Getting to 'Always' on Satisfaction

As providers and hospitals adjust to the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) survey instrument, several questions have arisen about the CAHPS response categories. The HCAHPS survey asks patients to evaluate how often a specific event occurred during their stay in the hospital. The responses range from “never” to “always,” with the Centers for Medicare and Medicaid Services (CMS) regarding “always” as the optimum answer. Many providers have wondered if satisfaction scales, such as Press Ganey’s, can predict how often a patient would say something happened “all the time.” After all, the CMS questions are more about the patient’s perception of the frequency of events than his or her satisfaction with events. The pivotal question is: How do we get someone to say that something happened “always?” The answer is relatively simple: How often you think something happened is a part of how satisfied you are with it when it happens.

So what is the connection to Press Ganey’s satisfaction scale? How can “very good” predict “always?” It is a matter of cognitive function. The connection of “very good” to “always” lies in the psychology of how humans judge frequency of occurrence. The ability of ratings questions (Press Ganey) to predict occurrence (CAHPS) lies in the ability of patients to reflect on what they thought was exceptional about their service. Simply put, satisfaction provides respondents with a point of reference for evaluating frequency of occurrence (see Susie Linder-Pelz’s “Toward a Theory of Patient Satisfaction” in Social Science and Medicine, Vol. 16). Our perception of how often staff responded promptly to the call button is a “piece” of our satisfaction with promptness in responding to the call button. Satisfied patients are more likely to say that staff “always” responded to the call button in a timely fashion. Other disciplines use this same type of cognitive connection. For example, our judgment of satisfaction with political figures is tied to how often we feel they voted for policies we like. In short, if we like something when it happens, we will report that it happened often.

Furthermore, there is a distinct lineage of research on the effect of happiness on our perception of time (see “Time Estimation and Orientation Mediated by Transient Mood,” a 1992 article by Jacob Hornik in The Journal of Socio-Economics). A person’s perception of how often something occurred and our perception of time passing are related to our contentedness during that time. This effect is amplified when the amount of time is subjective, like asking if something happened always versus sometimes. We have all heard the expression “time flies when you are having fun.” The same simple adage can be applied to patients in a hospital setting. If a patient is happy with services, they will report that the service happened all the time. However, keep in mind that humans are fickle creatures. Patients can be satisfied with a service nine out of 10 times, but, if on the 10th time they are dissatisfied, they will likely say that a particular service did not always occur.

In short, keeping patients satisfied is the most effective way to get them to say that a particular aspect of their care happened “always.