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Patient Satisfaction Critical to Hospital Value-Based Purchasing Program


Should patient satisfaction factor prominently into healthcare pay-for-performance incentives? That question recently became moot as the Centers for Medicare & Medicaid Services (CMS) began withholding 1% of hospitals’ Medicare reimbursement as part of its Hospital Value-Based Purchasing Program, restoring it to institutions based upon their quality performance. Thirty percent of the program’s financial incentive is based upon how well hospitals score on patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

Despite those data having been collected and reported for years, their use as a healthcare performance indicator continues to be controversial. To win back reimbursement withholds, hospitals must earn perfect scores: The only winners are the ones for whom patients respond “always satisfied” to such questions as “How often did doctors treat you with courtesy and respect?” or “How often did doctors explain things in a way you could understand?” or “How often did hospital staff tell you what the medicine was for?”

A perfectly happy patient, skeptics say, isn’t necessarily one who has received the best medical care, and several analyses suggest that HCAHPS has unintended biases, making it a flawed accountability tool. Some of the nation’s most prestigious hospitals, for example, receive bad patient reviews despite getting high scores on clinical quality metrics.1

Conversely, many hospitals that receive high patient ratings have low clinical quality marks (e.g. significantly worse mortality rates than the national average for heart attacks, heart failure, or pneumonia).2

Safety-net hospitals perform more poorly than other hospitals on nearly every HCAHPS measure of patient experience, with gaps that are sizable and persistent. These institutions have the most fragile operating margins and are the least able to absorb the additional reimbursement cuts that will result from their low scores.3

Teaching hospitals and other large hospitals also score more poorly, on average, than do small community hospitals.4

Unexplained geographic disparities persist, with hospitals in cities and certain regions, such as the Northeast and California, scoring lower than other regions.1

Quality Requires Clarity

“These are valid criticisms. Just because someone receives the best medical care doesn’t mean they are the happiest—and vice versa,” says Peter Short, MD, senior vice president of medical affairs for Northeast Hospital Corp. in Massachusetts. “Are there biases [in the way patient satisfaction is measured]?

Absolutely. But we’re all being held accountable and we can’t wait for a perfect system.

“Any definition of high-quality medical care must take into consideration how it is perceived by patients,” he adds, particularly when “value” in healthcare means delivering high-quality, patient-friendly care at the lowest cost.

James Merlino, MD, FACS, FASCRS, chief experience officer for Cleveland Clinic, says little peer-reviewed research exists to show that HCAHPS is a robust process of measuring patient satisfaction, but he says CMS is “focusing on the right areas.”

“It’s hard to say that paying attention to the patient experience is not something we should do. And yet, many physicians and hospitals have not done a good job focusing on patient satisfaction,” Dr. Merlino says. “How well we communicate with patients goes to the heart of the patient-provider interaction: It’s crucial that patients are clearly informed what to do while they are in a hospital and after they are discharged. Poor communication can drive confusion, noncompliance, and complications.”

Hospitalists and their teams might begin to think about processes that enhance a patient’s health confidence, which is very strongly associated with many outcomes.

—John Wasson, MD, emeritus professor of community and family medicine at Dartmouth Medical School

Proven Improvements

Hospitalists will be leaders in driving patient satisfaction, Dr. Merlino says, given their central role in managing patients across the continuum of care. That role gives them great responsibility—and opportunity—to champion practices at their institutions that improve the hospital experience of their patients, many of whom have complicated illnesses requiring a potentially bewildering array of tests and procedures.

Dr. Merlino

Several “best practices” have proven successful in boosting patient-satisfaction scores and can be readily adapted to a variety of local hospital settings, says Dr. Short, who is a speaker in SHM’s Hospital Value-Based Program Toolkit webinar series (see “Best Practices,”).

Cleveland Clinic has greatly boosted its physician communication scores by sharing HCAHPS performance data with physicians and by gleaning best practices from its high-scoring physicians, which include, for example, ensuring that residents and fellows speak with attendings before rounding with patients to ensure staff alignment and care coordination, Dr. Merlino explains.

