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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000418086.21908.e6
AJN Reports

Patient Satisfaction Metrics: Customer Service or Quality Care?

Nelson, Roxanne BSN, RN

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Nurses support better quality care but balk at using scripts to get there.

The quality of patient care is undoubtedly a top priority for nurses, but the new uses patient satisfaction metrics are being put to could be overshadowing this concern. Under its “value-based purchasing” proposal, the Centers for Medicare and Medicaid Services (CMS), beginning in October, will make incentive payments to acute care hospitals on the basis of how well they perform on certain quality measures or on how much their performance improves from baseline levels. The better the institution performs or the more it improves during a fiscal year, the higher its incentive payment for that fiscal year will be. But at many institutions, it's the nurses who are under pressure to make sure patients rate their hospital stays highly. Some hospitals are even requesting that nurses adhere to standard scripts—a practice known as “scripting”—when talking to patients, in order to achieve such ratings. Those scripts may be so detailed that they specify how many times nurses should use a patient's name in a shift.

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“Scripting has been around for a number of years and isn't a new concept,” said Sandy Fights, MS, RN, CMSRN, CNE, president of the Academy of Medical–Surgical Nurses. However, the purpose of scripting has shifted, she said, “and the plan to include patient satisfaction in CMS funding criteria seems to be at the core.”

There are also numerous consultants and plans for service excellence that promote the use of scripting, noted Fights. “But although the basic concept of scripting can be good, there's a concern that somehow patients and patient-centered care can get lost,” she said. “For example, including in every introduction that ‘I am Sandy Fights, your registered nurse,’ or saying, ‘I am Nurse Fights and I will be caring for you today,’ is a good way of helping the patient identify the RN. But when the script becomes rote or filled with subliminal messages, are you really still providing patient-centered care?”

Subliminal messages? Yes. Fights said that scripts used today tend to be filled with statements like, “Is there anything I can do to make your stay more excellent?” One of the intents of such phrasing, she explained, is to plant the word “excellent” in the patients' minds, so when they complete the satisfaction survey after hospitalization, they'll choose the “excellent” rating. And scripts employing terms like “side effects” or “drawing the curtain for your privacy” are aimed at helping the patient remember those terms when they fill out the satisfaction survey. When patients are asked about adverse effects or provisions made for privacy, they're more likely to recall those phrases and say, “Yes, they taught me about side effects” or “They did provide privacy,” according to Fights. (For one nurse's opinion of scripting, see the July Viewpoint.)

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Under the inpatient prospective payment system, the CMS initiative would apply to Medicare payments for inpatient stays in more than 3,000 acute care hospitals nationwide. The financial incentives will be 1% in fiscal year 2013 and increase to 2% by fiscal year 2017. One of the means of determining the amounts of those payments is the Hospital Consumer Assessment of Healthcare Providers and Systems patient experience of care survey. The survey was developed to “provide a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care” and to “produce comparable data on the patient's perspective on care that allows objective and meaningful comparisons between hospitals on domains that are important to consumers.” (For more on the survey, go to The survey is 27 questions long and covers 18 areas of patient care, such as communication with physicians and nurses, the responsiveness of hospital staff, pain management, communication about medicines, discharge information, and the cleanliness and quietness of the hospital environment.

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Naturally, patient feedback is important, but do these surveys really tell the whole story? Nurses want patients to be satisfied with their care, and they may well be committed to and supportive of these initiatives, but many have expressed concerns. For example, after a survey of hospitals in the Portland, Oregon, area showed that only 74% of patients believed their pain was “always well controlled” during hospitalization, Susan King, RN, executive director of the Oregon Nurses Association, expressed her belief in an opinion piece on that using the term “always” effectively ensures that the rating will never be 100%.

“In reality, not all pain can be controlled all of the time; some health problems are, by their nature, excruciatingly painful and require frequent assessment and medication,” she wrote. “A more relevant question would be to ask if nurses at the facility had sufficient time to stay on top of their patient's pain level and provide treatment promptly.” Although King agreed that publicizing patients' perceptions of the quality of their care is the right thing to do, she noted that it's imperative to dig deeper if the information is to be “anything more than a superficial review of customer service.”

Research suggests that quality ratings do deserve further attention and may well be important. In a recent study by Aiken and colleagues published online (March 20) in BMJ, nurse researchers surveyed patients and nurses in Europe and the United States and found that nurse staffing and the entire quality of the hospital work environment were significantly associated not only with patient satisfaction, but also with the quality and safety of care and with nurse workforce outcomes. Institutions with good work environments and adequate staffing had better patient and nursing outcomes.

King's concerns are echoed by Theresa Brown, RN, an oncology nurse based in Pittsburgh, Pennsylvania, and a contributor to the New York Times's health and science blog, Well. “Are nurses going to have to worry about serving people or about taking care of people?” she asked when interviewed by AJN. She noted that there are more obvious concerns than customer service per se when caring for people who are seriously ill. “That's not to say that comfort isn't important, but keeping patients alive is far more important,” said Brown. Hospitals aren't hotels, she pointed out, suggesting that evaluating them in the same way and using those evaluations to guide reimbursements could have negative effects. Although the proposal may be well intentioned, Brown said, the evaluation methods may not have been thought through well enough, and their ability to do what they are meant to do—empower patients—hasn't been tested. And there's certainly no guarantee that the incentive money hospitals receive will be spent on improving the patient experience or creating a safer environment. “It's missing the whole point; it's a completely superficial focus on quality,” said Brown. “And it's nurses who are feeling the pressure. But I don't see anyone giving more resources to help nurses do their jobs better—it's basically telling nurses to do more without any extra resources.” If the CMS is going to evaluate the patient experience and link these results to reimbursement, she added, “they also need to incorporate questions that address the complete and expected hospital experience.”

Fights predicts there will be an increasing emphasis on patient satisfaction over the next few years. However, she cautions, “We need to see the data demonstrating that high patient satisfaction is equal to better patient outcomes.”—Roxanne Nelson, BSN, RN

© 2012 Lippincott Williams & Wilkins, Inc.