Patient-centered care seems intuitive. However, it initiates many changes, involving a broad array of business units. As healthcare providers, we need to rethink the processes of being a patient, a caregiver or an employee. And we need to revisit some of the practices we have long ignored, such as patient waiting time, number of visits to treat one disease and many others directly related to non-medical issues.
Recently, I viewed a presentation by Stephen Hopkins, director of innovation at Dimensional Innovations given at NeoCon, a leading design convention that takes place in Chicago. The presentation, titled "11 Ideas to Transform the Healthcare Experience," encouraged healthcare providers to view the delivery of healthcare through a patient's eyes. Hopkins' initial iconoclastic statement: "Top-down strategy is not likely to bring the innovation that healthcare consumer is demanding" is refreshing in a world that so often looks to transform from the top down.
To change this way of innovating, the first step is the evaluation of the patient, and caregiver, experience. In his presentation, Hopkins encouraged providers to evaluate their patient experience with as much seriousness as rigor as would an amusement park. While hospitals will never be amusement parks, the concept and comparison trigger some valid points. What do we, as healthcare providers, offer to our patients and families?
First, when reviewing healthcare delivery from a patient perspective, one may sometimes find opposition between patient centeredness and provider's primary focus on compliance with rules and regulations. This is not paradoxical, as compliance does not build on the future, nor does it generate the drive to go beyond and above. Once a box is checked, that is the final statement; no one gets style points or honors graduation. From the temporal perspective, this checkbox is a snapshot, an instant picture. The idea of studying the experience, on the other hand, is a video. It is a constant recording of the landscape with the goal of changing the parameters as needed, a laboratory for constant study. Compliance provides a basic service, probably unrelated to quality and certainly not to engagement. Experience is the premium version, geared towards quality.
The second step, natural for a group of professionals such as Hopkins and his colleagues living in the creative world, is the necessity to engage employees. Is it mandatory to have happy employees to generate good patient experiences? Some support this unequivocal statement. Vineet Nayar in his book, "Employees First, Customers Second" (Harvard Business Press, 2010), describes the success of his company based on this ambitious program. Nayar's ambition is "transferring the responsibility of change from the office of the CEO to the employees in the value zone," no less.
Hopkins' presentation also advocated for employee engagement. Citing a Robert Wood Johnson study, Hopkins emphasized the pivotal capacity of nurses to generate success or failure. Hospitals function with a rigid silo model, and there is a clear separation between foot soldiers and management, almost similar to the societal difference between the "haves" and the "have-nots." One of the best examples is the interruption of the practice of nursing when nurses reach management positions (the "haves"). Such a shift rapidly creates a canyon of incomprehension between the two types of nursing positions.
This raises the crux of the question.
From a conceptual perspective, as the patient's experience changes, with a direct translation into hospitals' reimbursement, what is the cost for and of employees' satisfaction? I posit that if, indeed, patient satisfaction is an important metric, it should be measured longitudinally. In addition, patient satisfaction should be correlated to employee satisfaction and clinical outcomes.
In informal conversations, I have discussed this hypothesis as a project with hospital leaders. I believe hospitals should be collecting data about employees' satisfaction with the same methodology and value-weighting as used for reporting patients' satisfaction. Comments were not unexpected. Although employees' satisfaction carries a direct impact on patient care, few leaders are ready to accept the challenge to have to stand for a measurement directly impacted by their managerial methods, or lack thereof. As opposed to patient satisfaction — where a crowd of people can be blamed — employee satisfaction directly links back to management.
Pushing the reasoning somewhat further, should we consider that hospitals serve two clienteles? Indeed, hospitals serve patients and employees. For Hopkins, this is not a question; it represents an essential end-point.
Similarly, the concept of patient's satisfaction should not hide the fact that medicine is a complex field and that it takes for most physicians about a decade to integrate the sophistication of decision-making, the essence of therapeutics. Choice generates anxiety in individuals or institutions not prepared to the task. In a well-designed study, Fenton et al.1, demonstrated the price of satisfaction. After adjustment, patients who received treatment at hospitals with patient satisfaction scores in the highest quartile had a higher mortality scores (that is, they were more likely to survive, with a ratio of 1.26) than patients at hospitals with the patient satisfaction scores in the lowest quartile.
Finally, experience from other industries is welcome and adaptation to healthcare contemplated. IT, retail and others are scrutinized for modification and translational use. Communication, so important in healthcare, seems to have deteriorated since the time where smartphone did not exist and computers displayed blinking yellow dots on green screens. Paradoxically, progress in this field did not equate improvement. Although launched with a strong marketing tone, positive thinking and marginalization of critics, electronic medical records have not lived up to the forecasted high expectations. Errors, software or human driven, have not dropped. Initially employees had to acclimate to cumbersome products inadapted to the rapid pace of healthcare. From no fault of their own (but of the not-so-innovative healthcare system), and with the best intentions, innovators such as Hopkins perform "variations on a theme" on existing products to make them fit the convoluted systems and incentives engrained in our healthcare organizations. Can we practice patient centered care in places where patients are not the physical or organizational center of attention? Patient-centered care requires a commitment to modify existing workspaces.
In the era of declamatory truisms with undisputed supremacy of patient satisfaction and other miraculous solutions identified to fix many healthcare problems, innovators need to continue to challenge dogmas. Innovators may identify, at the local level, actions and processes potentially capable to affect durably both patient experience and theirs'. Individuals such as Hopkins, trained in fields outside healthcare, provide a fresh input, unaltered by the difficult interactions between physicians and administrators. They can, with a total freedom of speech, identify problems that we have been dealing with for generations, totally ignored, and offer solutions.
Patient satisfaction studies, as imperfect and unreliable as they are, are the ideal setting to a modification in measurement, longitudinal and multifactorial. It should be started at the basic level of interaction: patient-nurse-physician. In order to generate such a grass root movement, employees need to know that their opinion, their engagement and ideas to change healthcare experience are essential. Empowering people, allowing them to identify improvement processes in their field of action and design or modify tasks with rapid identification of results and celebration of success is usually easy to initiate and get rolling. Human investment is essential to success in healthcare as in other industries; the current focus on instant rewards and compliance should allow us to remember that if employees are happy in their hospital, patients may follow.
1 Fenton, J.J., Jerant, A.F., Bertakis, K.D., Franks, P. "The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality." Arch Intern Med. 2012;172(5):405-411.