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Patient Dissatisfaction

My cousin, Edith Nalo, is a nurse in Tennessee working with Oncology patients. Today, she posted on Social Media an article about patient satisfaction scores as they relate to hospitals in The Atlantic. It is well worth your time to read The Problem with Patient Satisfaction. Eventually, payment in home health and hospice will likewise be predicated in part on patient satisfaction.

If you have not heard of HHCAHPS or Hospice CAHPS, it isn’t surprising. The tasks required of the agency is to choose an approved vendor and pay them to do the work. The agency has very little to do with the data collection. A brief overview follows this post.

I couldn’t begin to state with a clear conscience that patient satisfaction is not important – even critical to the patient’s ability to heal. But, patient satisfaction is not a true measure of the standard of care. It never has been and it won’t ever be. In fact, The Atlantic’s article indicates that there is a negative correlation between satisfaction and outcomes.

There are so many ways that results can be skewed that the internet would probably run out of space if all of them were listed.  Here are just a few.

  • Patients who are dissatisfied are generally more likely to speak up.
  • Patients who have a negative outcome such as a terminal diagnosis may hate everyone and everything about the hospital and staff who are called to his or her home post discharge.
  • Patients may only be satisfied when a clinician gives into their demands. ‘Don’t want to get in the chair after surgery? No problem. Hope you have a satisfactory death.’
  • Patients come to us with their own prejudices and personalities. A fundamentalist Baptist may be uncomfortable with a nurse who is Jewish or Hindu.
  • Some patients (and nurses and doctors) will never be happy no matter what you do.
  • The role of Nurses is often misunderstood especially by the elderly. Handmaiden to the physician? Right. Let me get on that right away.
The most important factor is often unnamed and unable to be measured. Fear, especially in stoic patients, causes them to be overly ‘needy’. A person who feels that fear and anxiety are weaknesses find it very easy to call the agency ten times a day to ask a question about a medication they have been taking correctly for ten years. They are the patients who are afraid of running out of pain meds but when you make an extra visit you find that the bottle is still mostly full. And there are the patients that make you want to cry because they are so lonely and tend to hold you hostage at the door because they don’t you to leave. You may be the only person they have seen all week.

Another thing that Medicare totally disregards is that sometimes being a good clinician means allowing a patient to dislike you. We have all told family members to be careful with narcotic drugs for fear that a patient in pain and confused with standard dosing may take additional doses. The patient resents our interference with their medication if the family is diligent about following our advice. I’m okay with saving someone from an unintentional overdose even if it means a few hard feelings.

Finally, there is the questionnaire itself. 7 pages. You can find the home health questionnaire here. I am having a hard time imagining a typical home health care patient or their spouse zipping through the questions. Worse, some of the questions may elicit responses that say nothing about the agency providing care.

  1. In the last 2 months of care, how often did home health providers from this agency treat you as gently as possible?

Consider a patient who has recently had knee surgery.  Treating this patient as gently as possible may mean allowing them to stay in the bed instead of walking on a recently replaced knee.

  1. Would you recommend this agency to your family or friends if they needed home health care?

Whether or not a patient likes the agency enough to refer family and friends is not always a good indication of the quality of care.  An agency who fosters dependence by keeping an aide in the home too long will likely be recommended over an agency who sends an OT in early to facilitate the patient’s participation in ADLs long before it is easy for them to do so.

  1. In the last 2 months of care, did you and a home health provider from this agency talk about pain?

 Talking about pain is not the same as treating pain.  Even when treatment is unsuccessful, it is important that the patient’s orders and treatment plans are reevaluated when pain is present.  This question should include whether or not the agency tried to alleviate the pain or if the agency talked to the MD.

So, if a patient can stay awake and they are literate and have adequate vision and the questionnaire is completed, the information is still less than useful.  Even valid questions may pertain to care given by several clinicians and there is no attempt to isolate the clinician who needs education.  The agency may very well end up incurring the expense of educating an entire staff of clinicians when only one or two are leaving the patient without adequate information.

The Hospice survey is even longer.  You can find it here.

Building trust with a patient is far more helpful to them than being liked by them.  Compassion is critical to good care; sentiment is not.

Meanwhile, teaching your staff the questions that will be asked of your patients may help your scores by ensuring that they emphasize that all that information about Pain they are trying to get from the patient is because a pain assessment is very important, etc.  Use the same vocabulary the patients might hear later.  It is my recommendation that you do not script what your nurses say as is recommended by other experts.  If you do, be prepared to have shrewd patients recognize acting instead of authentic communication.

As far as dealing with the fear and anxiety of patients who become overly dependent on the agency, I would like to hear your thoughts by emailing me or posting in the comments.  Could be a good topic for another day.  If we could all get a handle on how to provide for those needs, life would be better for a whole lot of patients.

HHCAHPS Cliff Notes
  1. Medicare mandates that a standardized questionnaire be given to patients.
  2. Third party vendors are approved by Medicare and collect the data for the agency.
  3. The data is collected via telephone or written questionnaire.
  4. Data is then aggregated and results are posted on Home Health Compare.
  5. Your results are posted along with a comparison of how you perform compared to other providers and the national and state average.
  6. Home Health agencies can view results at Home Health Compare.
  7. Hospice results should be posted when three continuous quarters of good data is available.

10 Comments Post a comment

  1. This paragraph repeats on the blog, Julianne:

    Finally, there is the questionnaire itself. 7 pages. You can find the home health questionnaire here . I am having a hard time imagining a typical home health care patient or their spouse zipping through the questions. Worse, some of the questions may elicit responses that say nothing about the agency providing care.

