by Patrick J. Torcson, MD, MMM, FACP
Patient satisfaction is a highly desirable outcome of clinical care in the hospital and may even be an element of health status itself (1). A patient’s expression of satisfaction or dissatisfaction is a judgment on the quality of hospital care in all of its aspects. Whatever its strengths and limitations, patient satisfaction is an indicator that should be indispensable to the assessment of the quality of care in hospitals.
The word “hospital” comes from the Latin for both “guest” and “host,” and the true spirit of hospitality is at the core of the hospital experience (2). The original mission of hospitals was to serve as houses of mercy, refuge, and dying for pilgrims returning from the Holy Land at the time of the late Christian antiquity (3). The striving to please patients is in harmony with the service calling of medicine and is certainly the right thing to do.
From the patient’s perspective, hospitals can be scary and unfriendly places. The American Hospital Association’s Reality Check (4) evaluated the public’s perceptions of hospitals and hospital care using a time-honored technique of asking focus group participants to imagine that the hospital was an animal and a car. Two out of 3 respondents chose animals that would be seen as aggressive, scary, or lumbering to suggest traits such as arrogance, uncontrolled power, and sluggishness. For cars, no respondent chose the Toyota Camry or any other model that would likely make the Consumer Reports list of best values. Instead, the cars chosen were representatives of unreasonable overpricing, waste, and outdated engineering.
“Volkswagen bus...Old, very noisy, just not a real great car.”
“A Rolls Royce, because of the expense.”
“A Pinto, because it was run down.”
“Ford Escort, just barely passing the test.”
“A Cadillac…big and expensive.”
“A bear…a grizzly…horrible.”
“A leech.…I’m sure all hospitals aren’t that lowly.”
“A snake, kind of slithery and sneaky, because of what hospitals charge.”
The same AHA survey showed that patients felt that insurance companies and not physicians were in charge of their care in the hospital. A follow-up question revealed that patients clearly want to be in charge of their own hospital care. Additionally, patients do not see hospitals as part of a planned or consumer-focused health care system. In fact, they see quite the opposite: a confusing, expensive, unreliable, and often impersonal disassembly of medical professionals and institutions. If they see any system at all, it is one devoted to maximizing profits by blocking access, reducing quality, and limiting spending, all at the expense of the patient.
The American Customer Satisfaction Index (5) gave hospitals an overall 67% satisfaction rating, ranking 27th out of 31 industries. This ranking placed hospitals 10 percentage points below the tobacco industry and just above the Internal Revenue Service. A National Coalition on Health Care survey (6) found that 80% of respondents believe hospitals cut corners to save money, and 77% believe that these cuts have endangered patients. Quality of care and patient safety have become significant public concerns recently. “To Err is Human,” the 1999 report from the Institute of Medicine, highlighted the potential for serious injury and death in U.S. hospitals (7). Estimates are that 44,000 to 98,000 Americans die each year in hospitals as a result of medical errors and unsafe practices.
Patient satisfaction is the health care recipient’s reaction to aspects of his or her service experience (8). Patient satisfaction belongs to the service dimension as opposed to the technical dimension of quality of care. Most patients report few problems related to technical quality of care in hospitals and moreover do not feel qualified to judge technical quality and therefore assume technical competence (9).
From 1986 to 1992, the Health Care Financing Administration publicly reported hospital mortality rates as an effort to aid consumers in selecting hospitals (10). Hospitals with over twice the expected mortality rate saw very little change in volume during that time. Patients do not seem to be affected by morbidity and mortality statistics but more by personal stories of care. Patient perception of quality is assessed through dimensions of what is personally valued, and often they do not distinguish between the provider of the service and the service received.
Being treated with respect and dignity and involvement in treatment decisions are intangible issues of patient satisfaction that are paramount issues for patients (11).
As many as one quarter of 13,000 patients discharged from 51 Massachusetts hospitals reported problems with patient satisfaction issues such as the involvement of families in their care, communication and coordination of care, and the transition from hospital to home (12). Patients who had been admitted to academic health centers and teaching hospitals generally reported more problems than those cared for in community hospitals. As it turns out, service outcomes such as patient satisfaction drive market share and profitability for hospitals (13). With the average medical/surgery hospital charge amounting to $12,083, hospitals cannot afford to lose patients and, therefore, revenue due to issues of patient dissatisfaction (14). Recruiting new patients as customers is 5 times more costly than retaining an existing customer base (15).
