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April 20, 2015 6:29 AM   Subscribe

 
When hospitals improve nurse working conditions, rather than tricking patients into believing they’re getting better care, the quality of care really does get better.

News at 11.
posted by billiebee at 6:39 AM on April 20, 2015 [12 favorites]


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....

By treating patients like customers, as the nurse Amy Bozeman pointed out in a Scrubs magazine article, hospitals succumb to the ingrained cultural notion that the customer is always right.


The consequences are not life-and-death, but I see exactly this same thing at the community college where I teach. Upper administration refers to the students as "our customers" and much of our tenure application is based on student evaluations. You can be an amazingly gifted, demanding teacher and get pretty good evals, but you can also be a lazy one who hands out A's like candy and get incredible student evals. You can imagine how that is playing out. When you incentivize the faculty to meet an 18-year-old's idea of what good college classes are, that's what you get.

This, to me, seems related to the "everyone's an expert" mythos that has been on the rise recently. Who knows what's better for my health, a pastrami-eating, pack-a-day smoking manly man like me or some egghead doctor? Bring me more pastrami and let me sign the release forms.
posted by Pater Aletheias at 6:53 AM on April 20, 2015 [38 favorites]


This is, of course, one of those metrics which conclusively proves that the American system is better that Dread Socialism.
posted by Vulgar Euphemism at 6:54 AM on April 20, 2015


Increasingly, health is not so much about short term active interventions, but about long term patient behavior modification, medication regimen, and extended, long term, more passive interactions. Think chemo vs surgery, heart disease management vs triple bypass, etc.

This means, of course, that the patient must be a much larger part of their own outcomes, and that it only serves to reason that better health outcomes are the result of worse patient "satisfaction".

This is one, among a myriad of other, arguably more important reasons, why "for profit health" is a tremendously bad idea: across the entire spectrum, from patient to doctor, hospital to insurer, the incentives are intrinsically at odds.
posted by Freen at 7:11 AM on April 20, 2015 [3 favorites]


This is one of those "both sides are wrong" things. Funding should just be funding and "Patient satisfaction" shouldn't be an excuse to cut it. But nor should "patient satisfaction" become one of those evil buzzwords like "self-esteem". We already talked about a thing awhile back about how doctors are often incredibly dismissive of womens' concerns and blame everything on obesity, anxiety, etc. without looking deeper or solving actual problems.

I would much rather be sick and have it be my own fault than be sick because doctors don't give a shit about patient satisfaction.
posted by bleep at 7:18 AM on April 20, 2015 [11 favorites]


It also looks like they are basing things on weird measures of patient satisfaction -- I'm not convinced the metric is actually terrible as one in a bunch of things to look at, but it needs to be set up well and looked at in a larger context.
posted by jeather at 7:28 AM on April 20, 2015 [2 favorites]


Perverse incentives, and unreliable narrators. What a good combination for advancing healthcare!
posted by Dashy at 7:44 AM on April 20, 2015 [12 favorites]


Having spent a lot of time on a hospice ward of a hospital about a year ago (in exurban Toronto, not the US), much of this article seems breathlessly silly:

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.

Valet parking! Yes, hospitals should clearly stop wasting that money, because it's not at all like valet parking is a profit center for the hospital with huge margins that helps fund other shit.

Live music? Yeah, that's stupid to offer, because patient feelings and morale don't affect anything and ameliorating emotional suffering is too unimportant to care about. After we've made sure we're not wasting money on live music we can go after those assholes who waste resources by coming into a hospital to be nice to kids on cancer treatment.

Custom menus? Obviously there are limits, but, yeah, why should someone in hospital have anything at all that they could feel in control of when it's so much simpler for the staff just to give them whatever the plan is that day?

And flat screen televisions. Or, as they're also known, televisions less than twenty years old.

Great nurses are warm, funny, personal, or genuine—and requiring memorized scripts places a needless obstacle in their path.

