Problems With Patient Surveys

Hospitals must keep tabs on patient satisfaction, but does quality of care suffer?

Valet parking. Fresh flowers. Custom-order room service. Who doesn’t like a little extra attention and amenities—especially when you’re ailing or on the mend at the hospital?

More and more, health systems are under pressure to improve the patient experience, retain customer loyalty and collect patient payments. After all, an Affordable Care Act policy withholds 1% of total Medicare reimbursements from hospitals. Each year, only hospitals with high patient satisfaction scores and a measure of certain basic care standards will earn that money back. Top performers receive bonus money from the pool.1

So, there’s plenty of incentive for hospitals to measure patient satisfaction and make sure that the hospital’s customers are cared for. But are the activities intended to boost these measurements making a difference in the quality of care, or are they doing more harm than good? Are these sometimes-subjective scores leading hospitals to steer focus away from patient care?

“As physicians, we want our patients to have not only better outcomes, but also a positive experience of care,” gastroenterologist Shivan J. Mehta, MD, wrote in the American Medical Association (AMA) Journal of Medical Ethics. “If we care about the experience of our patients, why shouldn’t we measure it and strive to improve our performance?”2

But patient experience measurements aren’t perfect in their collection or their application. Mehta and the AMA noted three concerns about patient satisfaction surveys:

  • High survey scores may increase disparities. Safety-net hospitals often score lower on patient satisfaction than hospitals giving less care to underserved populations. That means one-size-fits-all financial incentives for experience scores could lead to larger disparities in care and satisfaction. Concerns over penalties for low satisfaction scores also may make physicians avoid caring for poorer patients and patients with mental illness.3
  • Survey responses can be suspect. Patients’ expectations and perceptions may not lend themselves to technical or objective measures of quality. Also, voluntary surveys can be long and may not be filled out immediately following consultation or recovery, producing selection and recall biases in those with experiences at the extremes. Limited sample sizes can similarly skew results. There may be a crowding-out effect of surveys on other, more reliable quality metrics.4
  • Patients may get unneeded treatments. Physicians frequently spend less time than they would like with their patients and may feel pressure to hasten the choice and explanation of treatments. If physicians face low patient satisfaction scores, they may approve requests for low-value or unneeded treatments to fulfill patients’ wants.5

One national study by Joshua Fenton, a University of California, Davis professor, revealed that patients who reported being most satisfied with their doctors had higher healthcare and prescription costs, and were more likely to be hospitalized than patients who were not as satisfied. The most satisfied patients, in fact, were significantly more likely to die in the next four years.6

Fenton wrote that these results could reflect that doctors who are reimbursed according to patient satisfaction scores may be less inclined to talk patients out of treatments they request or to raise concerns about smoking, substance abuse or mental health issues. By attempting to satisfy patients, healthcare providers unintentionally might not be looking out for their best interests.7

What’s needed?

Without feeling obligated to go overboard on lavish amenities, perhaps hospitals need to invest more on improving employee satisfaction, which studies have shown actually leads to high patient satisfaction scores.

One recent study looked at patient satisfaction scores with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys of almost 100,000 nurses. The study suggested that a better nurse work environment was associated with higher scores on every patient satisfaction survey question.8

Linda Aiken, a University of Pennsylvania professor, found that higher staffing of registered nurses has been linked to fewer patient deaths and improved quality of health. In other words, when hospitals improve nurses’ working conditions, rather than convincing patients to believe they’re getting better care, the quality of care gets better.9

Improving employee engagement can boost patient satisfaction and other elements of the patient experience, according to research from the Partnership for Public Service and Boston Consulting Group. The analysis found that improving the employee experience results in increased patient satisfaction, improved call center efficiency and reduced nurse turnover. 10

Administrative burdens can diminish the human connection that’s essential to a positive patient experience. No one is advocating for the complete elimination of that part of hospital work and patient surveys, but perhaps there’s a need to refocus on the partnerships that patients and caregivers must forge together.

