Raising the Standard: How Patient Satisfaction Drive Patient Safety

| September 1, 2020

by Anthony T. Petrick, MD, FACS, FASMBS, and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Petrick is Quality Director, Geisinger Surgical Institute; Director of Bariatric and Foregut Surgery, Geisinger Health System, Danville, Pennsylvania. Dr. Gadaleta is Chair, Department of Surgery, Southside Hospital; Director, Metabolic and Bariatric Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York; Associate Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2020;17(9):18

“Quality…is not what you put into it. It is what the (patient) gets out of it.”
-Peter Drucker

Peter Drucker was an author and educator known as the father of management thinking. The healthcare adaptation of his philosophy aligns well with our current focus on patient-reported outcomes. While most providers acknowledge that patient satisfaction is important, the link between patient satisfaction and clinical outcomes has been less certain. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationwide standardized survey for measuring patients’ perceptions of their hospital experience. Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) must collect and submit HCAHPS data to receive their full IPPS annual payment update. Failure to submit HCAHPS data results in reduced annual payment.

HCAHPS is designed to produce data about patients’ perspectives of care that allow objective and meaningful comparisons of hospitals. Also, public reporting of the survey results creates new incentives for hospitals to improve quality of care and to enhance accountability in healthcare by increasing transparency of the quality of hospital care provided.

The Patient Protection and Affordable Care Act of 2010 included HCAHPS among the measures to be used to calculate value-based incentive payments in the Hospital Value-Based Purchasing (VBP) program, beginning with discharges in October 2012. In 2013, the VBP program put at risk one percent of total Medicare payments, a number that rose to two percent by 2017; thus, poor performance on patient satisfaction metrics might represent a substantial financial risk for hospitals. The Centers for Medicare & Medicaid Services (CMS) publishes participating hospitals’ HCAHPS results on the Hospital Compare website (www.hospitalcompare.hhs.gov) four times a year.1

Critics argue that HCAHPS reflects nonclinical “concierge” services rather than quality of care. This concern is particularly important in surgical care, where the technical skill of the surgeon—not captured by surveys of patient experience—profoundly impacts procedural clinical outcomes.2 Few studies have analyzed the relationship between patient experience and surgical quality.

In 2015, Tsai et al3 examined this relationship in six major surgical procedures. The group used Medicare inpatient claims data from the American Hospital Association (AHA) annual survey on hospital characteristics, Hospital Compare data of surgical quality measures as well as the HCAHPS survey.

The relationship between patient experience and efficiency utilized length of stay as an outcome. They found that higher patient satisfaction was related to shorter lengths of stay (LOS) following major surgery. Hospitals in the highest quartile of performance on patient satisfaction had LOS that was 0.6 days shorter than those with the lowest patient satisfaction (7.1 days vs. 7.7 days, p<0.001).3

The relationship between patient experience and quality was determined by measuring surgical process, mortality, and readmissions. In the hospitals with higher patient satisfaction, the group found higher Surgical Care Improvement Project (SCIP) process scores (96.5 vs. 95.5, p<0.001), lower readmission rates (12.3% vs. 13.6%, p<0.001) and the lowest 30-day mortality rates (3.1% vs. 3.6%, p<0.001) compared to hospitals in the lowest quartile of patient satisfaction scores.3

Tsai et al’s group also built a composite z-score of surgical quality to assess if hospitals that performed well on patient experience would also perform well on all measures of surgical quality together. The z-score allowed for comparisons across different units of measurement, with a lower z-score representing better quality. They found no tradeoffs between patient experience and surgical quality. Hospitals with the highest patient satisfaction scores had the highest composite surgical quality (−0.145 vs. −0.010, p<0.001).3

While there are no studies in patients who undergo bariatric surgery that have specifically examined this relationship, the Employing enhanced Recovery Goals in Bariatric Surgery (ENERGY) study did collect HCAPS data from participating centers. Adherence to the ENERGY protocol was associated with significantly fewer patients with extended LOS (pre- 8.1% vs. postintervention 4.5%; p=0.01). The reduction in extended LOS was achieved without increasing readmission rates, reoperation rates, or overall morbidity.4 The ENERGY project did collect HCAHPS data, which showed that improved HCAHPS scores were associated with better adherence to protocol measures.5

The HCAHPS survey itself might be limited by selection bias in the patients who choose to respond to the survey with variations in response rates across hospitals. Additionally, racial differences in perceptions of care might also influence a hospital’s overall patient satisfaction rating.6,7 The underlying mechanisms defining the relationship between patient experience and both quality and efficiency of care have yet to be identified. However, current  financial incentives to improve patient satisfaction do seem well aligned with both more efficient and higher quality care.


Category: Past Articles, Raising the Standard

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