Most nurses aren't great nurses. By definition, most nurses are around-average nurses, and many nurses are below-average-but-not-unacceptable nurses.
posted by ROU_Xenophobe at 7:52 AM on April 20, 2015 [32 favorites]


I feel like there's a lot of pastrami-shaming going on in both the article and this thread.
posted by the uncomplicated soups of my childhood at 8:04 AM on April 20, 2015 [13 favorites]


I hate pastrami. Do you know how they make pastrami? That stuff will kill you. Or you'll end up in a hospital and be asked to fill out a patient satisfaction questionnaire. And so the circle begins.
posted by jerrywrite at 8:29 AM on April 20, 2015


Who knows what's better for my health, a pastrami-eating, pack-a-day smoking manly man like me or some egghead doctor? Bring me more pastrami and let me sign the release forms.

If we cure that man of his pastrami eating and chain-smoking habits, he'll live to be 85, all the while being miserable and making a living hell out of the lives of all those unfortunate enough to be around him.

If, by contrast, the pastrami-eating chain-smoking manly man is left to his ways, he'll die at age 65, a happy, fat, manly man. He's happy, the people around him are happy, and he won't burden social security for an additional 20 unhappy years.

See? It's win-win for everybody.
posted by sour cream at 8:57 AM on April 20, 2015 [4 favorites]


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.
Maybe the most satisfied patients are well aware of just how sick they are, and grateful for whatever their doctors can do for them, even if that doesn't keep them out of the hospital or the cemetery?

This whole article has that if-you-look-at-it-THIS-way feel to it. I'm sure that a focus on patient satisfaction has some negative effects, as would any other way patient care is delivered. I'm not convinced that ignoring patient satisfaction has fewer negatives. My opinion is informed by my own experience with being ignored, which would have had me sporting a pacemaker if I hadn't agitated for a different kind of care. Sick people should not have to endure dismissive or otherwise unnecessarily unpleasant treatment. That doesn't mean doctors should lie to them or not talk about personal choices, and I don't see any proof that those things are a common result of patient-satisfaction initiatives.
posted by Kirth Gerson at 9:00 AM on April 20, 2015 [3 favorites]


This article explains something that was puzzling me. I had a colonoscopy on Tuesday, then on Saturday I received a best wishes card in the mail from the hospital with the message: “we want to thank you for the opportunity to provide you with excellent care,” signed by the three nurses who had been looking after me.

I thought it was an odd thing to get, but now I understand. I was well looked after and had not the slightest complaint about my care, but I can’t say the card improved my satisfaction.
posted by Quinbus Flestrin at 9:19 AM on April 20, 2015 [1 favorite]


Once you have rules, you have a game.

Once you have a game, people play to win.

Thus beings the arms race between the players and the game. (cue Taylor Swift)
posted by GuyZero at 9:27 AM on April 20, 2015 [7 favorites]


My mother is one of those really, really sick patients who prefers the bad hospital with the good "service". She wants her drinks and her cigarettes, even though they are killing her, and she wants the doctors and nurses to pretend they haven't noticed. She wants that a lot more than she wants to get well.
posted by mumimor at 9:40 AM on April 20, 2015 [2 favorites]


On the other hand, some hospitals do what they can to gouge patients, and there's little that can be done about it once the service is on the bill. $1.50 for a Tylenol pill? Why not. Helps the hospital's bottom line.

If we're going to treat medical care like a business and not a basic human need, then expect principles of consumer capitalism to be applied in all sorts of ways. What goes around comes around, maybe.
posted by a lungful of dragon at 9:57 AM on April 20, 2015


She wants her drinks and her cigarettes, even though they are killing her, and she wants the doctors and nurses to pretend they haven't noticed. She wants that a lot more than she wants to get well.

You can't force someone to want to get healthy, whichever hospital they are in.
posted by jeather at 9:59 AM on April 20, 2015 [3 favorites]


“During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”

The article uses this question as an example of the problems associated with using patient satisfaction as a metric, but in my opinion as a nurse, this is the single best indicator a patient has as to the likelihood of a getting a good medical outcome out of their hospital stay.

Patients often ring their call bells to ask for a soda or to have their pillow fluffed. But they also ring to report their potentially fatal medical complaints. All us nurses know that. So if you are in the hospital and no one answers your call bell within a very short period of time, its either because the culture of the hospital doesn't put a high priority on safety or because the nurses are desperately overworked.

