Each day, thousands of patients get a call or letter after being discharged from U.S. hospitals. How did their stay go? How clean and quiet was the room? How often did nurses and doctors treat them with courtesy and respect? The questions focus on what might be termed the standard customer satisfaction aspects of a medical stay, as hospitals increasingly view patients as consumers who can take their business elsewhere.

This story also ran on NPR.

But other crucial questions are absent from these ubiquitous surveys, whose results influence how much hospitals get paid by insurers: They do not poll patients on whether they’ve experienced discrimination during their treatment, a common complaint of diverse patient populations. Likewise, they fail to ask diverse groups of patients whether they’ve received culturally competent care.

And some researchers say that’s a major oversight.

Kevin Nguyen, a health services researcher at Brown University School of Public Health, who parsed data collected from the government-mandated national surveys in new ways, found that — underneath the surface — they spoke to racial and ethnic inequities in care.

Digging deep, Nguyen studied whether patients in one Medicaid managed-care plan from ethnic minority groups received the same care as their white peers. He examined four areas: access to needed care, access to a personal doctor, timely access to a checkup or routine care, and timely access to specialty care.

“This was pretty universal across races. So Black beneficiaries; Asian American, Native Hawaiian, and Pacific Islander beneficiaries; and Hispanic or Latino or Latinx/Latine beneficiaries reported worse experiences across the four measures,” he said.

Nguyen said that the Consumer Assessment of Healthcare Providers and Systems surveys commonly used by hospitals could be far more useful if they were able to go one layer deeper — for example, asking why it was more difficult to get timely care, or why they don’t have a personal doctor — and if the Centers for Medicare & Medicaid Services publicly posted not just the aggregate patient experience scores, but also showed how those scores varied by respondents’ race, ethnicity, and preferred language. Such data can help discover whether a hospital or health insurance plan is meeting the needs of all versus only some patients.

Nguyen did not study responses of LGBTQ+ individuals or, for example, whether people received worse care because they were obese.

The CAHPS survey is required by the federal government for many health care facilities, and the hospital version of it is required for most acute care hospitals. Low scores can induce financial penalties, and hospitals reap financial rewards for improving scores or exceeding those of their peers.

The CAHPS Hospital Survey, known as HCAHPS, has been around for more than 15 years. The results are publicly reported by CMS to give patients a way to compare hospitals, and to give hospitals incentive to improve care and services. Patient experience is just one thing the federal government publicly measures; readmissions and deaths from conditions including heart attacks and treatable surgery complications are among the others.

Dr. Meena Seshamani, director of the Center for Medicare, said that patients in the U.S. seem to be growing more satisfied with their care: “We have seen significant improvements in the HCAHPS scores over time,” she said in a written statement, noting, for example, that the percentage of patients nationally who said their nurses “always” communicated well rose from 74% in 2009 to 81% in 2020.

But for as long as these surveys have been around, doubts about what they really capture have persisted. Patient experience surveys have become big business, with companies marketing methods to boost scores. Researchers have questioned whether the emphasis on patient satisfaction — and the financial carrots and sticks tied to them — have led to better care. And they have long suspected institutions can “teach to the test” by training staff to cue patients to respond in a certain way.

National studies have found the link between patient satisfaction and health outcomes is tenuous at best. Some of the more critical research has concluded that “good ratings depend more on manipulable patient perceptions than on good medicine,” citing evidence that health professionals were motivated to respond to patients’ requests rather than prioritize what was best from a care standpoint, when they were in conflict. Hospitals have also scripted how nurses should speak to patients to boost their satisfaction scores. For example, some were instructed to cue patients to say their room was quiet by making sure to say out loud, “I am closing the door and turning out the lights to keep the hospital quiet at night.”

About a decade ago, Robert Weech-Maldonado, a health services researcher at the University of Alabama-Birmingham, helped develop a new module to add to the HCAHPS survey “dealing with things like experiences with discrimination, issues of trust.” Specifically, it asked patients how often they’d been treated unfairly due to characteristics like race or ethnicity, the type of health plan they had (or if they lacked insurance), or how well they spoke English. It also asked patients if they felt they could trust the provider with their medical care. The goal, he said, was for that data to be publicly reported, so patients could use it.

Some of the questions made it into an optional bit of the HCAHPS survey — including questions on how often staffers were condescending or rude and how often patients felt the staff cared about them as a person — but CMS doesn’t track how many hospitals use them or how they use the results. And though HCAHPS asks respondents about their race, ethnicity and language spoken at home, CMS does not post that data on its public patient website, nor does it show how patients of various identities responded compared with others.

