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Patient Satisfaction: The Hospitalist's Role
Patient Satisfaction: The Hospitalist's Role
Introduction
Patient satisfaction is a highly desirable outcome of clinical care in the hospital and may even be an element of health status itself (1). A patients expression of satisfaction or dissatisfaction is a judgment on the quality of hospital care in all of its aspects. Whatever its strengths and limitations, patient satisfaction is an indicator that should be indispensable to the assessment of the quality of care in hospitals. The word hospital comes from the Latin for both guest and host, and the true spirit of hospitality is at the core of the hospital experience (2). The original mission of hospitals was to serve as houses of mercy, refuge, and dying for pilgrims returning from the Holy Land at the time of the late Christian antiquity (3). The striving to please patients is in harmony with the service calling of medicine and is certainly the right thing to do.
Current Reality
From the patients perspective, hospitals can be scary and unfriendly places. The American Hospital Associations Reality Check (4) evaluated the publics perceptions of hospitals and hospital care using a time-honored technique of asking focus group participants to imagine that the hospital was an animal and a car. Two out of 3 respondents chose animals that would be seen as aggressive, scary, or lumbering to suggest traits such as arrogance, uncontrolled power, and sluggishness. For cars, no respondent chose the Toyota Camry or any other model that would likely make the Consumer Reports list of best values. Instead, the cars chosen were representatives of unreasonable overpricing, waste, and outdated engineering.
A leech.Im sure all hospitals arent that lowly. A snake, kind of slithery and sneaky, because of what hospitals charge. The same AHA survey showed that patients felt that insurance companies and not physicians were in charge of their care in the hospital. A follow-up question revealed that patients clearly want to be in charge of their own hospital care. Additionally, patients do not see hospitals as part of a planned or consumer-focused health care system. In fact, they see quite the opposite: a confusing, expensive, unreliable, and often impersonal disassembly of medical professionals and institutions. If they see any system at all, it is one devoted to maximizing profits by blocking access, reducing quality, and limiting spending, all at the expense of the patient. The American Customer Satisfaction Index (5) gave hospitals an overall 67% satisfaction rating, ranking 27th out of 31 industries. This ranking placed hospitals 10 percentage points below the tobacco industry and just above the Internal Revenue Service. A National Coalition on Health Care survey (6) found that 80% of respondents believe hospitals cut corners to save money, and 77% believe that these cuts have endangered patients. Quality of care and patient safety have become significant public concerns recently. To Err is Human, the 1999 report from the Institute of Medicine, highlighted the potential for serious injury and death in U.S. hospitals (7). Estimates are that 44,000 to 98,000 Americans die each year in hospitals as a result of medical errors and unsafe practices.
patients and, therefore, revenue due to issues of patient dissatisfaction (14). Recruiting new patients as customers is 5 times more costly than retaining an existing customer base (15). There is compelling evidence from well-developed lines of research demonstrating that increasing patient satisfaction improves clinical outcomes, such as functional status and physiologic measures of health (16,17). Finally, it is important for clinicians to know that it has been clearly demonstrated that satisfied patients improve physician satisfaction (18,19).