I do think prioritizing patient satisfaction can have some negative unintended consequences. The scripted interactions are a good example of that. But the whole article reads as weirdly anti-patient to me- as if the bare technical aspects of being hospitalized are all that matter and all that patients should rightfully expect.

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

Well duh. Medical care takes resources, and it's more satisfying to have good medical care, which takes resources, than to be blown off or unable to afford care, both of which take less resources. It's cheaper to amputate your own arm at home with a hacksaw, but I would imagine it's more satisfying to have a surgeon do it for you, even though it costs more money and requires hospitalization.
posted by shiawase at 11:23 AM on April 20, 2015 [17 favorites]


I was full of the mocking when the new "outpatient center" (i.e., building with a lot of doctors' offices) near me opened with free valet.

Then I was nine months pregnant and having terrible back problems and it was all I could do to waddle across the lobby and I was like, "I LOVE YOU FREE VALET!"

It's like two guys getting minimum wage who also function as greeters and help people with limited mobility navigate the entry area (like getting wheelchairs over the slight door bump, when a frail old dude is pushing his even more frail wife in her chair and even the small bump is tricky; or it's slippery and someone has a walker). I think it's probably a good spend. Just the idea that when I got to the doctor's office, I could get out right at the door and they'd take my car for me made me more likely to go to my appointments in late pregnancy when suddenly I developed a problem and so had to go to FIVE BILLION APPOINTMENTS but also I was tired and huge and could barely walk. Imagine how much more compliant frail old ladies are when they don't have to cross a giant parking lot to get to the door, or remember where in that giant parking lot their car is.

My GP is in the same building, as is urgent care, and 99% of the time it's easier just to park my own car and walk across the parking lot. But it's a doctor's office! Lots of people are there because walking across the parking lot is AN IMPASSABLE OBSTACLE for them! I LOVE THE FREE VALET!
posted by Eyebrows McGee at 12:29 PM on April 20, 2015 [15 favorites]


I spent a portion of the weekend reading about the state of direct-entry midwifery in the US. Boy did it scare me straight. The tl;dr version is exactly this: a friendly nice empathetic midwife who spends 45 minutes with you at every appointment and a cosy home birth still gives you 800% increase in the rate of infant death over the OB + hospital birth method. Sure your c-section risk goes up but then the risk of infant death plummets, so.....
posted by St. Peepsburg at 2:17 PM on April 20, 2015 [7 favorites]


A happy person is a well person.
posted by rankfreudlite at 2:29 PM on April 20, 2015


I find the pastrami to be the most sensual of the salted cured meats.
posted by rankfreudlite at 2:40 PM on April 20, 2015 [2 favorites]


Patients often ring their call bells to ask for a soda or to have their pillow fluffed. But they also ring to report their potentially fatal medical complaints. All us nurses know that. So if you are in the hospital and no one answers your call bell within a very short period of time, its either because the culture of the hospital doesn't put a high priority on safety or because the nurses are desperately overworked.

Thank you for posting this. As a med student and a frequent flier patient, I found it utterly bizarre that response time to a patient's call button was dismissed as an obviously flawed metric.

I sometimes think that laypeople confuse the regular wards with the ICU and falsely assume that every patient in the hospital is hooked up to a "real" monitor that will alert a provider if there is a medical emergency, and thus the call button is little more than a little bell for summoning a servant. The fact is that most patients on the wards (not in any kind of ICU) are only hooked up to an IV, and only have their vitals monitored a few times per day. The call button can and does avert real medical problems if it is acknowledged.
posted by telegraph at 3:37 PM on April 20, 2015 [9 favorites]


I would be happy if hospitals stopped being miserable, disorienting places that made me go insane from confusion, lack of sleep, and weird food after they have parked me in hallways and taken away all my comforts, seriously. This is not an either-or situation. Hospitals can certainly make you better and they sure as heck can make you feel better than they do.
posted by Peach at 4:35 PM on April 20, 2015 [7 favorites]


A well person is a happy person.
posted by rankfreudlite at 5:32 PM on April 20, 2015


I'm really disappointed that people are making a big deal about the pastrami here. It's an extreme example. I had gastric sleeve surgery a year ago and even though I've lost weight, I haven't lost my psychological issues about food. Some people's brains aren't wired to think the way the oh-so-superior chattering classes think. That guy was dealing with an incredibly stressful experience using his particular set of survival skills (comfort food), and could probably have used gentle guidance rather than mockery and pearl-clutching thread titles.
posted by mirepoix at 8:12 PM on April 20, 2015 [2 favorites]


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.

