Press Ganey Data: Carrot or Stick?

I spent a lot of years working in hospitals, starting as a burn technician, becoming a registered nurse in intensive-care units and surgical services and ending up as a vice president for perioperative and emergency services. Being able to view health care from the bedside to the C-suite has been a wonderful experience and has given me perspective I would not have had working only as a clinician or an executive. Having now served as a consultant to many different hospitals, I have also seen the good, the bad and the ugly when it comes to how Press Ganey patient, physician and employee satisfaction data are used.

It will likely date me, but I remember a time when as a nurse I could pick and choose which of my patients received a comment card. While that was a way to make sure my evaluations were always good, it wasn’t a very consistent or meaningful gauge of how well my teams were meeting patients’ expectations or what we needed to do to get better. When we began to survey in a more consistent and objective manner, we began to see real opportunities to make the care we delivered better and, just as important, to make sure that our patients perceived it as better. We found that our patients were very perceptive and had very distinct expectations about the way they were cared for, listened to, talked with and participated in their overall health care experience. It was a Eureka! moment.

The government got involved when it was apparent that there was something to measuring patient satisfaction and that there was a real correlation between satisfaction and quality of care and safety. Then, we figured out that if we align everyone’s incentives around patient satisfaction, our scores could also get better. Now that there is real reimbursement tied to these scores, it makes it even more important to pay attention and improve them.

I have seen hospitals try desperately to improve their scores without really knowing what to do. These hospitals think that if they tie compensation in some way to scores, the scores will go up. In the short term, they might. The problem is that this modest, short-term increase comes at a cost, and I don’t mean bonuses. I had a physician once tell me that “the system” didn’t care how well he took care of patients as long as they were happy. Another colleague told me that his hospital had received notoriety for having “the happiest dead patients in town” after patient satisfaction and mortality rose at the same time. Needless to say, this is not and should never be anyone’s goal. So, how do we use this information as a means to an end (quality improvement and revenue) instead of as a hammer that our providers are afraid is about to hit them over the head?

We have to remember that it is not usually the people who create the problems we have in our systems. It is the processes the people are using. Therefore, simply tying money to the score won’t work. Taking a step back when we see lower scores to determine the underlying problems, rather than who the problem might be, is the first step. For example, if there are long ED waiting times, and ED satisfaction scores are tanking, this may actually have nothing to do with the department itself. Tying compensation to the emergency physicians and staff in an effort to improve those scores will have only modest effect and may result in increasing frustration for the staff and physicians and continued lower ED scores.

Instead, visionary leaders will look at the underlying cause for the long waits and realize that the real issue lies in the ED’s inability to move patients into inpatient beds. In order to improve patient satisfaction and sustain that improvement in this example, the processes by which patients move through the ED and to inpatient beds must be addressed and improved. Only then will the scores show sustainable improvement.

The patient satisfaction survey provides critical information regarding processes, flow and perception. Information in the ED survey about arrivals, waiting time to treatment areas and waiting times to see the physician are all indicators of organizational flow and operations (not just in the ED). On the inpatient side, speed of admission and speed of discharge along with waiting times for tests and treatment will also serve as good indicators of process, flow and operations pointing the visionary leader to sustainable improvement opportunities. It is in addressing these operational issues along with the service issues that will provide the kind of long-term success we all look for, not the short-term impact we find when we simply tie money to a score.

 As Donald Berwick has said:

“Every system is perfectly designed to achieve exactly the results it gets and if we want a new level of performance, we must get a new system.”

Read Christina Dempsey’s full bio.