Without wider use of explicit questions about discrimination, Dr. Jose Figueroa, an assistant professor of health policy and management at the Harvard School of Public Health, doubts HCAHPS data alone would “tell you whether or not you have a racist system” — especially given the surveys’ slumping response rates.

One exciting development, he said, lies with the emerging ability to analyze open-ended (rather than multiple-choice) responses through what’s called natural language processing, which uses artificial intelligence to analyze the sentiments people express in written or spoken statements as an addendum to the multiple-choice surveys.

One study analyzing hospital reviews on Yelp identified characteristics patients think are important but aren’t captured by HCAHPS questions — like how caring and comforting staff members were, and the billing experience. And a study out this year in the journal Health Affairs used the method to discover that providers at one medical center were much more likely to use negative words when describing Black patients compared with their white counterparts.

“It’s simple, but if used in the right way can really help health systems and hospitals figure out whether they need to work on issues of racism within them,” said Figueroa.

Press Ganey Associates, a company that a large number of U.S. hospitals pay to administer these surveys, is also exploring this idea. Dr. Tejal Gandhi leads a project there that, among other things, aims to use artificial intelligence to probe patients’ comments for signs of inequities.

“It’s still pretty early days,” Gandhi said. “With what’s gone on with the pandemic, and with social justice issues, and all those things over the last couple of years, there’s just been a much greater interest in this topic area.”

Some hospitals, though, have taken the tried-and-true route to understanding how to better meet patients’ needs: talking to them.

Dr. Monica Federico, a pediatric pulmonologist at the University of Colorado School of Medicine and Children’s Hospital Colorado in Denver, started an asthma program at the hospital several years ago. About a fifth of its appointments proved no-shows. The team needed something more granular than patient satisfaction data to understand why.

“We identified patients who had been in the hospital for asthma, and we called them, and we asked them, you know, ‘Hey, you have an appointment in the asthma clinic coming up. Are there any barriers to you being able to come?’ And we tried to understand what those were,” said Federico. At the time, she was one of the only Spanish-speaking providers in an area where pediatric asthma disproportionately affects Latino residents. (Patients also cited problems with transportation and inconvenient clinic hours.)

After making several changes, including extending the clinic’s hours into the evening, the no-show appointment rate nearly halved.

CAHPS surveys are embedded in American health care culture and are likely here to stay. But CMS is now making tentative efforts in surveys to address the issues that were previously overlooked: As of this summer, it is testing a question for a subset of patients 65 and older that would explicitly ask if anyone from a clinic, emergency room, or doctor’s office treated them “in an unfair or insensitive way” because of characteristics including race, ethnicity, culture, or sexual orientation.

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One patient may view success as meeting their goal of running a 5K pain-free in under 25 minutes. Anything less is a failure. Another patient may view success as simply finishing the race, even if walking breaks were required.

We don’t all live by the Ricky Bobby mantra of “If you ain’t first, you’re last.” How does everyone else in healthcare measure success?

If you ask a researcher, success may be exceeding the minimally clinically important difference (MCID) or achieving a greater level of change relative to a control (with acceptable p-values and confidence intervals of course).

If you ask Medicare, success is determined when a patient is “functional” (because that isn’t muddy at all…). If you ask a therapist, it may be 0/10 pain, full range of motion, 0% on the Oswestry Disability Index, or a beautiful single leg pistol squat with absolutely no compensation, pain, or difficulty.

But what if the patient doesn’t care about any of those things. How do we juggle the markers of “success” for all relevant stakeholders?

There is not a simple one size fits all answer. What I will try to untangle are the factors that influence how satisfied a patient is with physical therapy.

Why does this matter? Patient satisfaction has a substantial impact on both current and future performance. How a patient perceives their care can dictate the success of interventions, their compliance with care, how they speak about their providers in public, and potentially future reimbursement.

So, patient satisfaction is kind of a big deal.

THE DOMAINS OF PATIENT SATISFACTION

Patient satisfaction questionnaires target many different domains. At PT Solutions, the practice I work for, we ask patients their satisfaction with the treatment they received, the information provided about their condition, their input on goal settings, access to the physical therapy facility, and the availability of convenient appointments. I then receive a scorecard containing all individual scores and the overall satisfaction — an average of the five questions.

This provides us a substantial amount of information and allows us to tease out potential issues and highlight areas of strength.

Quick note, patient satisfaction scores are only valuable if we act on the data. Treating data as a “fun fact” is essentially useless and does not allow us to grow as clinicians. Of course, the data must be accurate.

Ulterior motives and biases can impact the answers patients provide and when the clinician provides the surveys. For example, if a clinician asks a patient how satisfied they are with face to face, they are more likely to receive a positive report. Most people do not like confrontation. This is different for outcome measures.

