Of Unasked Questions and HCAHPS Scores

My mother is a no-nonsense German immigrant who lived through the Second World War and does not generally take any guff from “any-von.” My father is a rugged blue-collar small business owner who grew up just north of Detroit, the kind of guy who always has dirt under his nails. People like my parents have a penchant for strong opinions and a flair for sharing them with just about anyone who will listen. Rarely have I seen my folks miss an opportunity to question someone when they don’t understand something.

Late last year my father was diagnosed with esophageal cancer. A pre-existing heart condition has complicated his treatment and recently led to a lengthy hospital stay. During the last hospitalization my parents saw a veritable parade of specialists, hospitalists, RNs, NPs, techs and other care providers. I was present to witness some of these exchanges and watched the messages being delivered (this hospital had clearly scripted around HCAHPS).

Each time a procedure was explained, I waited for the flurry of questions that was going to come from my mother or father. It never happened. They both sat patiently and listened, never asking more than a couple of cursory questions. It was the first time in my life that I had ever seen them at a loss for words. For some time I wondered why this was the case. Why would they not press the doctor about what was going to happen next? That is what they taught me to do. Then one conversation changed my perspective and shed light on their unexpected silence.

After leaving my father to rest for the evening, my mother began our drive home with the following: (in her thick German accent): “Sometimes I wish someone would just tell me what is going on so that I understand.”

“Mom, you just have to ask.”

“I don’t know what to ask.” The frustration in her voice was palpable. “I wish the doctors would just stop for a second and ask us if we understand, but I guess I just have to trust them. Also, I don’t want to ask so many questions that they get mad.” At this point it dawned on me.

My parents, who are in their late 60s, are part of a generation of Americans who were taught to keep quiet and listen to the doctor. My parents were never going to ask all the “right questions” because that is not what they were taught to do. This is a classic cohort effect. When my parents were growing up they were admonished not to make waves in the hospital because medical care was not as patient-centered as it is today. In the late 40s and early 50s the hospital was a place where you kept your head down and did what the doctor ordered. The paradigm has shifted in the last 60 years, but not fully for people in my parent’s age group. Sure, my parents read blogs and pay attention to online reviews of doctors and hospitals, but “in the moment” when the doctor or nurse is standing there, they revert back to what they were taught. This is a very natural human response to stress.

Providers would do well not to confuse my parents’ silence with satisfaction. Patients like my parents have lots of comments, questions and concerns (I hear about them). They are just not as overt as Generation Xers, Yers or Millennials. Remember also, that sexagenarians read enough about hospital care in the last 15 years to know they should be asked about their opinions. Silence does not mean that a patient does not expect explanations of what is happening or maybe even expect a prompt about whether or not he has questions. It was clear after the doctors and nurses left my father’s room that my parents wanted to be asked if they had any thoughts or questions.

I could see the HCAHPS scores slowly ticking downward.

My parent’s experience is an artifact of American culture that is important to remember, because they are largest single group of Americans who will respond to HCAHPS surveys over the next decade. Even though the hospital had taken great care to script around HCAHPS, I can guarantee my father will not mark “always” for the HCAHPS question asking how often “things were explained in a language he understood.” For my parents, it’s not about how many times something happens; it’s about the quality of the information they received.

"You look like you may have some questions. Are you sure you understand what is going to happen now? Are you sure there is nothing else I can answer for you?”

Taking 30 seconds to ask simple questions like these would have fundamentally changed my parents’ experience for the better and improved their rating of the facility. You don’t need to read their minds to understand the need for such an inquiry.

That evening after our conversation in the car, my mother and I were sitting in the living room when the phone rang: “Yes, yes. Oh, my son will want to hear this,” my mother told the caller. “Kris, you will never believe this. It’s Press Ganey on the phone and they want your father to take a survey.”