Ethics

3 legitimate concerns about patient-experience surveys

Patient satisfaction plays a significant role in hospital and clinic operations—from repeat visits and compensation to adherence and quality of care—yet the validity of some survey measurements is open to question.

Organizations may also encounter substantial internal disagreement about how, and even whether, patient surveys should be used. Knowing the nuances of measuring patient satisfaction can help your practice incentivize positive outcomes and avoid unintended consequences.

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Patients’ experience of care is considered to be one element of the quality of care. The AMA Code of Medical Ethics’ Opinion 1.1.6, “Quality,” says that individually and collectively, physicians should actively engage in efforts to improve the quality of health care. Measuring patients’ experience of care, however, can be a challenge.

“As physicians, we want our patients to have not only better outcomes but also a positive experience of care,” gastroenterologist Shivan J. Mehta, MD, MBA, wrote in the AMA Journal of Medical Ethics® (@JournalofEthics). “If we care about the experience of our patients, why shouldn’t we measure it and strive to improve our performance?”

The answer is a complicated one, wrote Dr. Mehta, assistant professor of medicine at the Perelman School of Medicine at the University of Pennsylvania and director of operations at the Penn Medicine Center for Innovation.

On the one hand, patient-experience scores can help physicians think more broadly about outcomes. They can also carry huge financial stakes, such as through the incentives and public disclosures that are Centers for Medicare & Medicaid Services’ efforts to improve quality through value-based purchasing.

But patient-experience measures aren't infallible in their collection or their application. Following are three concerns about surveys for physicians, hospital administrators and policymakers to consider.

Patients may seek low-value treatments 

Physicians often spend less time than they would like with their patients, and can feel  pressure to expedite selection and explanation of treatment plans. When confronted with low patient-satisfaction scores—or even the threat of them—some doctors may assent to requests for low-value or unnecessary treatments that patients have come to expect.

One large study even showed that high patient satisfaction was associated with higher utilization, expenditure and mortality—the very opposite of high value.

Gains could concentrate at the top 

It’s typical for safety-net hospitals to score lower on patient satisfaction than hospitals that provide less care to underserved populations—not surprising given the challenges of caring for sicker populations with fewer resources—so it follows that one-size-fits-all financial incentives could produce even wider disparities in care and satisfaction.

In addition, concerns over penalties for low satisfaction scores could cause physicians to avoid caring for more challenging patients, such as poorer people and persons with mental illness.

Responses can be suspect

Patients’ expectations and perceptions may not lend themselves to technical or objective measures of quality.

Also, voluntary surveys can be long and may not be filled out immediately following consultation or recovery, producing selection and recall biases in those with experiences at the extremes, and limited sample sizes can similarly skew results. There may even be a crowding-out effect of surveys on other, more reliable quality metrics.

“Physicians can no longer choose not to participate in, but they can decide how best to engage with, incentive programs,” Dr. Mehta wrote. “Patient experience scores should also be evaluated in the context of other clinician incentives, whether productivity or quality metrics.”