Just how important is patient experience of care?

There's an urban legend that floats through physician communities with a life of its own and not attributable to any real source: doctors who focus on patient satisfaction are doing so because they are otherwise bad doctors and are trying to cover it up.  The typical anecdote: "Oh, old Dr. So-and-so.  He's a real dinosaur, knows nothing about advancing medical knowledge but his patients love him."

This counter-intuitive notion leads some physicians to resist patient satisfaction measurement not only as unimportant but potentially a marker of bad care.

Published studies link good experience of care to good outcomes:

• Patients who get care in practices that are less likely to waste their time in the office and are have physicians who are more likely to listen to them are also more likely to have appropriate colorectal cancer screening.  Ling BS, Klein WM, Dang Q.  Relationship of communication and information measures to colorectal cancer screening utilization: results from HINTS.  Journal of Health Communication. 11 Suppl 1:181-90, 2006.

 

• Patients receiving care in practices less likely to delay care ("sorry, the next available appointment with your doctor is...") are more likely to show up for care they need.  Lacy, N., Pullman, A. Reuter, M., Lovejoy, B. Why we don’t come: Patient perceptions on No-shows. Annals of Family Medicine 2004;2:541-545.

 

• Patients who receive care from someone they know (good continuity) have better outcomes. Wasson JH, Sauvigne AE, Mogielnicki RP, Frey WG, Sox CH, Gaudette C, Rockwell A.  Continuity of outpatient medical care in elderly men. A randomized trial  JAMA. 1984; 252:2413-2417.

 

• Patients who receive good collaborative care (good access, good communication, good continuity, etc) have better rates of appropriate preventive needs met, have better control of their chronic conditions, are less likely to miss time from work/school, and have fewer preventable visits to the emergency room and hospitalizations. Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, July-September 2006 29(3), 199–206.

The interesting thing is that there is definitely a link between patient experience of care and important outcomes.  As you read these studies it is clear that patients respond positively to clinicians who take time, who treat them with respect (e.g. no intolerable waiting), who listen.  We often call this "good bedside manner" though of course it is much more: practices that can do this consistently have good processes in place.  It is no fluke that a practice consistently runs on time, gives the provider and patient the time they need, provides high continuity of care.

Intentional or not practices choose to do this well or badly.  Many practices working on improvement are adopting electronic health records.  A good EMR well implemented may indeed be a boon to more than just good billing, but health information technology alone does almost nothing to important outcomes. Hillestad R, Bigelow JH.  Can HIT Lower Costs and Improve Quality?  RAND Research Brief 2005 http://www.rand.org/pubs/research_briefs/2005/RAND_RB9136.pdf  Accessed January 11, 2009

Back to the urban legend: is good patient satisfaction a marker of bad care? While we may each site anecdotes that appear to support this odd notion, the evidence supports the opposite conclusions.

I risk one anecdote of my own:  I spoke to a physician policy-researcher who was evaluating Medical Home implementation. He visited many offices.  Some had achieved NCQA PPC-PCMH(tm) Level III recognition but were cold, impersonal, and had problems with how they served their patients (waits and delays, etc).  He visited some low tech practice that would receive no recognition from NCQA but found them to be very invested in their patients, knew them well, treated them with dignity, respect, and real care. 

He said he'd take his elderly mom to the latter every time.

Once practices have put their health technology in place it is time to implement the basic practice systems linked to improved experience of care and improved outcomes.  These improvements are not mutually exclusive though too many practice pursue improvement while allowing patient experience to suffer.*

This is a needless disservice to our patients.

 

*Nutting PA, Crabtree BF, Stewart EE, et al.  Effect of Facilitation on Practice Outcomes in the National Demonstration Project Model of the Patient-Centered Medical Home. Annals of Family Medicine 8:S33-S44 (2010)

Comments

[John WH]

Yes, Gordon. But it takes a bit of education and change to process flow to fully implement HYH. I'm wondering if a version of HYH could be put together that would 1) work like a typical patient satisfaction survey -- brief, on paper and 2) give a snapshot of how a practice is stacking up on outcome-correlated measures, compared to high-functioning IMP practices. For those who look at IMP and say "What's IMP all about, and why should I be interested?", perhaps that would be a way to pointedly and succinctly answer the question -- and initiate a broader movement toward effective quality measurement. What do you think?
John Haresch

[L Gordon Moore]

I agree Robert Watkins. Don't let it happen to your practice. While some payers may mistakenly force us to use unhelpful tools we should assiduously avoid implementing changes that hurt our patients. Plus we should continue to raise our voices to call for better ways.
Gordon

[L Gordon Moore]

Excellent comment John WH.

The solution we used in the Ideal Medical Practices project is www.HowsYourHealth.org Developed by a colleague at Dartmouth (John Wasson) this tool allowed us to simultaneously unmask issues that get between people and their good intentions as well as shine a powerful light on aggregate patient experience of care.
Gordon

[Robert Watkins]

"I spoke to a physician policy-researcher who was evaluating Medical Home implementation. He visited many offices. Some had achieved NCQA PPC-PCMH(tm) Level III recognition but were cold, impersonal, and had problems with how they served their patients (waits and delays, etc). He visited some low tech practice that would receive no recognition from NCQA but found them to be very invested in their patients, knew them well, treated them with dignity, respect, and real care.

He said he'd take his elderly mom to the latter every time."

So true. This is exactly why the emphasis on the administrative and bureaucratic requirements of the PCMH will be so destructive to what is truly valuable in family medicine.

[John WH]

What a good post. I've had a number of experiences in medical practices lately, as a dad. The (brief) interactions with the physicians have basically been fine. But the steps leading up to those interactions have been painful. Long waits with a toddler become intolerable. Often, staff obviously stressed by their own responsibilities don't get how this process affects patients, and couldn't do anything about it if they did.

As I sit and sit, I find myself planning how to avoid future visits. These experiences absolutely interfere with needed care.

And it is clear to me that typical patient satisfaction surveys will not clarify this problem. No one wants to badmouth the provider with whom they had a decent experience.

The kernel of this post needs to be spread to more practices. Perhaps our presentations need to be re-worked to help physicians see how their practices are affecting patients.

Can we develop a survey product that can be easily deployed in interested practices that would actually show how patients are affected and then be correlated with patient outcomes? Could that be a tool to involve more colleagues in improving real care, rather than improving NCQA checklists?