Monday, April 21, 2008

Only Sixty-Eight Percent Satisfied?

Or as the Rolling Stones put it, I can't get no... satisfaction.

My very second blog last year was on patient satisfaction. Well, I said it then and I will say it again, its more than the hotel services. Its not entertainment so Disney doesn't work well in serious life and death situations. Its about understanding and creating a culture of satisfaction which most healthcare professionals and organizations are clueless about. Clueless organizationally and clueless from a leadership perspective. So in the interest if time, here is the voice from the wilderness again......

The Patient Satisfaction Imperative
Ever wonder why in the healthcare industry that satisfaction is sometimes so hard to come by? That is not to say that every hospital or health system has a satisfaction or service problem. There are many exemplary examples of service focused healthcare organizations that day-in and day-out deliver high levels of patient and physician satisfaction.

Yet, in an industry where we "serve" individuals, we hear from consumer research that it's the other guy. My doctor and my hospital is fine as consumers report general happiness with their healthcare providers. Hospitals regularly report satisfaction in the 90th percentile. Get people outside of the hospital and you hear some pretty common complaints: the food is cold; I did not know about my test; you woke me up in the middle of the night; it was noisy; the room to cold; the room is hot; and on and on.

As organizations tout the JD Powers Satisfaction Award, show great improvements in Press Ganey or NRC-Picker or other survey instruments, there is still the uneasy feeling that all was not okay. These and other survey tools are all very valid, all worthwhile, show trends and document accomplishments.

With the government HCAPHS Hospital survey in play by reporting provider satisfaction as a common basis for measurement and consumer comparison, all the more imperative the focus on patient satisfaction. Healthcare is not an easy business by any stretch of the imagination. We work with people who are patients and their families that are at various states of emotional distress, caring employees (for the most part), good physicians etc. So satisfaction for so many different groups becomes interrelated. Why is it important? For several valid and researched reasons.

Satisfied patients are more compliant with treatment regimens. A satisfied patient even if the medical outcome is not good, believes that he or she had a quality medical experience. Satisfied patients recommend you to others. Satisfied patients return to you for care. Satisfied patients tend to litigate less.

It's the right thing to do.

Where does satisfaction start?
No surprise here - right in the executive suite. Yep, the CEO and senior leadership sets the tone, tenor and actions by what they do or don't do. How they treat others. How they measure and hold themselves accountable in the performance evaluation process. It's either part of the culture or not. People clearly understand the organizational rationale, polices and procedures for satisfaction and are part of the program, or they see it as the flavor of the day because so and so said so.

Satisfaction is not a program or a slogan, or simply a set of behaviors codified in polices or procedures, a bar chart on the wall. It is not the notice in the hallway or patient room that if you can't rate us as very good or excellent, call this person to immediately address your needs. Satisfaction is all that and more. The defining culture of the organization. A recognition that satisfaction is every ones responsibility. It is anticipating the needs of the person or family. Taking care of the little details day-in and day-out is what creates a satisfied patient. The successful healthcare organization recognizes and understands that patient, employee and physician satisfaction are interrelated, is a process and is controllable!

The Changing Dynamic
Did you know that here appears to be a major shift in how patients and their families judge the quality of medical care? Used to be it was all based on the the hotel services, food service, housekeeping etc. Arrogantly, clinicians and hospital leaders confidently stated that patients did not have the ability to judge the technical quality of what we do.... its magic to them! With the information available from the Internet, health and wellness programs, news stories etc, patients are very well informed and are making technical judgements of the quality of the care that they receive.

Most of the time research is indicating patients technical judgement of care is on par with those of the attending physician. Now that is a dramatic change and one which is little recognized. However, it goes one step further. The dirty floor, the torn wallpaper, the piece of paper on the floor are now adding into the mix. The patient is now judging, "If they can't take care of the little things, then how can I expect them to take care of the big things...... like my treatment......... " OK now what?

With the advent of HCHAPS, pay-for-performance, awards as well as the bragging and marketing rights in the community, patient satisfaction moves to the forefront of operational excellence. Here's the rub.... now comes the program to increase satisfaction and how to show statistically why we are better... Here comes the program, the flavor of the day, the decree from on high.... Lies.... damn lies....and statistics........ Patient Satisfaction is a process.

Satisfaction is a Process
Patient satisfaction is a process that is controllable and understandable. It is the voice of your customer. By listening to that voice, I mean really listening to that voice, you would be surprised at the improvements that you can make in your healthcare setting. Patients, physicians and others view the hospital experience not as a set of unrelated departments where things are done to me, but as a coordinated whole in a continuous process.

