High patient satisfaction ratings have become an urgent but uncertain goal for hospitals in response to Medicare plans, starting this October, to tie a small percentage of reimbursement to “value-based purchasing” bonuses. These bonuses will be determined by comparing hospitals both on their adherence to clinical performance guidelines (70% of weighted score) and on patients' perception of the quality of care (30%)—based on postdischarge survey questions on such aspects of care as pain control, cleanliness of rooms, and whether clinicians treated patients with respect.
This mandate in the Patient Protection and Affordable Care Act (ACA) stipulates that Medicare withhold 1% of normal reimbursements for the incentives bonus fund. While subjective patient satisfaction scores matter, the 30% weight they carry, and the penalties that low-scoring hospitals could incur, is disproportionately high. Lowering the 30% to 10%, and modifying the survey to adjust for risk, length of stay, and population, would be more reasonable.
Patient satisfaction scores are determined using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which was intended to allow objective comparisons between hospitals, create incentives to improve care, and enhance accountability and increase transparency in the quality of health care provided with public money.
However, certain trends have surfaced as HCAHPS data are analyzed, causing some hospitals to criticize the weight given to HCAHPS results. Research suggests that high acuity hospitals tend to have lower patient satisfaction scores, patients in some U.S. regions may be less likely to complain, and certain hospitals with superior scores in clinical measures and outcomes suffer from bad patient reviews.
Using data from the U.S. Department of Health and Human Services Hospital Compare Web site, USA Today analyzed death rates for nearly 5,000 U.S. hospitals and discovered that “120 of those most highly rated by patients have higher than average death rates.”
Most hospitalized patients suffer from pain, some have a surgical wound inflicted to heal an underlying problem, others must spend time waiting for tests or treatments. Are we placing too much emphasis on having happy patients?
Patients' perceptions of their care do have value, and their complaints can be drivers for systemic change. As Nancy Rutledge put it in a 2008 article in Nursing Management, “Perception is indeed the new reality in health care.” A hospital is neither a hotel nor a theme park, yet an industry has sprung up to provide contrivances designed to influence patients' answers on the HCAHPS survey. It's no longer enough to turn out the lights and close the door so patients can have an environment conducive to a good night's sleep. Now nurses must add the phrase, “I am closing the door and turning out the lights to keep the hospital quiet at night,” so patients have a mental cue implanted when they encounter a related HCAHPS question.
So, to the love and respect that season my tasks of kindness and the superior clinical excellence to which I strive, I must now add the artifice of a token script in a calculated attempt to influence my patients' perception of my care.
Patient surveys already in use by independent accrediting agencies such as the Joint Commission can and do improve patient care. But tethering 1% of government reimbursement to subjective satisfaction scores devolves the focus from improving patient care to manipulating patient perception. While mandating and measuring compassion doesn't necessarily poison it, doing so misses the heart of nursing. Compassion, empathy, and beneficence are basic virtues from which my nursing care emanates, and I control their exercise. But on any given shift there are innumerable circumstances that I have no control over—yet I and my institution will be held accountable for the patient's satisfaction regardless.