Outcome measures are designed to highlight functional areas of difficulty. These are best completed with the clinician present. Incorporating Patient-Reported Outcome Measures (PROM) throughout a plan of care has the potential to promote shared decision making between patients, their families, and clinicians.

PROM assessment heightens the provider’s awareness of patients’ health concerns and facilitates communication regarding available medical evidence for optimal treatment options. Geroge et al found patients who were satisfied with symptoms reported higher physical function, lower pain intensity, and less symptom bothersomeness (great word chosen by the authors) at six months.

The two strongest absolute and unique predictors of patient satisfaction with symptoms at six months were whether treatment expectations were met and change in symptom bothersomeness.

Patient satisfaction is most associated with items that reflected a high-quality interaction with the therapist — such as time, adequate explanations, and instructions to patients.

Environmental factors such as clinic location, parking, time spent waiting for the therapist, and type of equipment used are not strongly correlated with overall satisfaction with care.

HOW DO WE GET ACCURATE SATISFACTION DATA?

Clinicians work on their craft daily. They take courses, read the research, engage in clinical conversations, and reflect on past treatments to improve their care. All of these strategies certainly improve the care provided to patients, but they don’t guarantee satisfaction, and outcome scores will improve.

There is an art to administering outcome and satisfaction measures. Here are the strategies I have learned over the past few years as the National Director of Quality and Research for PT Solutions.

A quick caveat, this is not meant to artificially inflate your scores. Furthermore, the goal of obtaining outcomes and satisfaction scores is not simply to inflate the ego and display your awesomeness to everyone.

The purpose is to objectively assess your quality of care and make the necessary adjustments. You may apply guideline adherent care and have mastered your exercise prescription and manual therapy techniques, but if the patients are unhappy and prematurely ending the plan of care then the quality is not high.

Strategy #1: Obtain timely scores.

Patient evaluation worsens as the gap between encounter and completing the measure increases. Our memories become less clear as time passes. I would argue the most important indicator of whether your outcome data is accurate is the ‘days between status and discharge’.

This number represents how many days you treated a patient after obtaining their final outcome measure. The larger the number, the more days you treated and helped a patient without obtaining credit for the improvement. Additionally, patients (and clinicians) have poor long-term memory for our subjective experiences.

The longer a patient goes without a survey, the more they are guessing at how they previously felt.

Clinicians have to decide whether in-person or email surveys will provide more value. They both have benefits and drawbacks. In-person provides more immediate ratings and a larger volume of data, while emails rely on the patient open and answering the survey. However, a patient may feel less pressured to convey disappointment over email.

Strategy #2: Complete the specific actions from the outcome tool on the day a survey is administered.

If a questionnaire asks how difficult it is to walk a quarter-mile, then have the patient walk a quarter mile on the treadmill the day they complete the questionnaire.

Again, this limits the guesswork and provides a more updated assessment.

Strategy #3: Prep the patient but do not hover or bias them.

This strategy falls under ‘obtaining accurate scores’ not ‘maximizing your score, even if it is artificial’. If you hover over a patient during the survey, your body language or the way you ask a question (or your mere presence) may cause scores to be artificially high.

Patients are reluctant to disclose negative attitudes toward a health care provider because of a sense of dependency on patient-provider communication. This doesn’t benefit anyone. Instead, fully explain the survey and be available for questions.

FROM THEORY TO PRACTICE

Ok, your NVBs are top-notch, you are providing evidence-based care, and you are a master at collecting the data appropriately, what can go wrong? In many cases, it will be smooth sailing to world-class outcomes and satisfaction, but there are a few remaining barriers.

The malalignment of therapist and patient goals can be detrimental to satisfaction. It is imperative you are both on the same page with the goals and the methods for obtaining them. This is where motivational interviewing comes into play as this alignment may take weeks to obtain.

Another barrier is understanding what the patient values. They lack the knowledge to assess accurately the technical competence of health care personnel and therefore may only judge satisfaction on outcomes.

Others, however, may care far more about the ‘experience’ and weigh NVBs and the interaction with employees much higher. It is important to recognize these differences and assess them all.

A final thought on this topic is the impact the scores can have on our treatment choices. It can be tempting to provide whatever treatment a patient wants, regardless of the efficacy, to simply satisfy them. This can be a major driver of continued use of treatment with poor efficacy and limits both our progression as a profession and the long-term outcomes of a patient.

Patient satisfaction and outcome measures are by no means the pinnacle of assessment tools. However, they do carry immense value and can help guide improvement for the benefit of our patients and ourselves.

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