Psychology of Satisfaction
To create a culture of customer service excellence in hospitals and achieve outstanding patient satisfaction, it is necessary to understand the intangible aspects of perception and expectation that contribute to patient satisfaction. The First Law of Service provides a useful, simple mathematical model of satisfaction (20). The formula for this model is Satisfaction = Perception Expectation. If a patients perception of their hospital experience meets or exceeds the expectation, there will be a corresponding degree of satisfaction. However, if the perception does not meet the expectation, there will be resulting dissatisfaction. Thus, patient satisfaction results from meeting or exceeding patients expectations. Patient perceptions of care can be measured directly from patient satisfaction surveys, focus groups, and telephone surveys. A hospitals reputation and market share are indirect measurements of patient perceptions. There are 2 main directions in which patient satisfaction can be influenced: by working on what the patient perceives and on what the patient expects. Expectations are integral to the experience of being a customer. There has been confusion and controversy in health care as to whether patients are in fact customers. This confusion may be at the root of the overall service failing of hospitals (21). The more horizontal they are, the more they are a patient. The more vertical they are, the more they are a customer (22). Using a technical definition, a customer is anyone who has expectations about process operations or outputs (23). Therefore, all patients are customers, but not all customers are patients (21). Hospitals have a whole list of primary and secondary customers, each of whom has his or her own set of expectations. Patients and their families can be seen as primary customers, and referring physicians, third-party payers, external overseers, communities, shareholders, and employees are all secondary customers of hospitals. Expectations are psychological phenomena that can be defined as beliefs created and sustained by cognitive processes (24). Expectations of patients as hospital customers rise from past experiences of their own or of others, as well as from current needs and unique internal preferences that form the basis of a value system. Expectations cannot be mandated, because they are based in self-gratification. However, expectations may change over time, and, very importantly, they can be measured and perhaps modified through education. For most people, illness and hospitalization is a rare event. Patients will know something is wrong and that treatment is needed, but most wont know the nature of their disease, the diagnostic and therapeutic options, and the likely outcomes. Therefore, patients seek out health care professionals who have the opportunity to inform them on what to expect as a way to begin the process of managing expectations.
There is a tremendous opportunity in hospital care to modify patient expectations through education and to create high levels of patient satisfaction. Hospitals that are successful in this endeavor will have a significant competitive advantage. Hospital patients have a whole list of issues about which they have expectations: the smoothness of the admission and discharge process, accuracy and clarity of billing statements, courtesy of hospital employees, response time for calls and requests, the level of technology available in the hospital, nurse competency, taste and temperature of the food, and price. Most of these issues are not directly related to clinical care and certainly not under the control or influence of the hospitalist. What are the expectations that patients have for their clinical care by hospitalists, and how can we give it to them?
perceive statements of assured understanding as confirmation that they have been listened to. Remember the words of Sir William Osler: Listening is unspoken caring. The effective transfer of information is at the core of physician/patient communication (29). Patients have the need to provide complete information to physicians to facilitate an accurate diagnosis. The physicians role is to provide information that addresses the cognitive, behavioral, and affective needs of patients and their families concerning their illness. The discrepancy of language, time constraints, and the ability of patients to remember are all barriers to the effective transfer of information. Some useful techniques for effective information transfer include assessing a patients current level of understanding and asking about their self-diagnosis. Timeliness in providing results of diagnostic tests is an important issue to patients who are often waiting expectantly. Studies have shown that the majority of patients have questions about the so-called mysteries of medicine, related to the diagnosis, etiology, and prognosis of their illness (30). Patients may not specifically ask these questions; however, they are present, and patient satisfaction will increase if these questions are answered. Patients have decisively indicated their desire for shared decision making regarding their health care and for patient and family control of all-important choices (26). The process of shared decision making can be facilitated by collaboration between patients and the hospitalist around goals ands plans for treatment in the hospital (31). A barrier to shared decision making is a patient/physician relationship based on a model of paternalism (Im the doctor, and I know best). A more productive model for the therapeutic relationship is that of a partnership between the hospitalist and the patient, particularly in the present era of web-educated, sophisticated consumer patients. An important tool to achieving this type of collaboration involves the approach of presenting patients and families with treatment options and then actively soliciting patient preferences. A question is whether patients will actively participate in treatment decisions and then adhere to treatment plans. This is in large part determined by the interpersonal relationship skills of the clinician and can be further facilitated with simplified regimens that have been agreed upon by the patient and the hospitalist (32). A complete model of the hospital-care encounter provided by hospitalists has an opening and a closing. In between there is a series of moments of truth that can potentially be imbued with attentiveness, dignity and respect, effective information transfer, and shared decision making. The opening is a brief moment that will set the stage for the remainder of the encounter. Greeting patients by name and maintaining eye contact will help in establishing the early perception of being a caring and concerned clinician. It is important to close hospital encounters with a sense of hope and optimism, making sure that all of the patients issues have been addressed, as well as planning for the next steps. The development and growth of hospital medicine is the latest site-specific evolution of practice specialization and focuses on the complex care of hospitalized patients. Hospitalists spend most of their professional time in the hospital providing care for general medical patients and are well positioned and uniquely committed to improving the care of hospitalized patients. Exceptional patient satisfaction is a key outcome that should result from the care provided by hospitalists.
