Achieving joy in Canada’s health care system: what can we do today?

Johny Van Aerde, MD, PhD

Measuring patient satisfaction based on concepts borrowed from business and linking them incorrectly with outcomes can lead to problems. Terms such as quality and satisfaction depend on a number of variables, both objective and subjective. At the Cleveland Clinic, already renowned for technical excellence, system-wide emphasis on patient experience (the combination of objective and subjective elements) dramatically increased its ranking in terms of quality, safety, and efficiency in delivery of care.


During the Cold War, Soviet leaders didn’t use capitalist measures of outcome, such as profits, and no one tracked customer satisfaction. Instead, for nail manufacturing as an example, they measured production in terms of weight. When ordered to increase production, nail factories responded by switching from the nails needed for construction to huge, heavier railroad spikes that were not needed. When Moscow saw this result, they changed the measure of production to number of units; the factories went on to produce billions of tiny, useless nails.


When people fail to create measures that produce the right kind of influence or change in (organizational) behaviour, they end up measuring incorrect variables (Grenny et al. 2013). If the very process of measuring outcomes could drive the wrong behaviour, as in the case of nail production, then we must also be sure to measure faithfully the actions or behaviours underpinning the results that need to be produced. In health care, when the wrong measuring tools are used to evaluate evidence-based outcomes, e.g., patient satisfaction surveys, the results drive the wrong behaviour and lead to worse outcomes (Fenton et al. 2012, Detsky and Shaul 2013), just as in the example of the Russian nails.

A large amount of evidence indicates that patient satisfaction has no correlation with quality improvement or evidence-based medical outcomes (Rahmquist 2001, Lee et al. 2008, Fenton et al. 2012, Detsky and Shaul 2013). This is particularly bad news for jurisdictions with a legislated requirement for hospitals to perform yearly surveys of patient satisfaction to guide quality-improvement plans (Detsky and Shaul 2013).


Clear definitions needed


Some of the confusion around patient satisfaction and quality improvement may originate from the fact that definitions have not been clear. When we adopt customer-oriented concepts from the business world, we should examine them carefully before introducing them into the health care system.


According to Lowenthal (2001), customer satisfaction is related to the quality of the product or service delivered. What is quality? It has many definitions, depending on what lens is used to view it. Transcendentally, “Quality is neither mind nor matter…. even though quality cannot be defined, you know what it is [when you experience it]” (Pirsig 1974). It is a simple, unanalyzable property that we learn to recognize only through experience. It is mostly based on perception. The product-based approach defines quality as differences in the quantity of some ingredient or attribute of a product. It is a precise and measurable variable. The manufacturing-based lens, which looks at engineering processes and cost reduction, has us believe that quality is the degree to which a specific product conforms to design specifications and how reliable it is (Garvin 1984). The user-based definition indicates that, “Quality is the degree to which a specific product satisfies the wants of a specific customer” (Garvin 1984).


In the business world, all these definitions converge to define quality as a mark set by a customer for a product or a service, and much of the quality of a product lies in the way it is perceived. The manufacturing-based and product-based lenses define the objective elements, the specifications, the reliability, and the resulting cost of the product or service. Translated for the health care industry, this means evidence-based outcomes, such as morbidities, mortalities, efficiencies, costs. However, the customer- or user-specific and transcendental definitions of quality in business are about perception by the customer of the product or services delivered, i.e., mostly the subjective elements of quality.


Pitfalls in measuring quality and patient satisfaction


In health care, that perception is measured with patient-satisfaction surveys. If one erroneously uses subjective measures, such as patient satisfaction, to evaluate objective evidence-based outcomes, it is understandable that people will manipulate the subjective perception of quality. This helps explain why subjective, perception-based patient-satisfaction surveys do not correlate with quality improvement. Consequently, reports indicate that high patient satisfaction is more closely associated with higher prescription drug costs, higher overall health care expenditures, and higher mortality than the lowest levels of satisfaction, even after adjusting for covariables (Fenton 2012, Detsky and Shaul 2013). Besides the fact that the definition of satisfaction itself has varied across studies, it is greatly influenced by age, income, pain management, anxiety, education, comorbidities, and the length of time between the encounter and the survey (Rahmquist 2001, Lee et al. 2008, Manary et al. 2013). Top


Some have speculated that the use of discretionary care, i.e., interventions or treatments for which there is no proven benefit, is increasing, in part to avoid patient dissatisfaction. When discretionary care is demanded by the patient, it may lead to iatrogenic harm, diagnosis of pseudo-diseases, and overtreatment, resulting in an ongoing rise in medical costs. The power and fear of defensive medicine also contributes to this type of care (Glauser 2013). Patient satisfaction may be further decreased by conversations related to prevention and lifestyle, conversations that, despite being part of good health care, are often perceived negatively by the patient.