“Patients don’t want a medical transaction, they want a personal interaction,” said Kevin Gwin, chief patient experience officer at University of Missouri Health Care in Columbia, MO. “They want a relationship with their physicians and their nurses, and they want to feel connected to their hospital and their doctor’s offices. If I could change one thing, I would make us better at discernment, at gauging: ‘How is this relationship going?’”11

As Shannon Connor Phillips, chief patient safety and experience officer at Intermountain Healthcare in Salt Lake City, says, “You don’t get great quality if you don’t have a partnership with your patients.”12

—compiled by Mark Edmund, associate editor


  1. Alexandra Robbins, “The Problem With Satisfied Patients,” The Atlantic, April 17, 2015, www.theatlantic.com/health/archive/2015/04/the-problem-with-satisfied-patients/390684.
  2. Timothy M. Smith, “3 Legitimate Concerns About Patient-Experience Surveys,” American Medical Association, Dec. 13, 2018, www.ama-assn.org/delivering-care/ethics/3-legitimate-concerns-about-patient-experience-surveys.
  3. Megan Knowles, “The Problem With Patient Surveys,” Becker Hospital Review, Dec. 14, 2018, www.beckershospitalreview.com/patient-engagement/the-problem-with-patient-surveys.html.
  4. Smith, “3 Legitimate Concerns About Patient-Experience Surveys,” see reference 2.
  5. Knowles, “The Problem With Patient Surveys,” see reference 3.
  6. Robbins, “The Problem With Satisfied Patients,” see reference 1.
  7. Ibid.
  8. Ibid.
  9. Ibid.
  10. Mandy Roth, “6 Challenges Patient Experience Leaders Must Overcome,” HealthLeaders Media, June 7, 2018, https://patientengagementhit.com/news/6-challenges-patient-experience-leaders-must-overcome.
  11. Sara Heath, “Employee Engagement Tied to Higher Patient Satisfaction Levels,” Patient Satisfaction News, March 26, 2019, https://patientengagementhit.com/news/employee-engagement-tied-to-higher-patient-satisfaction-levels.
  12. Ibid.


Roth, Mandy, “Are Current Patient Satisfaction Surveys Good Enough?” HealthLeaders Media, July 18, 2018, https://www.healthleadersmedia.com/innovation/are-current-patient-satisfaction-surveys-good-enough


Healthcare Expert Warns Of Workforce Shortfall

A shortfall of 18 million health workers by 2030 will have a devastating effect on the world’s healthcare sector unless swift action is taken, an international think tank warned.

“Overcoming the health worker deficit and looming staffing crisis presents the single biggest challenge for healthcare during the next decade,” said Mark Britnell, the global chairman for healthcare at KPMG, an auditing, tax and business advisory firm.

“The short-term fix of simply addressing headcount is too simple and short-sighted—seismic changes are needed across healthcare to avert this impending disaster,” Britnell said while promoting the book, Solving the Global Workforce Crisis in Healthcare. “If we go about this the right way, I believe we can grow the capacity to care by as much as 20% to meet the anticipated staff shortfall.”

Britnell suggested that reframing the productivity debate, reimagining clinical services, changing national investment strategies, empowering patients and harnessing the power of technology and artificial intelligence will help “avoid the inevitably bleak future we face if we carry on as we are.”

For more information, visit http://tinyurl.com/healthcare-shortage-study.


Honorary Member, New Class Of Fellows Named

The ASQ Board of Directors recently named Marcos E.J. Bertin of Vincente Lopez Buenos Aires, Argentina, as an honorary member. Bertin joins the likes of Walter Shewhart, Joseph M. Juran, W. Edwards Deming and other high-profile quality thought leaders elevated to the highest grade of ASQ membership.

The board also announced the latest class of ASQ fellows. These eight ASQ members join nearly 650 active fellows:

  • Joseph Robert DeSimone—DeSimone Quality International, San Pedro, CA.
  • Sheronda E. Jeffries—Cisco Systems, Research Triangle Park, NC.
  • Willis A. Jensen—W.L. Gore, Flagstaff, AZ.
  • Jamison V. Kovach—University of Houston, TX.
  • Alfred E. Miller—consultant, Wichita, KS.
  • Michael S. SaccucciConsumer Reports, Yonkers, NY.
  • Steven Sibrel—Harman International, Novi, MI.
  • Ben Tomic—Bombardier Aerospace, Toronto, Ontario.

Bertin and the new fellows will be honored at a ceremony prior to ASQ’s World Conference on Quality and Improvement being held May 20-22 in Fort Worth, TX.


