Improving the patient experience has long been a goal of health care providers. However, health care reform is making the patient experience more than just a marketing consideration: the Centers for Medicaid and Medicare Services (CMS) have structured value-based purchasing to link 1% of Medicare reimbursement to a hospital’s performance in quality and safety measures, including patient satisfaction, and this figure will rise to 2% in the coming years. Private payors are poised to mirror the federal agency’s policy: “We believe that they’re going to adopt this performance-based approach, so hospitals will be at risk of reduced reimbursement from most of the payor mix,” notes Justin Holland, managing principal with GE Healthcare’s Performance Solutions’ Strategy & Leadership practice area. “For hospitals with low margins, excelling at patient-centered care may become a matter of economic viability.”
Holland observes that in terms of patient satisfaction, many health care organizations have a lot of room for improvement. “Health care is the only industry where we see lower customer satisfaction ratings than the airline industry,” he says. “Being an inpatient isn’t a lot of fun—you relinquish control and are often uninformed of your plan of care. Also, some caregivers are rooted in a paternalistic communication style, one that seems to say, ‘I’m your doctor and I know what’s best for you.’ This is different from other industries. If you’re in legal trouble, for instance, and you hire a lawyer, you’re an active participant in most key decisions that are made.”
The Airline Analogy
The health care industry is often compared to the airline industry, and Holland says the analogy is an apt one, especially in light of the trend toward consumer-driven health care. “The situation we’re in is similar to where the travel industry was twenty-five years ago,” he says. “People used to go to a travel agency and trust the agent to handle everything. Today, we book our own tickets online, and pricing smooths inefficiency in capacity. We have more information and make decisions to maximize the experience for the money we spend.” In health care, patients increasingly understand that they have a choice as to where to receive their care—and federal websites like hospitalcompare.org provide consumer-level transparency on quality, safety and patient satisfaction measures. “For elective procedures, hospitals that perform well in these areas will attract more patients,” Holland says.
Holland cites the Mayo Clinic, and other hospitals committed to team-based care delivery, as examples of facilities that are working to improve patient-centricity through experimentation. In typical academic hospitals, he notes, staff physicians round with a fellow and resident, and the group often stands at the bedside, discussing the patient’s care amongst themselves. “The senior physician will quiz the fellow and resident and generally carry-on as though the patient isn’t in the room,” Holland says. “The change progressive institutions have made turns this approach on its head; the staff physician begins by asking the patient, ‘What can you tell us about our plan for your care today?’”
This simple change, Holland says, reveals a lot about how the patient experiences care. “It requires nurses and doctors to be on the same page, but, importantly, it also requires that the patient and family are on that page as well,” he says. “It’s difficult for caregivers to keep people informed of the plan of care. This mechanism reinforces communication and puts the patient at the center of care.”
The Importance of Empathy
Holland also cites a University of Chicago study
1 that found that only 25% of inpatients were able to name anyone in charge of their care, and of those who gave at least one possible name, 60% gave the wrong name. “From the patient’s perspective, there’s often an absence of empathy,” he says. “They feel like they have to ask all these questions to find out what the physician should already be telling them. They don’t feel the physician or nurses are forthcoming with them, or are taking the time to interact with them in a meaningful way.”
That “absence of empathy” can be far more damaging than many health care practitioners realize. Holland discusses a mechanism for measuring customer satisfaction known as the Net Promoter Score, which asks patients two questions: “On a scale of zero to 10, how willing are you to recommend this hospital to a friend?” and “What could the hospital have done differently to earn a 10?” “Working with hospitals on this, you sometimes see those patients who responded favorably were discharged from the same units and underwent the same procedures as those patients who responded unfavorably,” Holland says. “They’re in the same hospital, of the same acuity level and at the same time. Yet the people who would not recommend the hospital were upset with matters of communication—not execution.”
This information is telling, although it’s also intuitive on a certain level: most patients are unaware of how an inpatient procedure was performed clinically, and aren’t in a position to judge its quality. What they are in a position to judge is the attitude with which their care was delivered. “If a patient is considering two specialists with different outcome rates, they will overlook the difference and chose the inferior option on the basis of a recommendation from someone they trust,” Holland says. “How patients perceive the delivery of care is different than the outcome. They are invariably upset by an absence of empathy.”
Starting and Sustaining Change
How can hospitals work to improve the patient experience? “My advice is to listen to patients and involve them in mapping the patient experience as we would clinical pathways,” Holland says. He says health care organizations can start small, with innovative, simple projects aimed at moving patients closer to the center of their care delivery. “At the Mayo Clinic, they experimented with giving patients a passport,” he says. “Everywhere they went in the hospital, it was stamped—it was ultimately a memento, but primarily a mechanism to record and help manage the plan of care.” At UCLA, patients are given “baseball cards” with their physicians’ names and photographs to help them remember which doctors they’ve seen, and for which reasons.
In the long term, Holland calls for hospitals and health care facilities to adjust their hiring practices to reflect a stronger focus on patient-centricity. “Understand that empathy is not something you can address though coaching alone,” he says. “You should be hiring people who already display it. Hospitals would be well served to really challenge the next generation of physicians to be more holistic and patient-centered, building a leadership pipeline of caregivers who are less tone-deaf to the patient experience.”
Holland also observes that there is a strong link between employee engagement and the patient experience—happy employees tend to translate that quality over to their patients, and are more likely to take the small, extra steps necessary to make patients feel they received optimal care. “It’s surprising to see how many hospitals have independent initiatives around these two areas, and miss opportunities to connect the dots between them,” he says. “But a few hospital systems understand the symbiotic relationship between employee engagement and patient experience.”
He concludes that improving patient satisfaction won’t be easy for hospitals—but it will be necessary to their fiscal health in the near future. “Getting away from a ‘fee for service’ paradigm means that hospitals won’t be able to spend their way to improved quality, safety or patient satisfaction,” he says. “In health care, we tend to think in terms of episodes of care. Hospitals often underestimate the lifetime value of a patient when doing the short-run calculus of how to achieve more with less. When you leave a patient with a bad impression, you risk losing her business, her children’s, her husband’s, and her parents.’”
Cat Vasko is editor of HealthCXO.