Although measures of patient satisfaction contribute valuable feedback, they do not represent the complete picture. Use of a more balanced scorecard — including accessibility, continuity of service, effectiveness, and appropriateness, for example — to plan, manage, and monitor health care activities and performance will yield more useful information to assist in continuous improvement in health care.
KEY WORDS: patient satisfaction, outcome measure, balanced scorecard, continuous improvement, quality of care, quality improvement, healthcare, Choosing Wisely
Since the 1980s, patient satisfaction has been recognized as a critical outcome measure of the quality of health services.1 A strong case was made for including patient satisfaction in quality assurance programs, including ethical issues, philosophical changes in the health care field, and clearly defining the impact of patient satisfaction on quality of care.2 Top
The value of patient satisfaction data
There is no doubt that patient satisfaction surveys are important in shaping health care delivery, as they offer important and timely feedback from patients themselves and the ability of health care providers and administrators to see care through patients’ eyes.3 Survey results have been used for benchmarking and quality improvement,4 and to enable accountability.5 In the United States, patient satisfaction scores have been incorporated into pay-for-performance agreements.6 In 2012, the Centers for Medicare and Medicaid Services finalized details of a new reimbursement method that adjusts payments based on patient satisfaction scores. Top
Enhancing meaningful patient engagement and improving our understanding of the patient experience will assist ongoing continuous improvement efforts to provide quality patient care. In addition to patient surveys, we see positive results from asking more open-ended questions and holding patient focus groups,7 forming patient and family advisory councils,8 and including the patient voice in hospital and medical organization committees to redesign care.9 Bate and colleagues10 proposed a comprehensive continuum of patient involvement in health care improvement in a range of activities: complaining, giving information, listening and responding, consulting and advising, experience-based co-designing. Top
Rising concerns about patient satisfaction as the ultimate metric of quality care
Yet, my discussions with medical colleagues across North America consistently reveal concerns about using patient satisfaction ratings as a marker of quality of care. In the emergency department, patients who come in seeking antibiotics for their sore throat will not be easily satisfied with an explanation of why this is not indicated. Patients who smoke do not feel satisfaction when their family doctor tells them, yet again, that they should consider quitting smoking. In hospitals in communities with high drug use, refusing to prescribe narcotics at a patient’s request does not lead to satisfaction.
Some of my colleagues in psychiatry tell me they could not work if they focused primarily on creating satisfied patients. “When I have to restrain a patient, or tell him that I cannot prescribe more pain medications, or tell an older man he can no longer drive, or admit someone involuntarily, I usually do not have a satisfied patient. I am consoled by reminding myself that I did the right thing.” Top
It is not just a few individuals with such concerns. The idea that we may need to re-evaluate patient satisfaction as the main metric of health care quality is growing. The Canadian Foundation for Healthcare Improvement published a “Mythbusters” article to debunk the common misconception that high patient satisfaction means high quality care.11
Researchers at Johns Hopkins University School of Medicine12,13 found no link between patient satisfaction scores and surgical care quality scores. Of interest, they did find a correlation between patient satisfaction scores and employees’ feelings about teamwork and the safety climate in their hospital, suggesting “improvement of workplace culture” as a potential area of focus. Top
Overemphasis on patient satisfaction may lead to harm. Many physicians tell me that they feel that they would have to cater to “patients’ wants, not their needs,” in attempts to keep them satisfied, and have expressed concerns that patients may be harmed unknowingly. Patients would receive unnecessary testing when requested, be prescribed specific drugs they may not need, not receive health counseling they require simply because it may upset them, or not realize how serious their situation is in an attempt to avoid telling them bad news.
An article in The Atlantic14 discusses how health care is now focused on “making people happy, rather than making them well... [on] smiles over substance.” It suggests that “by attempting to satisfy patients, healthcare providers unintentionally might not be looking out for their best interests.” Top
Researchers at UC Davis conducted the first national study that showed that an overemphasis on patient satisfaction can actually lead to unanticipated adverse effects.15,16 They found that people who are the most satisfied with their doctors are more likely to be admitted to hospital, and accumulate more health care and drug expenditures than patients who are less satisfied with their care. Satisfied patients also had higher death rates: For every 100 people in the least satisfied group who died over an average period of nearly 4 years, about 126 people in the most satisfied group died, despite the fact that the more satisfied patients had better average physical and mental health status at baseline. Although no definitive cause and effect relationship could be inferred, the higher death rates were not because these patients were more ill. Although many studies have found higher patient satisfaction associated with favourable outcomes,17,18 this remains a cautionary reminder of the old adage that “more is not better.” Top
Measures of patient satisfaction and experience remain useful and contribute valuable feedback on how we can continue to improve quality of health care. Yet, on their own, they do not represent the complete picture.