World Conference Keynotes Revealed

Technology, disruption and the future of business are topics that are front of mind for five keynote speakers scheduled to appear at this year’s ASQ World Conference on Quality and Improvement. The keynotes are:

  • Cheryl Cran is the founder of NextMapping, a consulting group that helps organizations strategize and navigate the future of work. Cran is also the author of seven books, including The Art of Change Leadership—Driving Transformation in a Fast-Paced World (Wiley, 2015).
  • Charlene Li is the founder of Altimeter Group, a disruptive industry analyst firm, and the author of five books, including the recently released The Disruptor’s Agenda: How to Create a Strategy for Breakthrough Growth (Influential Marketing Group, 2019). Li also has been named one of the Top 50 Leadership Innovators by Inc. magazine and one of the most creative people in business by Fast Company.
  • Benjamin Lavoie is the global head of technology and innovation for Anheuser-Busch InBev, where he is responsible for digital transformation of the global supply organization, which includes making a supply chain consisting of more than 1,000 facilities across 126 countries real-time, connected and continuously optimizing.
  • Patrick Schwerdtfeger is a business futurist specializing in technology trends including big data, artificial intelligence, fintech and blockchain technology. He’s the author of Anarchy, Inc.: Profiting in a Decentralized World with Artificial Intelligence and Blockchain (Authority Publishing, 2018), as well as four other books.
  • Tricia Wang is a global technology ethnographer and co-founder of Sudden Compass, a firm that helps organizations use data to make better decisions about customers. She is considered by many as an authority on digital transformation, operationalizing data science, customer experience and ethics of personal data use in artificial intelligence.

Board of directors vote

Results of three contested offices on ASQ’s 2020 board of directors will be announced at the conference. This year, multiple candidates vied for three positions: chair-elect, treasurer and director at large. Deadlines prevented QP from publishing these election results in the May print edition. Check asq.org/about-asq/leadership in late May for the results, or read July’s edition of QP.

The conference itself takes place May 20-22 in Fort Worth, TX. For more information, visit asq.org/conferences/wcqi.

New @ ASQ

Thirty-three young quality professionals—representing nine industries, 22 organizations, and 17 states and two countries—have completed ASQ’s 2018-2019 Emerging Quality Leaders program. The group is being recognized at ASQ’s World Conference on Quality and Improvement in Fort Worth, TX, in May. For more program details, visit asq.org/emerging-quality-leaders.

Guidance on interpreting management system standard requirements is the subject of a recent ASQ webcast. In the 52-minute recording, author and standards expert Milt Dentch provides guidance on understanding the requirements of the new quality, environmental, and occupational health and safety management systems standards. He also gives advice to organizations on how to review interpretation issues with auditors. To access the webcast, visit asq.org/2019/03/standards/guidance-on-interpreting-man agement-system-standard-requirements-webcast.html.

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To get a roundup of the week’s most noteworthy stories delivered to your inbox every Friday, subscribe to the QNT Weekly e-newsletter at asq.org/newsletters.

Getting to Know…

Gerald A. Johnson

Current position: Air Force Metrology and Calibration Program Evaluation team member.

Education: Associate’s degree in electronics system technology from the Community College of the Air Force.

What was your introduction to quality? My introduction to quality was a job as a quality assurance evaluator at Holloman Air Force Base in New Mexico. It was there I learned the basics of quality assurance and how to operate a quality assurance program. The training I received there was instrumental in my development as a quality technician and later as a quality program manager and Air Force quality assurance evaluator.

Is there a teacher who influenced you more than others? My high school computer studies teacher was my most influential teacher. The fact that this teacher is also my father makes him an easy choice. My father benefited from the Troops to Teachers program and completed his student teaching at my high school in Okinawa, Japan, while he was still on active duty. He is the reason I decided to join the Air Force and pursue a technology-related field of study.

Do you have a mentor who made a difference in your career? I have had many mentors throughout my career. The mentor with the biggest impact has been my father. He inspired me to join the military and has encouraged me every step of the way.

What’s the best career advice you’ve ever received? “Always be ready and willing to take advantage of the opportunities presented to you.” The basis of this advice was that you never know when opportunity is going to present itself. So, the best you can do is be ready (emotionally, physically and mentally) and willing (open minded) to pursue the opportunity.

What noteworthy activities or achievements outside of ASQ do you participate in?  While I was stationed in Okinawa, Japan, I had the opportunity to implement the Green Dot sexual assault prevention program. I led a team of 20 implementers that trained 8,500 personnel in six months. It was a Goliath undertaking, but such a rewarding experience to see our strategic plan end in success.

Recent awards or honors? ASQ Columbus Division’s Quality Technician of the Year, International Quality Technician of the Year and ASQ’s Inspection Division’s Inspector of the Year.

Personal: My wife Silvia, and two daughters, 8 and 4.

What are your favorite ways to relax? I am a huge audiophile, so listening to music is my favorite pastime. I also enjoy reading.

What was the last movie you saw? “The Incredibles.”

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