Clinician Reviews. 2017 January;27(1):13-14

Author(s): Marie-Eileen Onieal, PhD, CPNP, FAANP

In our December 2016 issue, we reported the results of our first annual survey on nonmonetary compensation (ie, the “perks”) and overall employment satisfaction (Clinician Reviews. 2016;26[12]:23-26). But the feedback I found most interesting came from the narrative responses—particularly those referencing patient satisfaction and the stress it creates for NPs and PAs.

Safety, quality, and affordability have been touted as today’s health care priorities. But it is unclear whether the majority of health care consumers agree with them. Patients may express understanding or accord initially, but when the discussion turns to what is appropriate as opposed to what is desired, conflict may arise.

Judging by the verbatim responses to our survey, NPs and PAs are concerned that quality measures don’t reflect the demands of our practice or focus on what matters to our patients.

One participant analogized, “Medicine is now like McDonalds or Burger King—patients want it their way, regardless of whether it’s in their best interest. I was fee-for-service for more than 10 years. As reimbursements have decreased significantly over time, I’m now employed by a hospital. I have become a waitress, considering my patients’ wishes—not for the benefit of their health, but to meet their more trivial ‘needs.’ These requirements can be as absurd as a specific brand of sweetener! If patients’ preferred sugar substitutes aren’t offered at my hospital, their ‘satisfaction’ may drop and I won’t get reimbursed as much. It’s a miserable experience.”

Perhaps the disparate views of what matters—Is it the softness of the pillows, or is it measurable improvement in the patient’s condition?—is the origin of the stress expressed by clinicians. This dissonance, in my opinion, exists among all involved—providers, patients, and payers. Today, patients see themselves as buyers of health services, and health care corporations have begun to function as a service industry. It may also explain why the concept of patient satisfaction has seemingly morphed into customer service, frustrating many of our colleagues.

Because it can affect clinical outcomes, patient retention, and medical malpractice claims, patient satisfaction is commonly used as a proxy for the success of doctors and hospitals.1 We know there is a correlation between higher patient satisfaction rates and improved outcomes—and conversely, research has demonstrated that unmet expectations significantly decrease satisfaction.2

However, there has been no explicit definition of patient satisfaction, nor systematic consideration of its determinants and consequences.3 As a result, measurement of “satisfaction” and its use as an indicator of quality of care remains controversial among health care providers. It can be a difficult concept to embrace.

Even setting aside the question of “amenities” and focusing on actual clinical care, satisfaction has different meanings for different people. For some, it is a positive, immediate improvement in the patient’s condition (recall my comments on pain management in my previous editorial).4 While that might be an unrealistic expectation, it is a factor in whether the patient and/or family express satisfaction with the care provided.

These high (if not unreasonable) expectations are fueled by the availability of information via the Internet. Patient attitudes and perceptions prior to receiving care also play a role. Instead of correlating with high-quality, appropriate, affordable care, a patient’s satisfaction might instead be based on the fulfillment of his or her predetermined ideas as to what treatment is needed!

The impetus for this change in perspective was the development of the patient-centered care model, which has patient satisfaction at its core.5 The model is intended to make patients partners in their health care; instead of depending solely on provider tools or standards, patients and providers discuss the options and preferences and develop a plan of care together. We all know that the relationship between patients and their providers greatly affects both treatment outcomes and patient satisfaction. But implementing a patient-centered care model means understanding and accepting from the start that patients will be asked to rate or judge their health care. It is therefore essential that there is agreement as to the standards that constitute “quality care” and congruence between these beliefs and the satisfaction ratings. You need to know what your patient expects to determine your likelihood of delivering it.

The patient-provider relationship has been a focus of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospital Survey, which, since 2006, has measured patients’ perceptions of their hospital experiences.6 The CAHPS Clinician and Group Survey, initiated in 2011, is a standardized tool to measure patients’ perceptions of care in an office setting.7 Data from both surveys are used to improve performance and productivity in these settings. But while the information about quality of care has enabled consumers to make more informed decisions, the data are in many ways limited and subjective.

What cannot be measured by either survey alone is the health of patients, employees, and the community. This limitation is reflected in the feedback to our survey, which suggests a preponderance of NP and PA dissatisfaction with the current methods of evaluating the health care system. How much strain is incurred when evaluative measures fail to demonstrate that high-quality, safe, affordable care is being provided? That is difficult to ascertain, but it does give one pause. We know that providers who experience professional satisfaction have higher overall patient satisfaction scores.8 If we’re frustrated, are we able to provide the highest quality care? If not, our scores will suffer. If our scores drop … around we go again.

Currently, most data collection methods focus on physicians, making NPs and PAs “invisible” providers. That certainly won’t help our satisfaction! Only when the data gleaned from these measurement tools include all ambulatory settings, and all providers are recognized as valued contributors to patient health and satisfaction, will we have the information we need to improve satisfaction levels. That will benefit not only our patients, but also ourselves.

Please share your thoughts on patient satisfaction and “customer service” by emailing [email protected].

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1. Prakash B. Patient satisfaction. J Cutan Aesthet Surg. 2010; 3(3):151-155.
2. Jackson JL,Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med. 2001;52(4):609-620.
3. Linder-Pelz SU. Toward a theory of patient satisfaction. Soc Sci Med. 1982;16(5):577-582.
4. Onieal ME. The paradox of pain management. Clinician Reviews. 2016;26(11):12,16.
5. Rickert J. Measuring patient satisfaction: a bridge between patient and physician perceptions of care. Accessed December 1, 2016.
6. Centers for Medicare & Medicaid Services. Hospital Consumer Assessment of Healthcare Providers and Systems CAHPS® Hospital Survey. Accessed December 1, 2016.
7. Agency for Healthcare Research and Quality. Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey. Accessed December 1, 2016.
8. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15(2):122-128.