Patient satisfaction—“the patient experience”—is given great weight by hospitals and the public alike. Physicians have always aspired to take excellent care of patients. What has changed is that assessments of the patient experience are now being used to measure and report the quality of our care. Although there are many venues for patients to share their opinions, including reviews and online ratings, only the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is standardized and allows for comparisons nationwide.
Given that HCAHPS is the standard by which hospitals, health systems, and individual hospitalists are judged, it is vital for us to understand the core drivers of measured patient experience—especially the factors within our control. Armed with this knowledge, we can more effectively promote a positive experience within our daily patient care.
HCAHPS (H-caps) is a national, standardized, and publicly reported survey of patients’ experiences in the hospital. The Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) developed and piloted the survey in 2002 and launched it in October 2006, with results first published in March 2008 on the Hospital Compare website.
The survey must be administered to a random sample of hospital inpatients 48 hours to six weeks after discharge, and it is offered in multiple languages, either by phone or mail. Twenty-one core questions cover seven composites (communication with doctors, communication with nurses, responsiveness of hospital staff, pain control, communication about new medications, discharge information and planning, and cleanliness/quietness) and two global items (patients’ overall rating of the hospital and likelihood to recommend it to family and friends). There are several additional questions adjusting for patient mix between hospitals, as well as any supplementary questions desired by individual hospitals.1
With the exception of the two global items, all core HCAHPS questions ask “how often” a patient experienced a particular aspect of hospital care. Possible answers are “Always,” “Usually,” “Sometimes,” or “Never”; credit is given to the hospital only for a “top box” score of “Always.” The three questions that are most applicable to hospitalists make up the “communication with doctors” composite; they focus on the quality of physician-patient communication:
- During this hospital stay, how often did doctors treat you with courtesy and respect?
- During this hospital stay, how often did doctors listen carefully to you?
- During this hospital stay, how often did doctors explain things in a way you could understand?
Importance to Hospitalists
A tremendous amount is tied to HCAHPS scores: hospital reimbursement from CMS (through value-based purchasing), hospital rating and “brand,” patients’ choice of hospital, and, in some cases, hospitalist performance bonuses. Hospitals and health systems therefore emphasize HCAHPS heavily. This emphasis has sparked some controversy, particularly surrounding the risk that inappropriate medical decisions (e.g. prescribing antimicrobials or pain medications when not indicated) will be made in order to generate higher patient satisfaction scores. Given the evidence that physicians’ biomedical skill and interpersonal qualities are equally important in determining patient satisfaction, however, we can remain optimistic that time spent explaining the rationale for appropriate medical care is highly valued by patients.2,3
The more satisfied patients are with the care they receive, the more likely they are to continue to seek care from the same provider, hospital, and/or clinic. Improved continuity can help increase adherence, improve patient safety, and decrease healthcare costs. Positive healthcare experiences are also correlated with improved patient compliance with treatment regimens and medical advice, which will lead to better outcomes.
We must also recognize that both the patient experience and physician-patient communication impact clinical care. First, a positive patient experience is linked to higher continuity of care.4 The more satisfied patients are with the care they receive, the more likely they are to continue to seek care from the same provider, hospital, and/or clinic. Improved continuity can help increase adherence, improve patient safety, and decrease healthcare costs. Positive healthcare experiences are also correlated with improved patient compliance with treatment regimens and medical advice, which will lead to better outcomes.5,6
Additionally, higher patient satisfaction is associated with decreased readmission rates. An analysis of more than 2,500 hospitals demonstrated a statistically significant correlation between lower 30-day risk-standardized readmission rates, higher patient satisfaction with discharge planning, and higher overall patient satisfaction with care.7
Furthermore, high quality physician-patient communication has been linked to improved health outcomes. A meta-analysis of 21 separate studies evaluating the effect of communication on health outcomes demonstrated a direct positive correlation with five outcome measures—emotional health, symptom resolution, functional status, physiologic measures (blood pressure and glycemic control), and pain control.8
Finally, higher patient satisfaction and improved physician-patient communication are inversely correlated with medical malpractice risk.9,10
Current data regarding the effect of patient satisfaction on mortality and healthcare utilization/expenditures are conflicting. Jaipaul and Rosenthal found that higher patient satisfaction was associated with decreased mortality.11 Conversely, Fenton and colleagues found an association between high patient satisfaction and both increased mortality and higher healthcare utilization/costs.12 More long-term data will be helpful in clarifying this question.
