I’ve been volunteering in an emergency department of a Southern Californian community hospital for five years. I clean gurneys, stock shelves, provide support for RNs and EMTs and translate for Spanish-speaking patients. Since my job requires minimal intellectual effort, I’ve had considerable time to observe the staff and contemplate the inspiring work they do.

I’ve watched them perform heroically with sick babies, agitated psychiatric patients, full cardiac arrests, and everything else from stroke to strep. I love what they do and who they are.

Over time, I’ve also became acutely aware of frustration among ER practitioners with increasing pressure to boost patient satisfaction scores. I began to share their skepticism about the validity, reliability and consequences of satisfaction surveys.

Wasn’t it self-evident that the surveys were bogus? We all knew that a patient might be happier if we order up that MRI his brother-in-law recommended for his backache, if we hand out antibiotics for likely viruses, or write a narcotics prescriptions for malingering addicts, or decline to tell obese problem drinkers that they need to quit the vodka and eat fewer Big Macs. Giving patients exactly what they want will score satisfaction points, but it’s often costly to the system and detrimental to individual and public health.

Then about a year ago, I was asked by our hospital’s quality department to be a patient advisor on the medical-surgery floors. My task was to administer a survey on hospitalist physicians and inquire in general about the quality of the patient and family experience. When I saw questions on the survey like, “Did the doctor sit down when visiting you?” I knew I had entered an alternate universe with values skewed in a way folks in the ER wouldn’t readily comprehend.

I found that although everyone’s priority is quality care for our patients, ER docs and nurses spoke a different language than the quality geeks. Sometimes they talked right past each other. “A hospital isn’t a hotel; patients shouldn’t expect to be pampered,” said the ER nurse. “We should learn from the hospitality industry, and patients should be treated like guests at a four-star hotel,” said the quality administrators.

The disconnect was profound. Even the peer-reviewed studies on outcomes seemed to arrive at contrasting conclusions. One study suggested a negative correlation between patient satisfaction and clinical outcomes. Others claimed the opposite.

Quality experts argue that honing in on tiny measures for improvement bump overall satisfaction scores and cumulatively transform hospital culture to one of overall patient-centered excellence. But nurses’ advocates warn, “Patients can be very satisfied and dead an hour later.” Or they cite the case of an RN who had been disciplined because a patient complained the hospital didn’t have Splenda sweetener.

So who is right? The docs and nurses who practice tough love on recalcitrant patients or the warm and fuzzy hospitality administrators who emulate business class flight attendants and remind us that Medicare reimbursement is inextricably tied to patient satisfaction?

What I’ve learned from both working in the ER and visiting patients on the floors is that real quality is not a zero-sum game. Quality is multidimensional and nuanced; we can’t sacrifice or neglect one dimension for another. Splenda fixation is a surface symptom that alludes to a deeper discontent. When patients are dissatisfied with the minutiae of care, their real message is that their emotional needs are not being met. They may feel disrespected, confined, vulnerable, fearful and lonely. These are all 10s on the scale of painful emotions. Not treating them interferes with healing.

To improve clinical outcomes, we have to pay attention to everything. We can’t supply Splenda on demand, but we can engage in honest conversation about the details of care so that patient and family understand we take them seriously and that the emotional quality of their experience matters. Such conversations foster intimacy; they are empowering for the patient and inspiring for the practitioner; they lead to genuine improvements.

Consider the patient I recently visited who had previously been admitted three years ago. “On my way to the ER last night I  broke into tears and begged my mom to please not take me to this hospital. But because of our insurance she had to.”

The patient thought she was in store for more anguish and trauma, but she was mistaken. We had listened and improved.

Three years ago her room had been “dusty, dirty and cobwebby.” Now it was clean. Three years ago staff often communicated through the overhead speaker. Now they showed up the minute you hit the call light.  Three years ago you couldn’t get in touch with anyone. Now all the RNs had hospital cell phones so her parents could call in from work or late at night.

“The hospital doesn’t just look different,” she concluded. “It feels different to be here.”

David Howard is a retired educator.

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