References
1. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260:1743-8. 2. Zaleski P. Knights Hospitaller: the rise and fall of a chivalric order of Christian caregiving. Parabola. 1990;15:55-62. 3. Risse GB. Mending Bodies, Saving Souls. New York, NY: Oxford University Press; 1999. 4. Reality Check: Public Perceptions of Health Care and Hospitals. The American Hospital Association. 1996. 5. Now are you satisfied? Fortune. February 1998:166. 6. National Coalition on Health Care. How Americans perceive the health care system. www.nchc.org/perceive.html. Accessed August 2004. 7. To Err Is Human: Building a Safer Health Care System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 1998. 8. Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Prog Plann. 1983;6:185-210. 9. Kenagy JW, Berwick DM, Shore MF. Service quality in heath care. JAMA. 1999;281:661-5. 10. Mennemeyer ST, Morrisey MA, Howard LZ. Death and reputation: how consumers acted upon HCFA mortality information. Inquiry. 1997;34:117-28. 11. Cleary PD, Edgman-Levitan S. Health care quality. Incorporating consumer perspectives. JAMA. 1997;278:1608-12. 12. Rogers G, Smith DP. Reporting comparative results from hospital surveys. Int J Qual Health Care. 1999;11:251-9. 13. Schlesinger LA, Heskett JL. The service-driven service company. Harvard Business Review. 1991;Sept-Oct:1-19. 14. Modern Health care. 2000;May:70. 15. Mittal B, Lassar W. Why do customers switch? The dynamics of satisfaction versus loyalty. Journal of Services Marketing. 1998;12:177-191. 16. Greenfield S, Kaplan S, Ware WE Jr. Expanding patient involvement in care: Effects on patient outcomes. Ann Intern Med. 1985;102:520-8. 17. Sobel DS. Rethinking medicine: improving health outcomes with cost-effective psychosocial interventions. Psychosom Med. 1995;57:234-44. 18. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278:502-9. 19. Suchman AL, Roter D, Green M, Lipkin M Jr. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Med Care. 1993;31:1083-92. 20. Maister DH. The Psychology of Waiting Lines. Case No. 9-684-064. Boston, Mass: Harvard Business School Publishing; 1984. 21. Fottler MD, Ford RC, Heaton CP. Achieving Service Excellence. Chicago, Ill.: Health Administration Press; 2002. 22. Mayer T, Cates RJ. Service excellence in health care. JAMA. 1999;282:1281-83.
23. James BC. Curing vs. Caring: The Art of Service Quality. Institute for Health Care Delivery Research. Intermountain Health Care. Salt Lake City, Utah; 2003. 24. Thompson AG, Sunol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care. 1995;7:127-41. 25. Larson CO, Nelson EC, Gustafson D, Batalden PB. The relationship between meeting patients information needs and their satisfaction with hospital care and general health status outcomes. Int J Qual Health Care. 1996;8:447-56. 26. Gerteis M, Edgman-Levitan S, Daley J, Deblanco T, eds. Through the Patients Eyes. San Francisco, Calif.: Jossey-Bass; 1993. 27. Spiro H, Peschel E, Curnen MG, St. James D, eds. Empathy and the Practice of Medicine: Beyond Pills and the Scalpel. New Haven, Conn.: Yale University Press; 1993. 28. Branch WT, Malik TK. Using windows of opportunities in brief interviews to understand patients concerns. JAMA. 1993;269:1667-68. 29. Worthlin Group. Communication and the physician/patient relationship: A physician and communication survey. Bayer Institute for Health Care Communication. New Haven, CT; 1995. 30. Clinician Patient Communication to Enhance Health Outcomes. Bayer Institute for Health Care Communication Workshop. Bayer Institute, New Haven, Conn.; 1999. 31. Donovan J, Blake R. Patient non-compliance: deviance or reasoned decision-making? Soc Sci Med. 1992;34:507-13. 32. DiMatteo MR, Reiter RC, Gambone JC. Enhancing medication adherence through communication and informed collaborative choice. Health Commun. 1994;6:253-65.