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.
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.
- 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.
- 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.
- 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|