Use of a balanced scorecard to strategically plan, manage, and monitor health care activities and performance and identify and track more metrics than just patient satisfaction and patient experience will yield more useful information to assist in continuous improvement in health care. Other dimensions that can be tracked include population focus, accessibility, safety, continuity of services, effectiveness, efficiency, and appropriateness.19 These can be selected to best meet the needs of a specific health care organization. Once developed, these metrics require careful and regular tracking and reporting. Even if pay-for-performance exists, all of the metrics on the balanced scorecard are assessed and incorporated into such agreements.
The Choosing Wisely initiative has helped to create and advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures in both Canada20 and the United States.21 Informed by the evidence-based recommendations of more than 70 specialty society partners, recommendations have been released to facilitate wise decisions about the most appropriate care based on a patient’s individual situation.
Such recommendations would be incorporated into deciding what care is safe, effective, efficient, and appropriate. Ideally, the Choosing Wisely lists can be used effectively by health care providers to explain to the patients why they may not receive the care, tests, or medications they want, as well as in more effectively balancing patient satisfaction ratings with quality of care received. Top
1.Williams B. Patient satisfaction: a valid concept? Soc Sci Med 1994;38(4):509-16.
2.Vuori H. Patient satisfaction — an attribute or indicator of the quality of care? QRB Qual Rev Bull 1987;13(3):106-8.
3.Tam JLM. Linking quality improvement with patient satisfaction: a study of a health care service centre. Market Intell Planning 2007;25(7):732-45.
4.2011 quality improvement plans: an analysis for learning. Toronto: Health Quality Ontario; 2011. Available: http://tinyurl.com/z5xuvs5
5.Veillard J, Champagne F, Klazinga N, Kazandjian V, Arah OA, Guisset AL. A performance assessment framework for hospitals: the WHO regional office for Europe PATH project. Int J Qual Health Care 2005;17(6):487-96.
6.Press I, Fullam F. Patient satisfaction in pay for performance programs. Qual Manag Health Care 2011;20(2):110-5.
7.Williams B, Coyle J, Healy D. The meaning of patient satisfaction: an explanation of high reported levels. Soc Sci Med 1998;47:1351-9.
8.Kreindler SA. Patient involvement and the politics of methodology. Can Public Admin 2009;51(1):113-24.
9.Crawford MJ, Rutler D, Manley C, Weaver T, Bhui K, Fulop N, et al. Systematic review of involving patients in the planning and development of health care. BMJ 2002;325(7375):1263-5.
10.Bate P, Robert G, Maher L. Bringing user experience to healthcare improvement: the concepts, methods and practices of experience-based design. Abdington, UK: Radcliffe; 2007. 224 pp.
11.Myth: high patient satisfaction means high quality care. Ottawa: Canadian Foundation for Healthcare Improvement; 2012. Available: http://tinyurl.com/jgw5bzg
12.Patient satisfaction with hospital stay does not reflect quality of surgical care (news release). Baltimore: Johns Hopkins Medicine; 2013. Available: http://tinyurl.com/ko7e5c2
13.Lyu H, Wick EC, Housman M, Freischlag JA, Makary MA. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg 2013;148(4):362-7.
14.Robbins A. The problem with satisfied patients. The Atlantic 2015; April 17. Available: http://tinyurl.com/m4ukzfy
15.Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012;172(5):405-11.
16.Brookes L, Fenton JJ. Patient satisfaction and quality of care: are they linked? Medscape Family Medicine 2014;June 11. Available: http://tinyurl.com/pk7eln3
17.Sequist TD, Schneider EC, Anastario M, Odigie EG, Marshall R, Rogers WH, et al. Quality monitoring of physicians: linking patients’ experiences of care to clinical quality and outcomes. J Gen Int Med 2008;23(11):1784-90.
18.Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care 2011;17(1):41-8.
19.Hicks L, Nininger J. A guide to developing and assessing a quality plan for healthcare organizations. Collaborative for Excellence in Healthcare Quality; 2012. Available: http://tinyurl.com/jmsf8cd
20.Choosing Wisely Canada. Ottawa: Canadian Medical Association and Toronto: University of Toronto; 2015. Available: http://www.choosingwiselycanada.org/
21.Choosing Wisely: an initiative of the ABIM Foundation. Philadelphia: American Board of Internal Medicine; 2015. Available: http://www.choosingwisely.org/
Mamta Gautam, MD, MBA, FRCPC, CPDC, CCPE — a psychiatrist with 25 years of experience treating physicians and physician leaders — is also a coach, author, and president of Peak MD, Ottawa, Ontario.
Correspondence to: firstname.lastname@example.org
This article has been reviewed by a panel of physician leaders.