There's a difference between happy and satisfied patients

Recently I have been reading articles regarding the patient experience that I find both stimulating as well as challenging. As the chief experience officer at Massachusetts General Hospital (MGH), you might imagine just how many times these articles are forwarded to my inbox when they are published.

In “The Problem with Satisfied Patients” by Alexandra Robbins in April’s edition of The Atlantic, and “Are Patient Satisfaction Surveys Doing More Harm than Good” by Heather Punke in June’s edition of Infection Control and Clinical Quality, both express concern and skepticism about how hospitals devote such focus on patient satisfaction. These two articles, along with others, reference a widely shared 2012 study by Joshua Fenton, MD called, “The Cost of Satisfaction.” Fenton posits that health care’s focus on making patients happy is contributing to increased cost and poor outcomes including increased mortality.

I read these articles with a sense of frustration — because I believe that they are based on a fundamental misperception of what patient experience work really is all about.

I think it is fair to acknowledge that there has been a dramatic shift in recent years in how hospitals approach improving the patient experience. With the advent of public reporting and reimbursement structures both from Medicare and private payers, there is a new imperative to “get the scores up.” This development is, for the most part, positive. It helps to sharpen our focus on what our patients want and need all while leading to deeper partnerships with the people we serve. But, if the call to action is misguided in its attempts, it can feel as though we’re “teaching to the test” and focusing on superficial approaches that are window dressing, not fundamental improvements to the way we deliver care.

While the articles highlight the danger that these new dynamics bring, they mischaracterize what patient experience is, leading to a false conclusions and cynicism about the work of improvement. I would argue that measuring patient satisfaction is not primarily about determining what makes patients “happy.” At its essence, it is about structuring our care and communication to make it more seamless and consistent — and thus more manageable for our patients and families. It’s about conducting our interactions with patients and with each other in a way that helps us to better know our patients and address their needs and concerns. This is the real work of patient satisfaction. In fact, I would argue that we should do away with the word “satisfaction” and embrace the word “experience.”

To illustrate what I mean, I’d like to address some of the points that these articles make.

Hospital vs. hotel

Robbins talks about efforts to turn hospitals into hotels or emulate other enterprises like Disney. At MGH, this is not our goal. Although we do try to address some of our patients’ needs with hotel-like services such as valet parking, we aren’t trying to be the Ritz Carlton. Our goal in creating valet parking is to make it easier for our patients with mobility issues to access our facility. Although, we can look at models that the Ritz and Disney use to teach us about consistency and having clear expectations about the way we will treat our patients, families and each other. We can learn from these models without having to compromise on our mission.

Scripting vs. key words and concepts

Another point these articles bring out is how caregivers react to having their communication scripted. In fact, Robbins’s article quotes a nurse (from Boston — but not MGH!) saying she felt she was being turned into a “Stepford nurse.” It is true that the patient experience surveys have a lot of questions that focus on communication. “How often did the doctor/nurse listen to you?” “How often did the doctor/nurse explain things in a way you understood?” This is for good reason. After working in this field for 20 years, I have learned that what patients care most about is communication. They want to know who we are, what we are doing with them and that we are listening to them. They want to know what is coming next and also about delays or changes in the plan. They want us to be talking with one another to make sure that the process and handoffs are coordinated.

Because of this, a great deal of patient experience work inevitably focuses on improving the communication skills of our teams. It’s worth mentioning that up until recently, many clinician education programs did not include much training on communicating with patients and families — and even less about communicating with each other. Even expert clinicians can struggle and stumble in this area. Our program at MGH helps clinicians hone these skills, but not by handing them a script. Our aim is to share key words and concepts that convey our goals of care and resonate with patients and families, but are delivered in the clinician’s own voice. When this happens, both clinicians and patients win.

Happy vs. satisfied

Perhaps the most challenging point made by the authors of the articles — especially by Dr. Fenton’s study– is that we are becoming so worried about making patients happy that we are giving them whatever they want, whether or not it is clinically appropriate. It’s a “customer is always right” paradigm. Thus, we are making patients happy — but potentially making them less healthy. And, we are making health care more expensive in the process. This is a danger with the current environment, and we must be vigilant about avoiding it.

In our experience, most patients want honesty and our best clinical advice. When patients ask about a test or prescription, what clinicians must uncover is the underlying concern for the patient and addressing those needs. And if this means advising against a particular test, medication or treatment, when communicated carefully and appropriately, the vast majority of patients will still leave our presence “satisfied.” It’s only when they leave with questions unanswered or concerns unaddressed that patients do not feel we’ve heard them and met their needs. Characterizing patient satisfaction as a choice between pandering to patients and good medicine is a false argument. There are stacks of studies to show that good communication and engaged patients are absolutely linked to superior outcomes. As further evidence to support this, many MGH providers who are the most highly rated by our patients are also skilled communicators and have stellar clinical outcomes.

So, while I was initially frustrated with some conclusions drawn by these articles, I do believe Robbins, Punke and Fenton are doing a good thing by raising their issues. We need to listen carefully to these critiques and assure that health care remains rooted in our mission and is evidence-based. We may understandably feel the pressure of the “scoring” or “starring” our work. Our world is changing where ratings for products and services will continue to be ubiquitous. We can rail against these changes or recognize that these systems allow us an opportunity to partner with the people we are caring for and help evolve our health care system into one that is more patient- and family-centered. If we do that, the numbers will take care of themselves.