providers (not just doctors) are communicating expectations and why they are doing what they're doing so people can understand the value behind how they are being cared for. 

Maybe, and I know this is crazy, we could engage the patient in their care process. Let patients know testing prevents unecessary drug interventions (or wrong ones). Guide them and then let them provide input.

Issue #2: Assumptions of possible situations and faulty conclusions of the problem

Additionally, the authors said providers might forego important population health management questions to avoid offending a patient. These doctors might avoid conversations about smoking cessation, weight loss, and drug and alcohol use in order to offer a more pleasant experience to their patients, despite their clinical instincts.

I've heard this a number of times and I'm really skeptical about it. Seriously, has anyone looked at their data to see if this is actually an issue? Sure, it's happened - but at what level? I would doubt this is an issue statistically significant enough to use as an overarching argument against measuring and holding providers accountable for patient experience.

Even if it was, is the only answer here because you can't talk about these sensitive issues or because the providers were lazy in how they communicate? Did they seek to understand before pushing information at people? Were the patients engaged in dialogue to see what they thought about the situation or maybe what obstacles they have in their efforts to lose weight, stop smoking, etc.?

Did they think about how the message was delivered? As some one who communicates for a living, I have learned that the responsibility lies with the communicator to ensure effectiveness of the communication. If you don't think about how the person will receive the communication, you'll often fail. Like it or not, if your goal is to influence action and change, then this is on you.

Issue #3: Assuming an all or nothing thinking to incentives/motivations

“Behavior motivated by patient satisfaction becomes especially dangerous when ratings are directly tied to compensation,” the authors asserted. “Health care administrators appear to be sending a mixed message by saying that patient satisfaction outweighs outcomes.”

Underlying this statement is the idea that if we use money as a motivator it will lead to dangerous gaming of the numbers to the detriment of the actual desired outcome. In reality, I have seen very few compensation plans where the percentage of salary/bonus for patient satisfaction scores is so significant that providers would actively game it.

While I can argue both ways on whether satisfaction scores should be a part of reimbursement I will say if it's tied to income, administrators have a responsibility to patients and providers to ensure they are doing it fairly and responsibly. We have to remember this is a very subjective metric and we have to account for that in how we use it.

For example, if you're talking about reimbursement tied to patient satisfaction in the emergency room you have to take into account the fact that NO ONE goes to the ER because they're happy. And if you're dealing with something like Rheumatology, patient satisfaction can be tricky because you're dealing with pain. Sometimes the pain just simply can't be made to go away instantly or even fully diagnosed quickly. And when someone's in pain they are not going to be in a frame of mind to understand why the doctor can't make it stop.

None of this means we shouldn't have a focus on patient experience and even tie it to some portion of reimbursement. In fact, I'd argue to the contrary. We need to better understand and design our interactions with patients to align with what it's like to be them. What would you feel like if it was you in their shoes? Sometimes the best way to get organizations and people engaged is to hit all of the motivational buttons. These can be a shared vision and values, the nobility of the effort and their craft, competition, money, etc.

But when designing the reimbursement structures we do have to take into account the realities that perfect satisfaction scores may be less than 100 points (or 5 stars) because of the reality of the situations we're operating in and adjust accordingly.

Issue #4: The clinical left-brain versus the patient experience right-brain

“The focus on patient feedback has already skewed hospital administrators’ agendas, and long-term hospital plans now center on renovating the physical buildings, elevators, lobbies, and patient floors, and also investing in luxuries such as valet parking and gourmet meals,” they noted. “One could argue that these costly expenses have more to do with the perception of health care quality rather than actual outcomes.”

My issue here is that these statements can lead to an assumption that one view is more important than the other. I often compare doctors and administrators to my world where a similar dynamic exists between engineers and executives.

When you're building a product, you have to have engineers. No engineers = no product. But engineers are highly analytical and rational creatures. If you left the product development to them alone you would very likely end up with something that absolutely does what you asked them to make it do...and no one but them would ever want to use it.

Product designers, user experience experts and sales/marketing types are needed to build excellent products. But there's a dynamic tension between these "creative" types and the engineers. It's in that tension that greatness can be found. Form and function find balance in that tension.

And there is balance to be had between hard core clinicians and the "creatives" in healthcare as well. While we should certainly have a primary focus on outcomes, I think it's at best naive to think with a strictly-rational, left-brain approach when designing how you care for people. Taken to an extreme in "Reductio ad absurdum" fashion, this approach leads us to bland and dreary buildings with cold, sterile environments that are the stuff of nightmares.

Yes, the protocol and diagnoses may be solid but it completely ignores the human side, the "care" in healthcare. People are emotional by nature. Put them in some of the most deadly and vulnerable situations possible and emotions don't cease to matter. They matter more.

Again, this needs to be in balance. Not experience to the detriment of quality. But not clinical devoid of humanity either. That's not quality care. 

Conclusion

Providing credit where credit is due, the end of the article does loop back around to the fact that patient experience is important. They note they believe we should be measuring it but think the current system isn't optimal. I agree.

The suggestion of measuring satisfaction in different ways by specialty I think is a great start to the change needed. More options may be to begin building an understanding of various cultures and how they interact with people, how they define health and what they value. These kinds of frameworks can help us begin to deliver personalized care in ways that are meaningful.

Finally, while we should certainly ensure that providers (hospitals, doctors, mid-level providers, etc.) are held accountable and are not completely self-regulating, we also need to admit the people in these lines of work have some of the most important and difficult jobs around. We should not demand perfection and we must admit our role as patients in the fight for better healthcare.

Bottom line, we have to work together and acknowledge what makes us human (good and bad) to build the system we need.