I read this paragraph and thought about my recent health care experiences -- when I had only healthy children, I really liked my kids' doctors. Now that I have sick children, I can name twenty people involved in their care whom I would leap into traffic to save. There are no words for the appreciation and love I have for these people. Needless to say, I fill out extremely positive patient satisfaction surveys.

Anyway so I went looking for the article she's referencing, which I think might be this one, and also found a response to the article which says that the research finding is inconsistent with what most work in this field has shown and suggests as one of the possible reasons insufficiently controlling for the sick patients being grateful thing.
posted by gerstle at 11:45 PM on April 20, 2015 [3 favorites]


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.

I am so incredibly skeptical of this narrative. As stated, there are so many uncontrolled variables as to make any kind of conclusion pretty meaningless. Maybe the ones who rate care higher are the ones who receive more care i.e. the least healthy? I am a bit suspicious of where this article is coming from.

You're really telling me that doing things to make patients happier is distracting from their care to the extent that they are "significantly" (no need to quantify that!) more likely to die? That sounds insane unless you really imagine things like nurses fluffing pillows while patients are flat-lining. None of the measures they actually described in the article, as extreme as they are supposed to sound, seem like the kinds of things that "significantly" increase patient mortality.

Health care really should take the mental and emotional state of the patient into account. Doing this effectively should contribute to positive medical outcomes. In addition, the hospital experience can be a living hell for a lot of people, and it's only humane to look for ways to make it less terrible.

If this is being done poorly, then we should address that, but it seems misguided to me to suggest that we need to deprioritize patient satisfaction.
posted by Edgewise at 11:53 PM on April 20, 2015 [2 favorites]


Then I was nine months pregnant and having terrible back problems and it was all I could do to waddle across the lobby and I was like, "I LOVE YOU FREE VALET!"

Seattle Children's has free valet parking, too. I've only ever used it at the ER. But let me tell you, when you have a limp, dusky, croupy four month old who is struggling so hard to breathe that their chest wall muscles are sucking in between their ribs and under their sternum and even in through the structures of their neck, the last thing you want to worry about is having to find parking. Being able to just run in with him and throw my keys at the valet and turn to the nurses who were urgently taking my baby out of my arms to get him on oxygen was one of the least awful things about that experience.
posted by KathrynT at 8:14 AM on April 21, 2015 [4 favorites]


This whole article has that if-you-look-at-it-THIS-way feel to it.

As does most everything in The Atlantic these days.
posted by blucevalo at 9:49 AM on April 21, 2015


'Live music', is that like 'music therapy', which improves patient outcomes? Yeah - it is.
posted by bq at 10:51 AM on April 21, 2015


The hospital where I had my kids had a cosmetologist, which I found very curious and asked some friends who worked there about. They said the hospital pays half her salary, and fees-for-services pay the other half. So for $45 or something I could have the cosmetologist come visit me in the maternity ward and style my hair and do my makeup, like if we were having a baby photo shoot or if the home-going was a culturally big deal (some groups have big parties for it). Or, apparently she does a lot of haircuts for 60-year-old dudes who have heart surgery and know they won't be able to get around too well for the next six weeks at home, so they get a haircut for $15 before they go home. Stuff like that, at prices comparable to what you can pay in town.

Then with the OTHER half of her time, that the hospital pays for, she goes and visits, like, 17-year-old car accident victims who've had half their head shaved and helps them figure out a hair style that works while their hair grows back in so they don't feel weird going back to school. She visits people having a long, depressing stay at the hospital and paints their toenails or styles their hair. She teaches people with scars how to use makeup to conceal (or accentuate!) the scar. I mean, she doesn't just ambush people with Mandatory Hospital Beauty, but if you've got a teenager crying because half her hair is gone, the nurses will say, "Hey, we actually have a stylist, I can call her if you want, she knows how to style it while it grows back in and she can show you what to do, and she'll make sure the style doesn't interfere with wound care."