Is the process of satisfaction in or out or control? Ask any hospital executive that question and for the most part, I think they would say yes it is. Ask them to show you the data that it is in control, nine times out of ten, the subject gets changed. The simple fact is they don't know. Healthcare leadership needs to know if their process of satisfaction is in or out of control to know if they even have a satisfaction issue. A simple percentage explanation won't do that. A bar chart won't do that. A new program that is the flavor of the day for increasing satisfaction won't do that. It takes a commitment to in-depth analysis, using all the tools of Quality Management. It takes a willingness to change the culture of the organization. That is not easy. Its hard and forces some very difficult personnel decisions.

For example, say hypothetical Hospital A is dismayed about its satisfaction scores and the CEO declares, we need a 10 percent improvement in the scores. Admirable, but misguided. If I am housekeeping and my percentage score of patient satisfaction is 70 percent, a seven point increase over time is probably doable. If I am nursing and my percentage score is 90 percent, a nine point score improvement is impossible. Flat out can't do it, not going to happen, Nada, no way. That is what happens when you only use percentage scores or a bar chart as the basis for action.

A Call to Action
Now, had the organization been analysing the satisfaction data with the tools of Quality Management, this could have been the action on the part of leadership in a conversation in hypothetical Hospital A. " We really need to move the culture of the organization and improve our satisfaction scores. I asked our Quality Department to do an in-depth analysis. When you look at the bar charts we see steady improvement, but regression analysis shows really not much change over time. The telling difference was when we looked at patient satisfaction scores though the use of Statistical Process Control Charts and what a story that told. It looks like our process of satisfaction is out of control, there seems is no rhyme or reason why the scores fluctuate so much. Yes, they are all in a narrow range, but this tells me we really don't understand the process of satisfaction and how to control it. When applying this analysis to individual departments and units, we find some striking differences. Some units and departments are outperforming the organization as a whole, others could really use some improvement. I really think we need to get to those units and departments outperforming the whole and benchmark what they are doing. So instead of everyone trying to improve 10 percent overall lets use the upper control limit of the charts as the incremental target for improvement based on historical performance. That means housekeeping you can improve 10 percent, but nursing, its really only one percent at this time. Lets make this measurement an ongoing process so that we know the point of when we designed an intervention, implemented and see the result."

Mythical CEO continues.." What gets measure gets done, so in your goals and objectives put in place a measurement for patient satisfaction for your departments that the scores will not vary by more than 2 points plus or minus of the top score. This isn't going to be easy. We need to really change the organization. I know we have done this before and seen some improvement. But we always fall back after a couple of months. If we go at this the right way, the employees won't see it as the flavor of the day. And we all know what that means. It may mean over time that we will lose some people. That is never good nor is it easy. But consumers, the government, payers and employers are all demanding higher performance from us. This does have a financial impact to us. As we move forward, we need to set behaviors and hold people accountable, that includes us. We need to become world class in delivering high levels of patient satisfaction."

That unfortunately, is a conversation that does not take place nearly enough.

Where do we go from here?
It starts with learning. It starts with an honest assessment of here is where you are. It starts in the C-suite. Commitment, compassion, understanding, listening, process control and improvement. Every hospital and healthcare provider out in the wider world has the talent, experience and expertise to do this. But what is lacking is the will. What is lacking is the understanding of the importance of patient satisfaction. Its not sexy and really hard work. For those that are willing to start, learn and change - the benefits are enormous!

If we as an industry really understood satisfaction as we claim too, do you really think that year after year dozens of books would still be published on how to improve patient satisfaction in healthcare organizations?

My Book Okay, here is the plug for the book..."How to Use Patient Satisfaction Data to Improve Healthcare Quality", Raph Bell, Ph.D., and Michael J. Krivich, FACHE, Quality Press, January 2000, 156 pages and available on or from Quality Press at the American Society for Quality.

A time for change
Its all detailed in an easy, readable book that will assist you in reaching your satisfaction goals. Patient satisfaction is a process, it is controllable and takes work and at the end of the day, you will be better for it, your patients will be happier for it and you can outperform your competition with it. Unless the hospital industry begins to take a more detailed data analysis and organizational approach to patient satisfaction and make it a part of the culture of the organization, we are left with lies.... damn lies.... and statistics.....

And in the end, we may be very proud of ourselves, but our patients will still have that nagging doubt about what just happened.


Anonymous said...

Hey, Micheal:

What's your thoughts on the GM facility closing in Jainesville, Wi and the impact of SSM brining in a new hospital? Are they changing their minds? There will be lots of unemployed, uninsured there as in Blue Island, IL.

Michael J. Krivich, FACHE, PCM said...

I really don't know. To pull out now will have some large PR issues for SSM. The cyncial marketing/PR side says that is a three day story and only matters in Janesville, WI.

This does change the dynamic and you are right, lots of uninsured, a high unemeployment rate and a once vibrant city moving from growth to potential decline. Now more than ever, Janesville will need SSM as one city's largest employers.

Given the changing in the market dynamics, will the SSM Janesville faclity go the way of St. Francis, Blue Island, Illinois? Only SSM knows for sure. I guess we will see how much of a not-for-profit and focused on community benefit they are.