Using legislation or reimbursement schemes to force a link between subjective satisfaction surveys and objective elements of quality improvement may mean that the interpretation of patient autonomy may also change (Detsky and Shaul 2013). At what point does patient-centred care, which includes the patient’s right to accept or reject proposed treatments, become patient-directed care, where patients demand specific tests or treatments, such as convenience cesarean sections or Internet-evidence-based interventions?


Patient experience: a complete model for quality care


Perhaps Merlino and Raman (2013) provide a complete model of quality care, in which they combine many organizational indicators of patient experience and health, including evidence-based objective outcomes and subjective measures of patient satisfaction. This successful new model takes patient-centred care to the next level.

Dr. James Merlino, a keynote speaker at this year’s Canadian Conference on Physician Leadership (www.2014leadership.ca), is CEO at the Cleveland Clinic, where CEO stands for chief experience officer. He oversees the Office of Patient Experience with 112 employees. Like many prestigious hospitals with impressive medical advances (the Cleveland Clinic’s heart program was ranked no. 1 for outcomes), the clinic had focused almost solely on medical outcomes in the past. Yet, in overall patient satisfaction, it ranked only at the 55th percentile. The clinic was good at performing procedures and treatments, but if they failed to explain those procedures fully in terms that patients could understand and did so in a room that was not clean (the clinic was in the 4th lowest percentile for room cleanliness), that would diminish the patient experience as reflected in the poor patient-satisfaction surveys. Patients came to Cleveland Clinic for clinical excellence, but they did not like the place! Top


As medical excellence could not be improved much more, and as many people perceive quality based on experience rather than on excellence in clinical outcomes, the Cleveland Clinic made patient experience an enterprise-wide priority. Merlino brought everyone at the clinic together, including the physicians who thought that only objective medical outcomes mattered. By impressing on everyone, from administrators to janitors, that patient satisfaction is a significant issue, the Cleveland Clinic demonstrated to its employees that all are caregivers who play a role in the patient experience (Merlino and Raman 2013). The patient is included, not only to develop an understanding of his or her needs, but also to establish realistic expectations. Patients are not always right and sometimes have desires whose fulfillment would not be in their best interests.


Although institutions in general talk a lot about the importance of empathy in delivering good care, there is actually little knowledge of what patients experience as they navigate the health care system, except for their interactions with physicians and nurses. For that reason, Merlino and his team undertook studies, the results of which indicated that patients want the reassurance that the people taking care of them really understand what it is like to be a patient. Patients want better communication and better coordination of their care. The studies also revealed that patients often use proxies in their ratings: for example, if a room is dirty, they might take that as a sign that the hospital delivers poor care. Another striking finding was the importance of a care provider’s demeanor: patient satisfaction is lower when caregivers appear unhappy because patients believe that they (the patients) are responsible or that something is going on that the caregiver does not want to reveal. Top


After the study results were known, Merlino had 43,000 employees — everybody in the organization with no exceptions — participate in a half-day exercise in groups of 10 with a facilitator. Everyone learned basic good behaviour, such as smiling, telling patients and other staff members their name and role, explaining what to expect during an activity, actively listening or assisting, learning something personal about the patient or staff member, and saying thank you (Merlino and Raman 2013).  The cost of the exercise was $11 million. Despite physicians expressing fears that the new initiative would conflict with efforts to maintain high standards in terms of quality, safety, and cost reduction, the Cleveland Clinic rose dramatically in rankings for quality and safety, and its efficiency in delivery of care improved too. Currently, the annual budget for the Office of Patient Experience totals almost $10 million and everyone is involved, including patients on whom the clinic relies heavily to identify problems and improve processes.




To change culture, which is driven by behavioural patterns, the correct tools have to be chosen. Patient satisfaction (the subjective measure of patient experience) and evidence-based outcome (the objective measure of patient experience) are two different components of how patients experience the quality of care provided, and each component deserves different, independent evaluation tools. Changing culture and processes to improve patient experience within the context of evidence-based objective quality outcomes can lead to substantial improvements in safety, quality, costs, and patient satisfaction as demonstrated at the Cleveland Clinic, where health and care around patient experience isn’t a new program, “It’s a way of life” (Merlino and Raman 2013). Top



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John Van Aerde, MD, MA, PhD, FRCPC is currently president of the Canadian Society of Physician Executives. He is senior consultant for neonatology at Fraser Health, BC, clinical professor of pediatrics at the University of British Columbia, an associate faculty member at the School for Leadership Studies as Royal Roads University in Victoria, and on the faculty of the Physician Management Institute.


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