For years, a dedicated cadre of health care workers has fretted about the importance of measuring and improving patients’ experiences in hospitals and other health care settings, but their concerns were often trumped by other priorities. Now that the Centers for Medicare and Medicaid Services (CMS) has begun judging hospitals on the quality of their patient care and patient experience – and penalizing those with subpar performance – hospitals are paying far more attention to their patients’ satisfaction. Lisa Allen, chief patient experience officer at Johns Hopkins Medicine, who will be speaking at the upcoming U.S. News Hospital of Tomorrow Conference, spoke with U.S. News about how the heightened push for satisfied patients is transforming health care. (The interview has been edited for length and clarity.)
Where do we stand with regard to patient satisfaction?
I think the intensity of interest is now at a much higher, more senior level – at the board [of directors’] level – because of the attention that the CMS has put on patient experience as one of the metrics they use [to measure] hospital performance.
What is the penalty for a poor patient-experience score? How much can it cost a hospital?
In Maryland we have something called quality-based reimbursement. It’s pretty closely aligned to [CMS’ approach, known as] value-based purchasing. We have 2 percent of our revenue at risk for quality-based reimbursement, of which, this year, 45 percent [of that amount] … is based on patient experience.
That’s right. That’s a lot of money. And then of course there’s the loyalty factor, the word-of-mouth factor – those are all things that are harder to measure. At Hopkins, like at other large academic medical centers, there’s a lot of revenue from international who don’t complete [the government surveys]. Making sure that we treat those patients in a caring compassionate way is important for business – and their satisfaction is not as easily measured.
And they’re patients who are often paying the full cost of their care, not discounted fees negotiated by insurers?
What does it mean that the board of directors is now involved?
When it used to be a just small group of passionate people focused on [patient satisfaction], we couldn’t get the resources, the attention or the platform we needed to help everybody understand we all play a role in how patients experience care. Now it’s talked about all the time, not just in Johns Hopkins Hospital, but in the majority of health care organizations where I have colleagues. This is on the strategic plan and on the board’s agenda every quarter. This is talked about at quality, safety and patient experience [meetings]. It’s really not seen as, “Let’s teach people how to smile nice,” those fluffy things, it’s now seen as part of what we do. … People truly understand that you can’t just cure a disease. You have to create a healing environment. If you don’t feel cared for as a patient, it’s a patient harm.
What surveys do you use?
We use different versions of the [Agency for Healthcare Quality and Performance’s] CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey. We do lots of measurement. We also use patient letters, patient comments to advisory committees – if we have grievances we learn from grievances – and we learn from observation. How you hear the voice of the patient has to be many-faceted. We know that nationally [there’s] about a 30 percent response rate to surveys, and it’s biased toward the more highly educated. That’s a national problem. We need to think about how we hear the voice of all of our patients.
Johns Hopkins is a huge place. How do you ensure a consistent patient experience across all of the hospital’s units and services?
Part of it is by declaring shared goals, and that really starts at the top with the board and the strategic plan. It involves creating a common language. We have communications styles that we teach people. We have an approach to teaching caring communications. It’s also holding people accountable and building [these capabilities] into our hiring practices, performance reviews and coaching. We have coaches now that work with teams. Still, I can’t say we’re 100 percent there. It’s so complicated, there are so many people involved. … It’s really a journey.
How do different personality types play into this?
In every field, I see real champions and fantastic communicators. In every field, I’ve also seen people who need some help. … Some people are incredibly brilliant but just are not great communicators in stressful situations.
How does being an anthropologist inform your role in evaluating patient experience for a hospital?
So much of what we bring [involves] expectations: You have health care providers’ expectations about how they’re going to treat people and you have patients’ expectations of what’s going to happen to them. So much of what happens in this very stressful interaction is based on expectations and culture. For me, as an anthropologist, it’s fascinating. I started my career in New England. I remember a migrant population moving into the area. New England’s health care establishment [found itself] trying to figure out how to work with these patients. Now we have such a multicultural workforce and multicultural patients. A lot of what we see in [the world of] patient experience is around cultural clashes. … You have different expressions of pain, different expressions of sorrow and different support systems – and a lot of these things come into play … because you’re bringing people in at a time when they’re really the most stressed out.
How can you tell when you do everything right?
That information comes to us from many different sources: the engagement of the workforce, satisfaction in the work they do. From the patient, it’s expressions of gratitude and feeling as if they’re partners in their care. Some of the most touching letters that I’ve read over the years involved someone who passed away in a hospital setting, but, because of the way that the family was treated – the way that the patient was being treated as they were dying. That caring, that compassion, that sense of family is something people never forget.
What kind of accountability is there when there’s a problem on a unit?
We know – we know this nationally – that we see more satisfied patients if they have elective surgery or obstetrical procedures. If you’re coming in for a planned surgery, you’ve got your life in order, someone is taking care of the dog, your mail has been stopped, your loved one has taken time off for work – everything is planned. In medicine, people are not as happy. They [may] come in through emergency department, they often have chronic conditions, their lives aren’t settled at home. We do a lot to try to alleviate that for those patients, but we do … see lower scores. We know that going in. It would be unfair to say to medicine, “You’re not doing as well as the OB floor,” because it’s much a different experience.
How do you deal with those issues?
We have champions on the units. We engage vocal, front-line managers in this journey. It’s having and keeping their engagement every day. I don’t see this as a one-time intervention. I think that’s where a lot of things fail: “Let’s throw these best practices against a wall and see what sticks.” You really have to build it into the culture and the way we do the work.