'Right or wrong, the customer is always right.' - Marshall Field

'Customers don't expect you to be perfect. They do expect you to fix things when they go wrong.' - Donald Porter, British Airways

'If the shopper feels like it was poor service, then it was poor service.' - Mark Perrault, Rally Stores

I've often wondered how these popular corporate slogans of customer satisfaction get translated into the world of health care. In our industry, who is the customer? What defines customer service? What does it mean to have a satisfied or dissatisfied customer?

In a 2009 survey of more than 200 top-level healthcare executives, nearly 90 percent ranked patient experience as either their top priority or among their top five priorities. The growing consciousness about the importance of patient satisfaction with the health care experience stems at least in part from increased use of the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. Developed by a partnership of public and private organizations and funded by the Federal government through the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality, HCAHPS (pronounced 'H-caps') is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. The survey reports are being used to help patients make fair and objective comparisons between hospitals, allow individual hospitals to compare themselves to state and national benchmarks, and inform health care providers, accrediting and regulatory bodies, lawmakers, purchasers, and researchers about health care quality.

From the latest data reporting period between April 2009 and March 2010, over 8.8 million medical, surgical, and maternity care patients from 3,798 hospitals participated in the HCAHPS survey. HCAHPS asks a random sample of recently discharged patients 27 questions about their recent hospital stay. An integral part of this survey are 18 core questions about critical aspects of patients' hospital experiences such as communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quiet nature of the hospital environment, pain management, communication about medicines, discharge information, overall rating of the hospital, and whether or not the respondent would recommend the hospital. The answers are then consolidated into ten quality measures that are publicly reported on the Hospital CompareWeb site. Although the latest mandate does not yet include maternity care patients, HCAHPS performance will be a condition for value-based incentive payments to hospitals providing inpatient services to Medicare beneficiaries beginning in FY2013 (money talks!).

One of the most striking features of HCAHPS, and what differentiates it from previous patient satisfaction surveys, is not the questions that are asked, but those that are not asked. For example, HCAHPS asks patients:

• How often did doctors/nurses communicate well with you?
• How often was your pain well-controlled?
• Would you recommend this hospital to your friends and family?

And not:

• Did you sign an informed consent document? [Because a signed informed consent form does not always mean a patient was necessarily informed or fully consenting]
• Did you receive written discharge instructions? [Because giving out discharge instructions may not mean a patient understands them].
• Did you receive an epidural or medication for pain? [Because the administration of anesthesia and drugs does not always mean that pain has been adequately assessed or managed]

Do you see the difference? The uniqueness of HCAHPS is the emphasis placed on the patient'sperspective and satisfaction as a valid outcome measure of quality. Although accurate documentation, appropriate use of medical intervention, and timeliness of care are all important quality goals, it is not the focus of this survey. This represents a seismic shift away from other surveys that use provider-centric metrics driven by concerns for regulatory compliance. HCAHPS is an important first step towards acknowledging that there is more to the patient care experience than simply whether or not mother and baby make it out alive, and that patients themselves are capable of evaluating the quality of the care they receive.

The general public has seized the idea of using HCAHPS as a hospital report card, thanks in part to patient and family advocates like Regina Holliday, a gifted muralist who wields 'paint and brushes to promote health reform and patients' rights.' Here is a three-minute video of Regina painting the HCAHPS visualization 'Apples to Apples' and interacting with curious passers-by on the sidewalk outside a major hospital in Washington D.C.:

Apples to Apples by Regina Holliday (used with permission by the artist)

Some birthing advocates have questioned the validity of HCAHPS, pointing out that the survey is not maternity-care specific and has severe limitations for capturing the experiences of childbearing women and newborns. With mothers and children accounting for 25 percent of all hospital discharges, it is indeed critical to ensure that the questions are relevant to the particular needs and sensitivities of maternity care patients in order to maintain the instrument's validity and utility. Our colleagues at Childbirth Connection have introduced legislation to include provisions to adapt the survey for use in maternity care (see Congressman Engel's bill H.R. 6437 ' Partnering to Improve Maternity Care Quality Act of 2010 and Kimmelin Hull recently wrote an excellent post in December that reviewed several large scale maternity-focused satisfaction surveys conducted in the U.S. and abroad.

So where do we go from here? Some of you may remember my last post in December about a root cause analysis (RCA) of a maternal death. We talked about use of RCA as an essential tool in quality improvement, the difference between 'deep' and 'shallow' RCA, and the importance of serially asking 'Why?' as we drill down the chain of events to uncover the fundamental and systemic root causes that contribute to an adverse outcome. Although RCA is typically performed in cases of serious or fatal harm, these approaches and tools can be applied to any situation in which there is a gap between expected and actual outcomes. Patient dissatisfaction with a negative birth experience is one such gap. As the use of surveys like HCAHPS continues to spread, the survey instruments become more refined to maternity care, and detailed follow-up surveys are developed, we can expect to see patient-centered RCA emerge as the next frontier in quality improvement. In my next post, I will do just that. Do you think the root causes of a patient death and a dissatisfactory patient experience will be the same or different? Stay tuned and find out! Until then,

'If the patient feels like it was poor care, then it was poor care.' - Tricia Pil, MD

Thank you to Regina Holliday for sharing her inspiring work with Science & Sensibility

Posted by: Tricia Pil, MD

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