Cleveland Clinic also is rolling out to its entire medical staff a communication training program taught by a carefully selected team of peer physicians, which Dr. Merlino says is proving to be very effective in boosting patient satisfaction and improving care by enhancing patient-physician conversations. The program features Kaiser Permanente’s “Four Habits” model to help organize medical interviews with patients:

  • Invest in the beginning by creating rapport quickly, and let the patient know what to expect.
  • Get the patient’s perspective by asking for their ideas concerning the meaning of symptoms and the request for care.
  • Demonstrate empathy by being open to the patient’s emotions and conveying empathy verbally and nonverbally.
  • Invest in the end by delivering diagnostic information, explaining the rationale for tests and treatments, involving the patient in decision-making, and reviewing the next steps.5

“Organizations have to evolve in an increasingly value-based healthcare environment by developing a culture that can adapt to any set of questions or regulations that CMS mandates,” Dr. Merlino adds.

Next-Generation Patient Satisfaction Measures

Tools to guide patients and healthcare/hospitalist teams toward more satisfying dialogues with patients—as well as tools to improve their outcomes—are becoming increasingly available, says John Wasson, MD, emeritus professor of community and family medicine at Dartmouth Medical School and a member of The Dartmouth Institute Patient-Reported Measure Trust, which is developing and testing next-generation, patient-reported healthcare measures.

One example is, a family of communication-enhancement tools designed to build patient confidence in managing and controlling their health problems by helping them “get what they want and need exactly when and how they want and need it,” Dr. Wasson says.

“Hospitalists and their teams might begin to think about processes that enhance a patient’s health confidence, which is very strongly associated with many outcomes,” he notes. The hospital version of the tool—at—immediately provides information tailored to patients’ needs, as well as a summary hospitalists can review with their teams in order to improve patient/caregiver confidence for successful management of conditions when discharged, Dr. Wasson says.

“Overall patient satisfaction is not particularly useful for predicting health confidence,” he says. “Information quality tailored to patient need is what boosts patients’ health confidence—and has real power to improve patients’ clinical outcomes.”

Christopher Guadagnino is a freelance medical journalist in Philadelphia.

Best Practices

Addressing the clinical, physical, and emotional needs of patients takes very little extra time, according to Dr. Short. “The hallways are quieter because there are fewer alarms ringing. Caregivers are not being pulled away as often, because their patients are happier and well-cared-for,” he says. He and Dr. Wasson suggest trying these simple strategies:

Physicians and nurses should round together, showing the patient that your care team is coordinated and caring while helping nurses to reinforce physician instructions with the patient throughout the day.

Caregivers should conduct hourly rounding, rather than wait for patients to ring the call bell. During rounding, cover Position (“Are you comfortable?”), Potty (“Do you need the bathroom?”), Pain, Plan (verbal review of the patient’s test and treatment schedule for the day), and Pump (check of the patient’s IVs to pre-empt alarms and preserve quiet in patient rooms).

Establish a culture on the floor that no one passes by a call bell so patients needn’t wait for their nurse to respond.

Establish a high-risk readmission team that meets with patients who have a history of frequent hospital readmissions, to review their medications and discharge plans, and address special needs to avert a future preventable readmission.

Make patients and family members feel like they’re the priority. Never say, “I’m too busy.”

Ask your patients (or their caregivers), “How confident are you that you can control and manage your (or the patient’s) health problems?” If the response is anything less than very confident, explore their reasons and help them obtain the resources they need to become more confident.

—Chris Guadagnino


  1. Rau J. When TLC doesn't satisfy patients, elite hospitals may pay a price. Kaiser Health News website. Available at: Accessed Aug. 15, 2012.
  2. Sternberg S, Schnaars C. Medicare data can help patients fill perception gap. USA Today website. Available at: Accessed Aug. 15, 2012.
  3. Chatterjee P, Joynt KE, Orav EJ, Jha AK. Patient experience in safety-net hospitals: implications for improving care and value-based purchasing. Arch Intern Med. 2012 Jul 16:1-7. doi: 10.1001/archinternmed.2012.3158 [Epub ahead of print].
  4. Rau J, Medicare to begin basing hospital payments on patient-satisfaction scores. Kaiser Health News website.. Available at: Accessed Aug. 15, 2011.
  5. Frankel RM, Stein T. Getting the most out of the clinical encounter: the four habits model. The Permanente Journal website. Available at: Accessed Aug. 15, 2012.

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