Tuesday, April 10, 2012

Happy Patients vs Healthy Patients

Recently, I published a blog post entitled "The Disneyfication of Nursing" wherein I examined the relatively new practice of "scripting" nurse-patient interactions, demanding that nurses communicate with patients in a specific manner.

The reality is that hospitals now want to provide care with an eye towards positive scores on patient satisfaction surveys upon which Medicare will soon begin basing some of their payments. While this is an understandable---yet short-sighted--reaction on the part of facilities that receive payments from Medicare, it is clear that there is a slippery slope that may very well backfire when it comes to achieving desired patient outcomes.

An anonymous comment on "The Disneyfication of Nursing" expressed it this way:

"More concerning to me is that this goal is to keep patients happy, not healthy. Does this mean we can't discuss the topics they might not want to hear for fear of a bad review. Don't suggest they don't NEED morphine every hour or they will say they were mistreated. Heaven forbid we strongly encourage them to get out of bed. Often what is in our best interest is not the easiest choice. I feel it is my job to help patients understand this, but it doesn't always make them happy."

This anonymous reader, presumably a nurse, makes a salient point. If we provide care based on our desire for a positive patient satisfaction score, will it perhaps cause us to refrain from pushing our patients aggressively towards rehabilitation and to give in to their pain, fear, anxiety or lack of motivation?  Will we choose to assuage their fears and agree with them, even when our best clinical judgment tells us we should instead motivate them to do that which they dare not do?

Medicare may feel that basing payments based on satisfaction scores will improve care and patient outcomes, but keeping satisfaction scores in the back of our mind while we interact with patients could cause us to back away from potentially difficult conversations "for fear of a bad review".

An apt comparison might be the ways in which public schools feel the necessity to "teach to the test", gearing lesson plans and learning towards the goal of having as many students earn the highest scores possible on standardized tests. The federal government bases schools' success (and perhaps the availability of federal funds) on these outcomes, and teachers often feel that they are not providing the education they would like to ultimately provide since they are obliged to focus most strongly on the pending examinations.

Patient satisfaction is important, and hospitals and clinicians all want patients to feel that they received the best possible care. However, when we base Medicare payments on such scores, it puts hospital administrations in the position of guiding clinicians towards care that focuses as much (or more) on patients' subjective ratings of their care rather than actual clinical outcomes.

If I am hospitalized, I of course want my nurses, doctors and other providers to care for me in ways that will make me feel that I am in competent, caring and compassionate hands. However, if a nurse is directed to speak to me like a used car salesman and cater to my every whim based on the assumption that such actions will earn a higher satisfaction score, my fear is that my care would be potentially undermined by this focus on my subjective experience.

Patient satisfaction is only one aspect of the calculation, and facilities may have knee-jerk reactions to Medicare rules that will eventually backfire in as yet unforeseen ways.

We all know how to provide great care, and we (hopefully) also know how to interact with patients on a level that provides a clear indication of our professionalism and expertise. Health care may be broken on many levels, but band-aids such as satisfaction surveys are only a drop in an ocean of potentially more powerful ideas to bring attention to ways in which we can improve care, improve outcomes, and still have very satisfied consumers.

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