    April 20, 2015

    • Thank you so much. There were no less that 21 revisions to this post because I could make a space between two of the paragraphs. A good portion was duplicated but it seems I missed that sentence. The sad thing is that I love this theme but might have to find another. I will see if it behaves next time.

      April 20, 2015
  2. RM #

    Our agency has excellent outcomes but we have struggled with the “Patient Satisfaction” scores. We recently received a copy of one of our surveys that the client obviously meant to give us an excellent review but gave us the worst possible one because she spoke Spanish. In the comments section she wrote in Spanish that the nurses were all angels, everyone was so kind and God bless us for taking care of her. She then gave us a 1 out of 10 thinking that she was giving us the highest score and when asked if she would referr us to family and friends she again marked the worst possible answer. It was clear to me that this patient did not mean to give us such a poor score but the language barrier created the confusion. Although I have heard from many that the 1 to 10 scale is often confusing to our clients. Our vendor assured me that they do have Spanish questionnaires but the issue is getting them to the correct clients.

    We also received a very poor score from a patient who had a history of drug abuse and the reason we were seeing the individual was because of a recent accidentaly overdose of pain medication. When asked the pain questions the patient gave us a very low score and wrote in the comments how unsympathetic the nurses were to his pain. I could go on and on with all the times we have been scored inappropriately because of misunderstandings or frustration with a part of their care that we had no control over. I am not sure what the answer is to this problem but I appreciate an opportunity to vent.

    April 20, 2015

    • This is the perfect example of why it is sometimes okay to allow a patient do dislike you. Want a happy patient? Give him all the meds he wants. Want to take care of patient? Be tough enough to go outside your comfort zone and reiterate what the docs and social workers said about rehab.

      Also, as an afterthought – how would a HHCAHPS vendor know the language that a patient spoke? Seems like it should be on OASIS. Is it?

      April 20, 2015
      • RM #

        It is in our demographics, when audited appropriate primary language was checked 100% of the time, yet the vendor sent surveys only in English. Unfortunately I don’t have control over the vendor.

        April 20, 2015

        • That’s sad. There are teaching guides in other languages and resources usually from colleges that can provide you with materials in Spanish. In fact, if you go the the Medicare HHCAHPS site, they have the survey in simplified chinese, spanish and a few other languages.

          When a patient does not speak English as a primary language and the nurse does, wouldn’t that sort of complicate teaching a little?

          April 21, 2015
          • RM #

            Absolutely….That’s why I have nurses that speak, Spanish, Portugese, Farsi, Hmong, Russian, Punjabi, and Hindu. We also utilize a “language service”.
            I have had several conversations with my vendor about sending the survey in the right language. I will take the information you provided above and talk to them again.

            April 28, 2015
  3. Gail Batson #

    You wrote “Some patients (and nurses and doctors) will never be happy no matter what you do.”
    These are the ones you’re likely to hear from. As you said, the dissatisfied are usually the ones who write the Letter to the Editor or post on Facebook about the terrible experience they had at Such-and-Such Hospital or Home Health.
    As a science, these patient satisfaction questionnaires are anecdotal at best. Since when have evidenced based practices relied on stories and opinions? Hospitals should be evaluated by statistical information: how many surgeries did you do this year, what is your post-op infections rate, what is the mortality rate for individual surgical procedures, what is your nosocomial infection rate for UTI, Pneumonia, or other acquired diseases, Sentinel events, and other quantitative based facts. There is a place for qualitative information, but should not be used to decide whether the hospital or home health deserves to be paid or not.

    April 20, 2015

    • You’re BACK!

      And you are also correct. I personally like satisfaction surveys in an agency. Call a bunch of patients and ask them five questions and then ask if they have any comments or concerns that were not covered in the questions. In doing this, you can easily graft the results and the comments are usually very pleasant. I like to make a poster for the agency and include some of the comments. It is a real morale booster.

      BUT inside the agency, the staff know about the patient who insists he needs continued services because he can’t get to the lab for blood draws. Heck, I’d be upset, too, if I lived in rural Louisiana. But, we don’t make the rules and when the patient is communicating directly with the physician and knows the chemical make-up of each drug, the hepatic pathway used for metabolism, potential side effects, etc., his care no longer meets coverage criteria. I don’t blame him for being angry but we can’t very well push him down the stairs to ensure he needs additional services.

      So, the information is good but only in context. Payment should definitely not be predicated on subjective responses. Even the verbiage in the questions is subject to interpretation. What does ‘gentle’ mean? Oh, and how many times have you had a patient who tells you he knows all about his meds only to find out he’s been reading the Scientology website again? I always tell nurses to watch established diabetics inject their insulin at least once because about one in ten do it correctly.

      When I am sick, I hate pretty much everyone. I wonder how many patients also feel less than charitable to their fellow man? How would a third party surveyor know that the wife was incredibly impressed with your care but a past stroke caused the patient to be continuously cranky?

      Like The Atlantic article said, a patient can be extremely satisfied and in an hour be dead.

      I think we all love most of our patients and enjoy being with them for the most part. But the patient’s opinion of our job is rather like us sharing our opinions of an engineer. We like them or not. That’s about the only credible information we can give (unless you actually went to Engineering school).

      April 20, 2015

  4. Hi nice reading your ppost

    October 2, 2022

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