Patient satisfaction surveys have been on consumer advocates' wish list for more than 10 years—and at 3 p.m. today their wish was finally granted. The federal government's Hospital Compare page has added a massive amount of information about 2,521 hospitals that reveals how often (never, sometimes, usually, or always) and how well patients' various needs were met: nurses listened to them, doctors treated them with courtesy and respect, their pain was kept in check, and in 19 other ways they were recognized as individuals. The survey is called HCAHPS (read as H-caps), for Hospital Consumer Assessment of Healthcare Providers and Systems. "A long acronym for a simple concept," said Rich Umbdenstock, president of the American Hospital Association, at a press briefing this morning. "It will be the same as getting answers from hundreds of friends and family members" about a hospital.
Here's how it will work: No more than six weeks after they are discharged, adult patients who spent at least one night in a hospital (omitting those admitted for psychiatric reasons) will be surveyed by mail or phone. Each hospital will need to contact as many patients as needed to generate at least 300 completed responses per year to the 22-item questionnaire. (A PDF version is available here.) Every month or quarter (it's up to the hospital), each facility will report its results to the federal Center for Medicare and Medicaid Services. CMS will adjust the responses to correct for patient age, size of the hospital, and other lurking biases. Results will be posted, hospital by hospital, for the most recent four quarters' worth of data and will include national and state averages and other information to put the numbers into perspective. CMS says it will look closely at the survey responses, make on-site visits, and otherwise try to control hanky-panky. (Hospitals can continue to commission their own surveys and even put the questions on the federal survey, but the federal questions have to be listed first.)
Hospitals don't have to participate, but the rollout suggests that most will. Even though there was no penalty for skipping the initial round, and hospitals that did participate could hide the data from public view if they wanted, about two thirds of all hospitals submitted data and only about 100 opted to suppress it. Hiding the information will no longer be permitted for future submissions. Starting this July, moreover, hospitals that opt out will find their Medicare reimbursements for inpatient care cut by 2 percent. But CMS expects the number of hospitals that cooperate to grow to about 3,900 later this year.
What does the survey accomplish? Studies show that patients are hungry for "interpersonal process indicators," as an Archives of Surgery paper put it in 2002. Each patient wants "to be treated," the authors quickly added, "as a unique individual by a caring, attentive, and competent professional who involves them in care decision." We all want that when we are ill and relatively helpless. Do patient satisfaction surveys convey information that is medically relevant or even worth serious consideration? Should a patient choose a hospital based on its ability to be caring and attentive?
At least in part, maybe so. About a third of the survey questions have an obvious relationship to medical consequences of a hospital stay. Three ask about pain (for example, "[H]ow often did the hospital staff do everything they could to help you with your pain?"). Three others, if hospitals pay attention to the answers, could bring down the alarming number of hospital-related medication errors and deaths (example: "Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?"). And three questions get at the need to make sure patients are fully informed when they are discharged (example: "[D]id you get information in writing about what symptoms or health problems to look out for after you left the hospital?").
But it is fair to ask whether the chance of living or dying, of departing the hospital on schedule or having to stay because of a complication, truly depends on answers to "[H]ow often did nurses listen carefully to you?" and similar questions. If someone has a condition or needs a procedure that demands an extremely high level of medical skill, it might not be wise to weigh responses to "[H]ow often was the area around your room quiet at night?" into one's choice of hospitals. And the obvious subjectivity in any individual's take when asked such questions makes for decidedly squishy answers. I have a high tolerance for dust bunnies in my hospital room—truthfully, I don't even notice them. But they may horrify you. (Elderly patients tend to be less satisfied than younger ones on matters of noise, cleanliness, and other items found on satisfaction surveys.)
These are major reasons that patient satisfaction has never been factored into the annual rankings of "America's Best Hospitals." In 2004, CMS asked for my opinion of an earlier version of the survey. I told them I wasn't sure how or whether consumers would benefit. I'm still unsure.
"I'm concerned with true measurable quality and safety, and in some ways it's separate from patient satisfaction," M. Michael Shabot, chief medical officer of the Memorial Hermann Healthcare System in Houston, told me yesterday when I asked what he thought. "I don't know how well the average patient would understand the importance of reducing ventilator-associated pneumonia or bloodstream infections unless it happened to him. But patients understand when a doctor doesn't communicate very well." The multihospital system kicked off a pilot program in 2006 to improve the flow of information to patients so that they understood what was happening to them, and when and why. The results of patient surveys administered by an outside vendor soared, and Memorial Hermann regained patients it had lost to other hospitals.
Now that it has just gone live, I'll check out the HospitalCompare survey section, probing its ease of navigation, clarity of explanation, and other, yes, user satisfaction indicators. You'll hear my assessment shortly.
The survey hogged the limelight today, but to me equally or more important is that CMS has used the occasion to completely revamp the HospitalCompare website, bringing together disparate and valuable elements. The site is already a source of data showing the relative diligence of individual hospitals in following accepted practices like giving heart attack patients aspirin. It now folds in data that had languished on hard-to-find pages such as hospital volume for 45 procedures and conditions and the amount that Medicare paid for each one. Good job, CMS.