There is compelling evidence from well-developed lines of research demonstrating that increasing patient satisfaction improves clinical outcomes, such as functional status and physiologic measures of health (16,17). Finally, it is important for clinicians to know that it has been clearly demonstrated that satisfied patients improve physician satisfaction (18,19).
To create a culture of customer service excellence in hospitals and achieve outstanding patient satisfaction, it is necessary to understand the intangible aspects of perception and expectation that contribute to patient satisfaction. The “First Law of Service” provides a useful, simple mathematical model of satisfaction (20). The formula for this model is Satisfaction = Perception – Expectation. If a patient’s perception of their hospital experience meets or exceeds the expectation, there will be a corresponding degree of satisfaction. However, if the perception does not meet the expectation, there will be resulting dissatisfaction. Thus, patient satisfaction results from meeting or exceeding patients’ expectations. Patient perceptions of care can be measured directly from patient satisfaction surveys, focus groups, and telephone surveys. A hospital’s reputation and market share are indirect measurements of patient perceptions. There are 2 main directions in which patient satisfaction can be influenced: by working on what the patient perceives and on what the patient expects.
Expectations are integral to the experience of being a customer. There has been confusion and controversy in health care as to whether patients are in fact customers. This confusion may be at the root of the overall service failing of hospitals (21). “The more horizontal they are, the more they are a patient. The more vertical they are, the more they are a customer” (22). Using a technical definition, a customer is anyone who has expectations about process operations or outputs (23). Therefore, all patients are customers, but not all customers are patients (21). Hospitals have a whole list of primary and secondary customers, each of whom has his or her own set of expectations. Patients and their families can be seen as primary customers, and referring physicians, third-party payers, external overseers, communities, shareholders, and employees are all secondary customers of hospitals.
Expectations are psychological phenomena that can be defined as beliefs created and sustained by cognitive processes (24). Expectations of patients as hospital customers rise from past experiences of their own or of others, as well as from current needs and unique internal preferences that form the basis of a value system. Expectations cannot be mandated, because they are based in self-gratification. However, expectations may change over time, and, very importantly, they can be measured and perhaps modified through education. For most people, illness and hospitalization is a rare event. Patients will know something is wrong and that treatment is needed, but most won’t know the nature of their disease, the diagnostic and therapeutic options, and the likely outcomes. Therefore, patients seek out health care professionals who have the opportunity to inform them on what to expect as a way to begin the process of managing expectations.
The Kano Model provides a useful tool for studying different levels of patient expectations (23).
This model is useful to examine the voice of the customer in the relationship between satisfaction and quality, and it is relevant for hospital encounters. According to the model, patients will have a basic set of subconscious expectations about their care that will be taken for granted. These expectations are so routine and expected that patients don’t recognize them as comparative quality factors, but they will be shocked if they are absent. For example, patients assume that physicians are basically competent, and that hospitals are capable of providing safe, courteous, lifesaving medical care (25). Although these expectations are in the patient’s subconscious, if they are not met, the patient will be dissatisfied. Providing this level of basic quality isn’t necessarily enough to create satisfied patients.
There is a normal level of service that patients consciously consider, they have to do with the anticipated issues of hospital care related to access, wait times, scheduling, and billing. The model shows that satisfaction increases as more of these expectations are met and that patients will be dissatisfied if these quality expectations are not met. Patients use comparisons of these expectations to recognize differences among competitors and to make choices.
The latent quality curve lies entirely in the satisfaction region and represents supraconscious, unexpected quality items that patients didn’t know they wanted and result in a delightful surprise when present. In this experience, patients receive more than they had expected, often as the result of innovation that can raise patient expectations and provide a significant competitive advantage. The data from hospitals show that this is achieved primarily through the patient’s perception of personalized, customized service, provided by caring and concerned clinicians (26).
There is a tremendous opportunity in hospital care to modify patient expectations through education and to create high levels of patient satisfaction. Hospitals that are successful in this endeavor will have a significant competitive advantage. Hospital patients have a whole list of issues about which they have expectations: the smoothness of the admission and discharge process, accuracy and clarity of billing statements, courtesy of hospital employees, response time for calls and requests, the level of technology available in the hospital, nurse competency, taste and temperature of the food, and price. Most of these issues are not directly related to clinical care and certainly not under the control or influence of the hospitalist. What are the expectations that patients have for their clinical care by hospitalists, and how can we give it to them?
A useful model to define the hospitalist’s role in patient satisfaction is that of a caring and concerned clinician. This caring and concern for patients is exemplified by attentiveness, dignity and respect, effective information transfer, and shared decision making (23).
