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.

The post How Do We Define Success In Healthcare? appeared first on Medika Life.

We have preferences for the manner in which we learn and communicate. Introverts prefer one-on-one conversations with low stimulation and ample time to critically assess. Extroverts prefer high stimulus environments and frequent interaction.

As an introvert myself, I am capable of working and interacting in an extrovert habitat, but my performance and enjoyment will suffer. The same holds true for patient preferences. If we try to engage and inform each of them with the same methodology, we will accomplish the objective, but the effectiveness will be poor in many cases.

The following subtypes are described in more detail in Your Medical Mind: How to Decide What is Right for You by Jerome Groopman and Pamela Hartzband. They write through the lens of a physician while I will take a physical therapy approach.

Understanding these tendencies and preferences of your patients can help you better tailor a message and understand the patient’s point of view and values.

I’m a believer vs. nothing does or ever will work (believer vs. doubter)

The eternal optimist versus the pessimist is not a new concept nor will the debate about the value of each ever resolve. The comparisons extend well beyond patient subtypes.

Optimists tell themselves that bad events are temporary and maintain a positive outlook. They are often viewed as opportunists who find the silver lining in any situation.

Conversely, pessimists tell themselves that bad events will last a long time and focus on the negatives of a situation. A pessimist will often describe themselves as a realist and keep expectations low.

In his book Barking up the Wrong Tree: The Surprising Science Behind Why Everything You Know About Success Is (Mostly) Wrong, Eric Barker explains:

Optimists told themselves a story that may not have been true, but it kept them going, often allowing them to beat the odds. Psychologist Shelley Taylor says that “a healthy mind tells itself flattering lies.” The pessimists were more accurate and realistic, and they ended up depressed. The truth can hurt.

Yes, blind optimism can lead to unrealistic expectations, so there is a balance to be had. How does this apply to physical therapy patients?

Believers are the eternal optimist, always believing a treatment option exists for them. They are more prone to trust most recommendations from the clinician. Conversely, the doubter is the skeptic, challenging the efficacy of the recommendation, and wanting to know all the facts. Knowing which one patients lean towards changes your education strategies.

The doubter will be resistant to treatments they are unfamiliar with or do not conform to their expectations, making them more likely to self-discharge at the beginning of a plan of care. On the flip side, we have more wiggle room with the believer, but therapists need to be wary of how this can affect their treatment decisions.

Unconditional trust in our treatments can lead to shooting from the hip and investing less effort into the treatment. The doubter creates vigilance while the believer can foster laziness.

Can’t Stop, Won’t Stop vs. Nah, I’m good (maximalist vs. minimalist)

The maximalist lives by the mantra more are better. This is the patient who wants every treatment you can possibly throw at them. The tricky part is knowing what the “treatment” is and where it is coming from.

A maximalist may be completely reliant on a provider and lack any self-efficacy, seeking every potential treatment for a condition, or a maximalist may live in the gym 3 hours a day and have a gym bag full of all the latest and greatest supplements. Maximalists rarely see the harm in treatments — or at least don’t put much stock into them — only the potential benefits.

The minimalist, meanwhile, cares about the minimum dose needed for a response. They are more apt to use the “wait and see” approach. They are more likely to ghost at the first sign of improvement.

Once they believe they can handle the treatment on their own, they no longer seek care. It can be an abrupt transition. Minimalists will question treatment decisions more frequently and keep treatment plans short, not wanting to commit to more care than may be needed.

Clinicians will likely need to reign in the maximalist and build appropriate self-efficacy. The maximalist will be all ears, but they will also be eager to jump into treatment. Clinicians must ensure the patient is fully aware of all potential risks and benefits.

The opposite will be true for the minimalist. They will require more convincing. Some clinicians will challenge their inner Barney Stinson and boldly claim “challenge accepted” while others will become frustrated at the patient’s lack of trust in their recommendations.

At the end of the day, the treatment goals are the patient’s decision. Our job is to help achieve it in a manner that aligns with their beliefs and preferences.

The latest and greatest vs. tried a true (technology vs. nature)

Technology-oriented patients want the latest and greatest treatment. They are not impressed by experience unless it directly translates to more effective use of new treatments. If a clinician expresses he has perfected a 20-years-old technique and refuses to use the new intervention the patient learned about after consulting Dr. Google, session over.

When speaking to a patient with a technology orientation, the statistics on risk factors and information about a lack of clinical trials for a new technique falls on deaf ears. They want innovation.

Conversely, someone with a naturalistic orientation believes the body can heal itself when provided the proper environment; no fancy technology needed. They seek to harness the mind-body connection and avoid invasive procedures. They are more apt to rely on herbal remedies, lifestyle modifications, and meditation.

In many ways, this can be ideal for clinicians, however, expectations need to be held in check. No herbal supplement will reattach a ruptured Achilles tendon. Meditation does not hypertrophy muscle.

A patient with a naturalistic orientation may also choose interventions outside the clinic that impedes progress in the plan of care. Ever see someone in the middle of a juice cleanse? Your pain and function scores are going to be a little skewed.

Being aware of a patient’s lifestyle and home interventions can help guide the plan of care and in-clinic treatment decisions. Technology oriented patients may even seek to replace physical therapy with the $300 Theragun.

Clinicians will need to highlight their use of the latest evidence, even if exercise and education are not “technology.”

One size does not fit all

While recognizing these categories are beneficial for tailoring patient communication, it is important to note that patients do not neatly fit into a single category; they lie along a spectrum.

Clinicians will often see a blend within a patient. For example, someone may be a minimalist doubter with a naturalism oriented. They will want the hard facts to justify treatment and prefer to allow the body to recover on its own.

Conversely, you may have a maximalist believer with a technology orientation. This patient will always believe a treatment solution exists for him and he continually seeks the newest treatment to try, often self-experimenting.

Knowing your patients’ beliefs and mindset will allow you to better refine your treatments. Groopman and Hartzband describe this process as “judgment-based medicine.” They wrote the following:

We are often asked who is the “best doctor” to treat a particular condition. One criterion is a physician’s knowledge about your condition and its treatments, his or her command of the scientific data, so-called evidence-based medicine. But we believe the best doctors go one step further and practice “judgment-based medicine,” meaning they consider the available evidence and then assess how it applies to the individual patient.

The heterogeneity of patients will always lend to challenges with translating research to clinical practice, but through refined assessments of patient beliefs and expectations, we can improve our chances of success.

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