For hospitalists, the importance of patient satisfaction might reach beyond its clinical impact. Both new residency graduates and more seasoned hospitalists will find that their personal HCAHPS scores can either be highlighted as a strength or work to their detriment when they apply for new positions. Many physicians find that they are asked about their patient satisfaction scores during job interviews. Being knowledgeable about both the patient experience and whether your patients perceive you positively can be an asset.
What Influences Patient Satisfaction, and How Do We Promote It?
Studies show that excellent medical care and strong interpersonal qualities are equally important influences on patients’ satisfaction with physicians.2,3 Having a high quality interaction with their doctor—during which patients feel that they are valued and listened to, that their opinions are taken into consideration, and that they have received a clear explanation—is more important to patients than having a lengthy visit with their provider.13
Consequently, interventions that focus on improving the humanistic aspects of our care and enhancing the quality of our communication will be the most effective strategies for improving patient satisfaction. Remembering to practice empathy for our patients in the midst of our very busy and stressful workdays is an excellent start. We can also utilize the following proven practices for enhancing physician-patient communication:
- Sit down at the bedside;
- Use patient-centered communication techniques, such as asking open-ended questions, using the teach-back method and shared decision-making, and avoiding jargon;
- Clearly outline the plan for the day and explain how it fits into the overall goal of the hospitalization;
- Invite questions; and
- Utilize patient whiteboards.
In addition, demonstrating to patients that we collaborate and effectively communicate with the rest of the healthcare team can also enhance their experience.
Ultimately, patient satisfaction should not be regarded as an extraneous amenity for our patients or as a necessary evil to placate hospital administrators. Instead, improving our patients’ hospital experience can help improve their overall care and health.
Strong physician-patient partnerships and high patient satisfaction increase continuity of care and adherence to treatment, while also resulting in better health outcomes and decreased hospital readmission rates. Furthermore, if hospitalists emphasize a positive patient experience by fostering effective communication and positive relationships, they can also decrease their malpractice risk.
We must therefore find ways to foster patient satisfaction while maintaining safe, effective, quality-driven patient care. Emphasizing humanism and communication, while providing safe and high quality care, is the optimal way to promote patient satisfaction. In this way, we can improve not only the patient experience but also health outcomes.
Dr. Bergin is an academic hospitalist for the internal medicine residency program at Banner-University Medical Center Phoenix in Arizona and a clinical assistant professor at the University of Arizona College of Medicine. Dr. O’Malley is the internal medicine residency program director at Banner and an assistant professor of medicine at the University of Arizona College of Medicine. She currently serves as SHM’s representative on the Alliance for Academic Internal Medicine’s Internal Medicine Education Redesign Advisory Board. Dr. Donahue is assistant professor of medicine at the University of Massachusetts Medical School in Worcester.
- Agency for Healthcare Research and Quality. HCAHPS Fact Sheet (CAHPS Hospital Survey) – August 2013. Available at: http://www.hcahpsonline.org/files/August_2013_HCAHPS_Fact_Sheet3.pdf. Accessed April 9, 2015.
- Matthews DA, Sledge WH, Lieberman PB. Evaluation of intern performance by medical inpatients. Am J Med. 1987;83(5):938-944.
- Matthews DA, Feinstein AR. A new instrument for patients’ ratings of physician performance in the hospital setting. J Gen Intern Med. 1989;4(1):14-22.
- Safran DG, Montgomery JE, Change H, Murphy J, Rogers WH. Switching doctors: Predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract. 2001;50(2):130-136.
- DeMatteo MR. Enhancing patient adherence to medical recommendations. JAMA. 1994:271(1):79, 83.
- Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47(3):213-220.
- Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41-48.
- Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423-1433.
- Tan SY. Issues in medical malpractice IX. Doctors most prone to lawsuits. Hawaii Med J. 2007;66(3):78-79.
- Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice: Lessons from plaintiff depositions. Arch Intern Med. 1994;154(12):1365-1370.
- Jaipaul CK, Rosenthal GE. Do hospitals with lower mortality have higher patient satisfaction? A regional analysis of patients with medical diagnoses. Am J Med Qual. 2003;18(2):59-65.
- Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405-411.
- Blanden AR, Rohr RE. Cognitive interview techniques reveal specific behaviors and issues that could affect patient satisfaction relative to hospitalists. J Hosp Med. 2009;4(9):E1-6.