The vast majority of the thirty-two-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”
This question is misleading because it doesn’t specify whether the help was medically necessary. Patients have complained on the survey, which in previous incarnations included comments sections, about everything from “My roommate was dying all night and his breathing was very noisy” to “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.” An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery). “Many patients have unrealistic expectations for their care and their outcomes,” the nurse said.
In fact, a national study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years.
Joshua Fenton, a University of California, Davis, professor who conducted the study, said these results could reflect that doctors who are reimbursed according to patient satisfaction scores may be less inclined to talk patients out of treatments they request or to raise concerns about smoking, substance abuse, or mental-health issues. By attempting to satisfy patients, healthcare providers unintentionally might not be looking out for their best interests. New York Times columnist Theresa Brown observed, “Focusing on what patients want—a certain test, a specific drug—may mean they get less of what they actually need. In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should.”
As a Missouri clinical instructor told me, “Patients can be very satisfied and dead an hour later. Sometimes hearing bad news is not going to result in a satisfied patient, yet the patient could be a well-informed, prepared patient.”
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How far will a hospital go to satisfy a patient? Recently, some have rushed to purchase extra amenities such as valet parking, live music, custom-order room-service meals, and flat-screen televisions. Some are offering VIP lounges to patients in their “loyalty programs.”
And because almost every question on the survey involves nurses, some hospitals are forcing them to undergo unnecessary nonmedical training and spend extra time on superfluous steps. Perhaps hospitals’ most egregious way of skewing care to the survey is the widespread practice of scripting nurses’ patient interactions. Some administrators are ordering nurses to use particular phrases and to gush effusively to patients about both their hospital and their fellow nurses, and then evaluating them on how well they comply. An entire industry has sprouted, encouraging hospitals to waste precious dollars on expensive consultants claiming to provide scripts or other resources that boost satisfaction scores. Some institutions have even hired actors to rehearse the scripts with nurses.