The Art of Balance
Rahul K. Shah, MD George Washington University School of Medicine Children’s National Medical Center, Washington, DC My hospital is making me see more patients and is going to penalize me financially for not achieving a patient satisfaction goal of more than 90 percent where patients rate me as “very good”! —AAO-HNS member The email I received from the Academy member above succinctly juxtaposes the competing demands that clinicians are currently facing: increasing volumes (in the face of declining reimbursement) and improving patient satisfaction. Many AAO-HNS members have implored me to write this month’s column to demonstrate that this dual aim is simply not possible. Since when did a monthly column dedicated to improving safety, quality, and outcomes for our patients start discussing the satisfaction of our patients? As you may have noticed, over the past five years, this column has tried to keep AAO-HNS members abreast of the latest trends in patient safety and quality improvement. We have discussed myriad topics such as zones of risk, pitfalls, strategies to ameliorate problems, reporting systems. Recently, probably in the last 18 months, we have started discussing the issue of patient satisfaction and how payers and others are using this as a pure quality measure and linking reimbursement and even at-risk compensation to ensure our patient’s experiences are the “top box.” The literature certainly supports that an optimized patient experience drives overall quality and is a surrogate for safety within an organization. However, operationalizing this is difficult. For example, I could guarantee that I would run/manage the safest and most efficient operating room in the world. It is easy to do this: I would simply operate on one patient a month. We would ensure that we spent millions of dollars and resources to keep that patient safe. If you ask me to do this for a thousand patients a month, it becomes difficult. Similarly, as the AAO-HNS member writes above, it is becoming difficult for physicians to increase their clinical volumes to achieve Relative Value Unit (RVU) targets while optimizing patient satisfaction. On many levels the paradox becomes apparent—the waiting room is swamped, your staff is exhausted, your phone line pick-up times are extended, etc. Elements Are Not Equal The problem is that external forces are driving hospitals to include the experience of care in their metrics and eventually will tie this to reimbursement. Organizational scorecards have started emphasizing and reporting on patient experience and satisfaction. The end result of such is that these organizational priorities have trickled down to the providers. The stress that organizations are feeling from external agencies is now being transferred to the providers and the competing demands emerge. I am secretly worried that piggybacking patient satisfaction to quality and safety will de facto erode the huge gains the industry has made in improving the overall outcomes of our patients. I have had the pleasure of hearing James Merlino, MD, the chief experience officer of the Cleveland Clinic, speak many times. One of his excellent analogies on these competing demands uses the airline industry as an example. He states that when we fly, our absolute priority is to not crash (safety), we really want to take-off and arrive on time (quality/ efficiency), and if the first two criteria are met, it would be great to have a nice experience (satisfaction). How does this relate to the hospital and how do we prioritize patient safety, quality, and satisfaction? We can use Dr. Merlino’s airline analogy to help us prioritize these demands in our realms of care. I wish I had an easy answer or a crystal ball to assuage our AAO-HNS members’ concerns. What I can guarantee is that for the short-term, there is no solution in sight and I eagerly look toward our exceptionally intelligent, passionate, and motivated membership for innovative solutions to this apparent paradox. We encourage members to write us with any topic of interest and we will try to research and discuss. Members’ names are published only after they have been contacted directly by Academy staff and have given consent. Please email the Academy at qualityimprovement@ entnet.org to engage us in a patient safety and quality discussion pertinent to your practice.
George Washington University School of Medicine
Children’s National Medical Center, Washington, DC
My hospital is making me see more patients and is going to penalize me financially for not achieving a patient satisfaction goal of more than 90 percent where patients rate me as “very good”! —AAO-HNS member
The email I received from the Academy member above succinctly juxtaposes the competing demands that clinicians are currently facing: increasing volumes (in the face of declining reimbursement) and improving patient satisfaction. Many AAO-HNS members have implored me to write this month’s column to demonstrate that this dual aim is simply not possible.
Since when did a monthly column dedicated to improving safety, quality, and outcomes for our patients start discussing the satisfaction of our patients? As you may have noticed, over the past five years, this column has tried to keep AAO-HNS members abreast of the latest trends in patient safety and quality improvement. We have discussed myriad topics such as zones of risk, pitfalls, strategies to ameliorate problems, reporting systems. Recently, probably in the last 18 months, we have started discussing the issue of patient satisfaction and how payers and others are using this as a pure quality measure and linking reimbursement and even at-risk compensation to ensure our patient’s experiences are the “top box.”
The literature certainly supports that an optimized patient experience drives overall quality and is a surrogate for safety within an organization. However, operationalizing this is difficult.
For example, I could guarantee that I would run/manage the safest and most efficient operating room in the world. It is easy to do this: I would simply operate on one patient a month. We would ensure that we spent millions of dollars and resources to keep that patient safe. If you ask me to do this for a thousand patients a month, it becomes difficult. Similarly, as the AAO-HNS member writes above, it is becoming difficult for physicians to increase their clinical volumes to achieve Relative Value Unit (RVU) targets while optimizing patient satisfaction. On many levels the paradox becomes apparent—the waiting room is swamped, your staff is exhausted, your phone line pick-up times are extended, etc.
Elements Are Not Equal
The problem is that external forces are driving hospitals to include the experience of care in their metrics and eventually will tie this to reimbursement. Organizational scorecards have started emphasizing and reporting on patient experience and satisfaction. The end result of such is that these organizational priorities have trickled down to the providers. The stress that organizations are feeling from external agencies is now being transferred to the providers and the competing demands emerge.
I am secretly worried that piggybacking patient satisfaction to quality and safety will de facto erode the huge gains the industry has made in improving the overall outcomes of our patients. I have had the pleasure of hearing James Merlino, MD, the chief experience officer of the Cleveland Clinic, speak many times. One of his excellent analogies on these competing demands uses the airline industry as an example. He states that when we fly, our absolute priority is to not crash (safety), we really want to take-off and arrive on time (quality/ efficiency), and if the first two criteria are met, it would be great to have a nice experience (satisfaction). How does this relate to the hospital and how do we prioritize patient safety, quality, and satisfaction? We can use Dr. Merlino’s airline analogy to help us prioritize these demands in our realms of care.
I wish I had an easy answer or a crystal ball to assuage our AAO-HNS members’ concerns. What I can guarantee is that for the short-term, there is no solution in sight and I eagerly look toward our exceptionally intelligent, passionate, and motivated membership for innovative solutions to this apparent paradox.
We encourage members to write us with any topic of interest and we will try to research and discuss. Members’ names are published only after they have been contacted directly by Academy staff and have given consent. Please email the Academy at qualityimprovement@ entnet.org to engage us in a patient safety and quality discussion pertinent to your practice.
