Patient Satisfaction: Can Academic Medical Centers Compete?

Otolaryngologists practicing in academic medical centers score lower than those practicing in a community setting on a number of key patient satisfaction measures, especially in categories that involve access and convenience, such as “promptness in returning phone calls” and “time spent waiting before going to an exam room,” according to an analysis of Press Ganey Medical Practice surveys completed by otolaryngology patients and published earlier this year (Laryngoscope. 2012;122(10):2304-2310).

Despite this gap, academic otolaryngologists rated higher than those in community practice on questions relating to loyalty, such as confidence in the care provider and willingness to recommend the practice or care provider to others.

This study, the first to broadly quantify and assess patient satisfaction scores in the otolaryngology outpatient setting, as well as the first to explore the impact of the teaching setting on patient satisfaction with otolaryngology, has a clear message for otolaryngologists regardless of practice setting: “Physician behaviors were those most likely to correlate with whether or not a person decides to come back to a practice,” said Emily Boss, MD, MPH, the study’s lead author and an assistant professor of otolaryngology-head and neck surgery at Johns Hopkins University School of Medicine in Baltimore.

Small Differences May Be Significant

The Press Ganey survey analyzed 29 Likert-scaled questions grouped into six service domains—access to care, moving through the visit, nursing, care provider, personal issues and overall assessment. On many questions within each of the six domains, the difference in mean Press Ganey scores between the community setting and the academic medical setting did not rise to the level of statistical significance.

And, even in those areas where there was a significant difference, both types of providers scored fairly high. One example is “ease of scheduling appointment,” in which non-teaching otolaryngologists scored 89.1 and teaching otolaryngologists scored 90.2. “That’s like saying, ‘Statistically speaking, Michael Phelps swims faster than Ryan Lochte,’” said C.W. David Chang, MD, assistant professor of clinical otolaryngology at the University of Missouri School of Medicine in Columbia. “The difference is miniscule.”

Dr. Boss sees the statistics differently. “Actually, this small difference is much more significant than it may seem,” she said. Scores received on a satisfaction survey are right-skewed and typically have a very small range for each question, she added. The majority of patients give physicians or practices scores of 4 (“good”) or 5 (“very good”/“great”). The individual survey scores, typically ranging from 75 to 100, are averaged and then benchmarked against all other otolaryngology practices, so that each practice receives a national percentile rank of 1 to 100. Depending on the question, a difference of approximately 0.7 in mean score may mean a difference of more than 10 percentiles nationally, she said, and added that small differences perceived in the mean score are actually quite significant.

“Practices need to strive to obtain scores of all 5s to differentiate themselves from being good to being great. It is this differentiation that makes patients return despite other inconveniences,” she said. “Moreover, many hospital incentive plans reward physicians based on their overall percentile and not their mean score.”

The ‘Halo Effect’

Why are academic otolaryngology practices inspiring more patient loyalty even as otolaryngologists in community practice do better on scores relating to access and service? To some degree, it’s probably a “halo effect” from the academic setting, said Brian Nussenbaum, MD, the Christy J. and Richard S. Hawes III Professor and vice chairman for clinical affairs in the department of otolaryngology at Washington University School of Medicine in St. Louis. “People who come to academic medical centers may view their doctors a little differently because they’re at the place that’s No. 5 or No. 8 on the U.S. News & World Report top hospitals list,” he said. “And more patients at an academic center have conditions that require tertiary care, so they have been referred there by a community provider in the first place.”

Meanwhile, customer service has been much more historically part of the business model for community physicians than in academic centers. “While, on an individual basis, I think most physicians pride themselves on [having] concern for their patients no matter where they practice, in large academic medical centers there may be a substantial administrative hierarchy that can sometimes can be divorced from the patient,” said Myles Pensak, MD, the H.B. Broidy Professor and chair of otolaryngology at the University of Cincinnati. “Physicians with an ownership in their practice are much more attuned to inherent patient dissatisfiers like cancellation rates, bump rates and office delays, which are much more common in larger systems.”

Dr. Nussenbaum said that the patient satisfaction scores in his practice are very similar to what the Laryngoscope study found. “Where we have problems are in areas that the individual practitioner has little control over: ease of parking, were you able to find your way to the office beforehand and so on. Some of these things we can work to control as physicians, such as staff attitudes, but others are facility issues we can’t do much about.”

His department focuses attention on the survey metrics that are specific to patient care and that the doctor has control over: caring and respect, ability to communicate, explanation of tests and procedures, how well the patient’s concerns were addressed and willingness to return and recommend.

“We compile each practitioner’s ‘excellent’ rating in each of those domains and come up with an average score,” Dr. Nussenbaum said. There’s a pretty broad spread of ratings in the department: The provider with the lowest percentage of “excellent” ratings scored 50 percent, and the doctor with the highest percentage got an 89 percent rating.

“Interestingly, though, even those physicians with a low score on things like ‘effort to include patient in decision-making’ and ‘explanation of tests’ still had nine out of 10 patients say that they would recommend them or come back,” said Dr. Nussenbaum. “There’s a lot that we still need to figure out about these scores. What are the key domains that make people happy and willing to come back? That’s not clear yet.”

Accountability

Hospitals can’t afford to wait to fine-tune understanding of these measures before paying more attention to patient satisfaction. Dr. Nussenbaum’s institution has recently hired a “director of the patient experience.” His department just this year began to incorporate patient satisfaction scores into all faculty members’ individual reviews. “We’ve been reviewing these scores on a leadership level for about three or four years now, but this is the first year they’ve been incorporated into the annual faculty review,” he said.

“Increasingly, major medical centers are becoming attuned to these service expectations,” said Dr. Pensak. “Community-oriented practitioners have set a benchmark that academic centers should aspire to in terms of providing service excellence.”

An academic physician can’t move the parking lot closer to the office, but he or she can demand that the staff—nurses, paraprofessionals and administrators—show respect for a patient’s time and needs. “Physicians need to find a way to be involved with the administrative aspects of their practice and understand how these processes work in order to improve them,” said Dr. Chang.

“Hold your staff accountable and demand that they hold you accountable as well,” advised Dr. Pensak. “While an individual physician in a large medical center rarely has the power to influence on a grand scale, there’s no doubt in my mind that holding a system and its leaders accountable for driving optimal quality care is something that all doctors should do.”

Tips to Improve Patient Satisfaction

As the physician, you’re the leader in your practice when it comes to providing quality care, said Dr. Boss. She advises physicians to engage employees they work with in ways that help to meet patient service expectations and to influence the overall attitude of care in their practices.

“Respect your patients, allow them input and include them in developing their plan of care,” she said. “People think that including the patient and performing some of these formalities may take a lot of time, but it doesn’t. It’s simple—just be fully present with your patient.” She recommends several additional ways to improve patient satisfaction:

• Knock before entering the room;
• Ask what name your patient would like to be called;
• Sit down and look her in the eye;
• Lean forward, look up and stop writing or typing;
• Allow the patient to speak without interruption for a minute or two;
• Ask the patient’s permission to examine her, explain what you’re doing as you’re doing it and relay your findings as you go; and
• Repeat the plan of care at the end of the visit, then ask the patient if there are any questions you can answer.

These behaviors, which can be exhibited by any physician in any setting, said Dr. Boss, can improve the way you communicate with your patients and influence their overall experience. —GS