The outcome service chain for hospitals begins with the patient’s perception of caring and concerned clinicians who demonstrate these attributes of attentiveness, dignity and respect, effective information transfer, and shared decision making. This leads to the degree of patient satisfaction and loyalty that results in patients who will return to the hospital, seek related business, and refer additional business. This drives market share and financial success for hospitals (9).
The characteristics of the caring and concerned clinician begin with attentiveness. This is the practice of establishing a person-to-person connection with patients and involves attending to them as unique individuals and not just in their role as patients. The constant interruptions that occur in physician/patient encounters, control issues, discontinuity of care, and the often overwhelming complexity of a patient’s illness can be obstacles to the perception of attentiveness that result in patients feeling connected with the clinician. Some effective tools for attentiveness are demonstrating curiosity about the patient as a person, using open-ended questions to gather clinical data, orienting patients to the process of care, and actively eliciting a patient’s agenda for their care and then summarizing their concerns.
The demonstration of dignity and respect results in a patient’s feeling understood and accepted as a person. This is the practice of empathy, which is often confused with sympathy (27). Sympathy is an expression of one’s own feelings (“I’m sorry”). Empathy is the demonstration of an understanding of the patient’s feelings (“You must be very sad”). The confusion of medical terminology as well as the time constraints of modern hospital-care encounters can be obstacles to achieving the type of dignity and respect that results in a high degree of patient satisfaction. A number of effective tools are available to facilitate this important result. Sitting down during patient encounters greatly enhances the perception of time and caring of hospitalists on the part of patients. Eye contact and appropriate touch are demonstrations of dignity and respect, as is seeing patients fully clothed. It is important to pay attention to nonverbal communication issues with patients. An important element of how hospitalists are perceived by patients has to do with nonverbal issues such as demeanor, body posture, and verbal tone. Using a patient’s own words and addressing underlying feelings facilitates the practice of dignity and respect (28). Patients perceive statements of assured understanding as confirmation that they have been listened to. Remember the words of Sir William Osler: “Listening is unspoken caring.”
The effective transfer of information is at the core of physician/patient communication (29). Patients have the need to provide complete information to physicians to facilitate an accurate diagnosis. The physician’s role is to provide information that addresses the cognitive, behavioral, and affective needs of patients and their families concerning their illness. The discrepancy of language, time constraints, and the ability of patients to remember are all barriers to the effective transfer of information. Some useful techniques for effective information transfer include assessing a patient’s current level of understanding and asking about their self-diagnosis. Timeliness in providing results of diagnostic tests is an important issue to patients who are often waiting expectantly. Studies have shown that the majority of patients have questions about the so-called “mysteries of medicine,” related to the diagnosis, etiology, and prognosis of their illness (30).
Patients may not specifically ask these questions; however, they are present, and patient satisfaction will increase if these questions are answered. Patients have decisively indicated their desire for shared decision making regarding their health care and for patient and family control of all-important choices (26). The process of shared decision making can be facilitated by collaboration between patients and the hospitalist around goals ands plans for treatment in the hospital (31). A barrier to shared decision making is a patient/physician relationship based on a model of paternalism (“I’m the doctor, and I know best”). A more productive model for the therapeutic relationship is that of a partnership between the hospitalist and the patient, particularly in the present era of web-educated, sophisticated consumer patients.
An important tool to achieving this type of collaboration involves the approach of presenting patients and families with treatment options and then actively soliciting patient preferences. A question is whether patients will actively participate in treatment decisions and then adhere to treatment plans. This is in large part determined by the interpersonal relationship skills of the clinician and can be further facilitated with simplified regimens that have been agreed upon by the patient and the hospitalist (32).
A complete model of the hospital-care encounter provided by hospitalists has an opening and a closing. In between there is a series of moments of truth that can potentially be imbued with attentiveness, dignity and respect, effective information transfer, and shared decision making. The opening is a brief moment that will set the stage for the remainder of the encounter. Greeting patients by name and maintaining eye contact will help in establishing the early perception of being a caring and concerned clinician. It is important to close hospital encounters with a sense of hope and optimism, making sure that all of the patient’s issues have been addressed, as well as planning for the next steps.
The development and growth of hospital medicine is the latest site-specific evolution of practice specialization and focuses on the complex care of hospitalized patients. Hospitalists spend most of their professional time in the hospital providing care for general medical patients and are well positioned and uniquely committed to improving the care of hospitalized patients. Exceptional patient satisfaction is a key outcome that should result from the care provided by hospitalists.
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