Again that seems to me a pretty low-cost (and the hospital only pays for half!) but AMAZING way of helping people heal from injuries and illnesses. I'd imagine having less anxiety over your physical appearance while healing from an accident probably really improves outcomes, and I'd also imagine that for long-term hospital patients, the cheering up you get from a little frivolous personal care is non-negligible.
posted by Eyebrows McGee at 11:50 AM on April 21, 2015 [10 favorites]


Again that seems to me a pretty low-cost (and the hospital only pays for half!) but AMAZING way of helping people heal from injuries and illnesses.

We have been sneering at this sort of thing for the length of my politically-aware life, and thinking it's a stupid thing to denigrate greatly informed my political positioning. The earliest memory I have of an example is the sneering during the Reagan administration about "midnight basketball," which kept gyms open for at-risk kids to play rather than get up to other shit.

The spending got knocked around a lot but I, in my teens, thought "you already bought the gym and the equipment, why wouldn't you keep it open at the cost of a little electricity if it provides an alternative to crime?" The fact that it was a pittance compared to so many other expenditures at the time was just icing on the fuck-you cake.

All of this may be beside the point as far as this article's fallacious premise. For one, for all it tries to malign this survey with anecdotes I don't think this sounds as dopey as they make it sound.
What items are on the HCAHPS Survey?
The HCAHPS Survey is composed of 27 items: 18 substantive items that encompass critical aspects of the hospital experience (communication with doctors, communication with nurses, responsiveness of hospital staff, cleanliness of the hospital environment, quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and recommendation of hospital);
For another, this sort of gets glossed by quickly in the article: Each year, only hospitals with high patient-satisfaction scores and a measure of certain basic care standards will earn that money back (emphasis mine)

Well wait a second. AND? So that AND... what's the weighing here?

CMS says more than 3,000 hospitals will be affected. Under the proposal, patient scores would determine 30 percent of the bonuses, while clinical measures for basic quality care would set the rest.

Oh look. That 1% holdback turns out to only be 30% determined by the surveys. What other sort of trivial nonsense being gamed by scripts and talking up the microwave meals is DHS paying attention to?
This year, 45 percent of a hospital’s score is based on how frequently it followed basic clinical standards of care, such as removing urinary catheters from surgery patients within two days to decrease the chance of infections.
Medicare added its first measure of a medical outcome, looking at death rates of patients admitted for heart attacks, heart failure or pneumonia.Those mortality rates, calculated from the number of Medicare patients who died in the hospital or within a month of discharge, count for 25 percent of a hospital’s score.
Faugh! What nonsense!

Sarcasm aside, color me not at all surprised at this pushback from medical professionals at actual metrics. Our healthcare system is so amazingly bad at doing outcome-based decision making that it's astonishing anyone gets treated properly at all. You can lay a lot of that blame at the feet of pharma, who has an interest in selling the new and patent-protected-for-the-next-17-years drug over the old generic that does just as well, sure. But plenty of that comes from the people on the front lines who want to treat this as an art and not a science.
posted by phearlez at 1:36 PM on April 21, 2015


'Live music', is that like 'music therapy', which improves patient outcomes? Yeah - it is.

Not necessarily. A large private hospital in suburban MA has a grand piano in its main entrance lobby. I never saw it being played, so it is probably more potential live music than actual live music. It also has the worst Emergency Room of my admittedly limited experience.
posted by Kirth Gerson at 1:37 PM on April 21, 2015


bleep: This is one of those "both sides are wrong" things. Funding should just be funding and "Patient satisfaction" shouldn't be an excuse to cut it. But nor should "patient satisfaction" become one of those evil buzzwords like "self-esteem". We already talked about a thing awhile back about how doctors are often incredibly dismissive of womens' concerns and blame everything on obesity, anxiety, etc. without looking deeper or solving actual problems.

I would much rather be sick and have it be my own fault than be sick because doctors don't give a shit about patient satisfaction.
100%. Doctors are trained to treat patients as objects, and patients are raised by their parents to passively submit to the will of doctors. It begins at introductions: "Hi, I'm Doctor Jones, and you must be Janie!"
posted by IAmBroom at 4:57 PM on April 21, 2015 [1 favorite]


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