Forbes recently published a scathing article about Press Ganey, calling it "a hated target of hospital physicians…the Yelp equivalent for hospitals and doctors." The idea of trying to achieve superior patient satisfaction scores is a source of consternation and discomfort for many of us. As physicians, we are competitive but intrinsically compassionate people who are already trying to provide outstanding patient care. Despite concerns over the validity of Press Ganey data, I am regularly asked for advice on how to improve interactions with patients and increase satisfaction scores.
The answer is simple, but not necessarily easy to implement—patients want doctors who listen and treat them with respect.
Nearly a decade ago an article in the Wall Street Journal said that "people place more importance on doctors' interpersonal skills than their medical judgment or experience," and a Harris Poll showed that the main thing patients want from us is to be treated with dignity and respect. Other characteristics on the list are that we listen carefully to patients' health concerns and take them seriously, that we are easy to talk to and are willing to spend enough time with them and that we truly care about them. And in 1998, a clinician-patient communication leadership group at Permanente reported that "patients are less concerned with how much their physicians know than with how much they care."
This prioritization of interpersonal skills seems counterintuitive to many of us who primarily want the most expert medical care available for ourselves and for our families when we are ill, and are willing to put up with less than stellar interpersonal skills to get it. I suspect this difference is at least in part because most of our patients assume that physicians' medical skill sets are roughly equivalent (and may have no way to judge that), but they can easily recognize differences in empathy, caring and respect among their health care providers.
Thus, demonstrating these qualities is imperative to improving the patient experience, which is important for a number of reasons. First, it's the right thing to do. Secondly, there is a fair amount of evidence of a correlation between the patient experience and the quality of physician-patient communication and health care outcomes. A less altruistic but nonetheless compelling reason is that patients now have the opportunity to comment on the quality of our inpatient performance on several metrics through a nationally standardized Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and data from these surveys are publicly reported. Soon our outpatient performance scores will be evaluated by a similar survey and will also be publicly reported. Finally, if altruism and a competitive spirit are not incentive enough, a portion of our Medicare reimbursement is at risk beginning this year if we do not meet defined standards based on HCAHPS surveys.
The obvious question then is what steps can we take to improve the patient experience? In 1990 investigators at Kaiser Permanente implemented a program to help practicing clinicians "thrive in a busy practice." Over a five-year period, nearly 1,400 clinicians attended a one-day seminar designed to enhance communication. They were taught how to improve the efficiency and effectiveness of patient interactions, and how to handle difficult patient visits. The situations that clinicians described as difficult will sound very familiar: dealing with patients who were angry, brought lists, were demanding, had unrealistic expectations, were drug-seeking and who challenged their authority. Seminar participants learned strategies to improve physician-patient communication including allowing patients to finish their opening statement without interrupting them, and how to negotiate an agenda and set limits for brief visits, respond to lists, elicit patients' beliefs and information about psychosocial issues and negotiate a treatment plan. Interestingly, when questioned three months after attending the seminar, clinicians were more satisfied with their interactions and reported a decrease in the number of patient visits they found to be frustrating.
While we don't currently have access to such a program, there are things physicians can do now to improve the patient experience at SHC. Based on Press Ganey data, the main factors that influence the likelihood of patients to recommend us and our practice is our sensitivity to their needs, our concern for the things that worry them, the degree to which we work with others to coordinate their care, the time we spend with them and the instructions we provide for follow-up care. Contrary to popular belief, the inconvenience of finding parking and negotiating our complex environment play a relatively small role in their likelihood to recommend us to others.
Patient satisfaction "solution starters"
Armed with this information we can begin to take action. Press Ganey offers "solution starters" to help address the issues that are most important to patients. They recognize that asking the patient something as simple as the reason for the visit can set the tone for a successful interaction. It is surprising how often the patient's chief complaint differs from the physician's understanding of the reason for the visit. Expressing empathy can diffuse a tense situation when a patient is upset. Sitting at the same level with the patient and using body language that implies interest rather than impatience, asking permission to do tests and even a physical exam, including patients and family members in decisions about therapy and ensuring that patients know the treatment plan all go a long way towards making for a satisfying encounter.
The Permanente group recommends establishing rapport quickly by introducing yourself to everyone in the room, acknowledging the wait and conveying knowledge of the patient’s history. They suggest being open to a patient's emotions and making at least one empathetic comment (e.g. "That sounds really difficult"). These are simple, quick (and painfully obvious) examples of ways we can provide more personalized care.
Improvement is already evident
At SHC, in spite of the challenges of time constraints and other day-to-day obstacles, we have actually made huge strides to improve the level of satisfaction of our patients over the past couple of years. There have been significant and laudatory increases in Press Ganey "likelihood to recommend" scores in all areas surveyed – ED, inpatient, ambulatory clinics and the Cancer Center. More than one department in the Cancer Center has improved from the 30th or 40th percentile in 2011 to the 97th or 98th percentile in 2012. One of the ambulatory clinics improved from the 29th to the 92nd in the same time period. We're clearly all working very hard to improve the quality of care we deliver and the quality of the experience we provide. While there is still room to improve, we are very much on the right path.
For anyone who would like more individualized coaching or feedback in your clinic or on the hospital wards, the SHC Process Excellence group can have a coach work with you. Contact firstname.lastname@example.org for coaching or to receive more information about Press Ganey scores, methods and "solution starters." In addition, the four Service Medical Directors – Steve Coutre, Paul Maggio, Matt Mell and myself – are always willing to help.