64. Why Focusing on Patient Experience and Not Satisfaction Is the Right Move

Patient satisfaction and the patient experience are vastly different different things. In this pod we discuss: how experience is influenced by every conceivable touchpoint, and perception, how making a purposeful choice to care helps ensure that our patients have a positive experience, efficiently handling the situation when a patient has extra questions, the best way to acknowledge a patient’s long wait, and de-escalating the unhappy patient.

Guest Bio: Justin Bright MD, CPXP is an attending physician and the Assistant Medical Director for Patient Experience in the Department of Emergency Medicine at Henry Ford Hospital in Detroit. He is fascinated by the intersection of patient experience, interpersonal communication, customer service, and employee engagement. Check out his ideas at www.ptexpmd.com or on The Patient Experience podcast on Spotify, Apple Music, or any other listening platform you enjoy. In this episode, we learn that patient satisfaction and the patient experience are different things. We can improve the patient experience by asking open-ended questions, recognizing nonverbal cues, validating emotion, and pausing to listen.

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We discuss:

A patient satisfaction survey rant [02:45];

People who fill out the surveys tend to be dissatisfied. The happiest patients may write a letter to the department chair, but they may do this in lieu of filling out the survey. Who wants to duplicate their efforts?
These surveys have serious sampling issues. For example, only discharged patients receive one. Admitted patients, the ones a provider spends the most time with, are not mailed a questionnaire.
Reimbursement is often tied to patient satisfaction scores. But some researchers speculate that physicians whose compensation is linked to patient satisfaction are more likely to give in to patient requests for tests or treatments that may have adverse effects or be unnecessary. The implications are scary.
When individuals have low scores and are perceived to be underperforming, they’re commonly mandated to get them up without being given the guidance or tools to do so.

“The patient satisfaction process, in its current iteration, is contrary to excellence in the practice of medicine. It could be done well. It’s a great idea. But it comes down as heavy handed, disingenuous, and potentially dangerous.”

The “patient experience” and how it is influenced by every conceivable touchpoint, perception, and logistical thing that may happen to a patient [11:10];

Improving the experience is dependent on the intrinsic desire to do better for our patients everywhere in the system — the coffee shop, the parking lot, at registration, and during the clinical encounter.
There are many extrinsic motivators for (ostensibly) making the patient experience a positive one. Examples include metrics such as Press Ganey and likelihood-to-recommend scores. These extrinsic motivators often cause angst and upset for providers, clouding our ability to find real joy in helping people.
The manner in which we provide whatever a patient needs (ie. an explanation of their diagnosis, access to follow-up) makes a world of difference in terms of patient safety, compliance, and satisfaction with the patient experience.

How making a purposeful choice to care helps ensure that our patients have a positive experience [16:15];

When a patient has a negative experience, it almost always comes down to not being heard, not being attentive to emotion, or not being able to effectively navigate all the intricacies of human interaction.
Show the patient that you really do care about them and want to help.

The power of the pause [19:35];

When you ask a question, just sit there and listen for the answer before pouncing on the next question (are you listening or are you reloading for your next salvo of questions?). Allowing a pause will give the patient the chance to say the things they want and need to say.

Avoiding the “doorknob complaint” by asking open-ended rather than direct questions [22:00];

We are trained to do a very algorithmic H&P, approaching it from a cognitive and pragmatic standpoint. We ask direct questions to serve our own agenda which is to very quickly identify what’s wrong, create a differential diagnosis, and come up with a treatment plan.
Instead, ask open-ended questions and listen to what the patient has to say. Let them express emotion and tell their story. Ask in an open, welcoming way, not in a way that can seem confrontational. Tone matters.

“Recognize that communication is not easy. Communication is the most complex thing that we’re ever going to do in our life.”

Efficiently handling the situation when a patient has extra questions after you thought you had already completed the encounter [24:50];

Bright recommends teach-back. Summarize what got done, what needs to be done, and with whom they need to follow-up.
Remind patients that, “If things change or get worse or scary in any way, we are always open. We never close. Come back and let’s do it again. I’m happy to help you.”
Be willing to say, “Did we cover everything that you felt needed to be covered today?” Routinely asking this question at the end of an encounter can prevent the last minute, extra questions and can prevent bounce backs and bad outcomes.

The best way to acknowledge a patient’s long wait [26:40];

Some patients wait several hours to be seen by an ED clinician.
It’s important to validate that the patient waited and to recognize that their time is valuable. If you don’t defuse that bomb before you get into your encounter, it’s going to sit there and fester, sidetracking you from what you really need to accomplish in caring for the patient.
Rather than apologizing for the delay, turn it into a positive by expressing your gratitude. You might say, “Thank you for waiting. I know that you’ve waited quite some time to see me, and I want you to know that I appreciate it. What can I do to help you today?”

How to respond to the disgruntled patient who voices complaints about other people involved in their care or their prolonged wait [29:30]

As a clinician, it is natural to either get defensive or to throw somebody under the bus. Try not to do this. Instead, redirect the conversation to why the patient is in the department and reiterate that you’re ready to help. “I’m terribly sorry that that happened, but I know that you’re uncomfortable and I’m here now. You’re very important to me. Let’s talk about what I can do to help you.”
If the patient pushes back, continue to keep the focus on taking care of the patient. “Let’s figure out how you and I can get you feeling better. Once we’ve gotten you feeling better, if you’d still like to get into that, I’m happy to talk to you more about it or refer you to our charge nurse so we can look into it further.”
Avoid attributing prolonged waits to more critical patients in the department. Many patients will remain angry, countering that the ED should be better staffed. Keep owning it. “I’m here now. I want to help you, and I appreciate that you’ve been waiting.”
The more you can be positive without pulling in other variables that you expect they’re going to care about when it’s not their job to care, the better things will be.

Deescalating the unhappy patient whose expectations of care were not met [33:10];

Recognize nonverbal cues. Name whatever palpable energy you’re sensing.“I can’t help but notice that you’re looking a little upset/anxious right now.”
Validate their emotion. It’s an important step to understanding what’s going on. Be quiet and listen to what’s bothering them. Don’t simply defend yourself or your health system.
Master the skill of delivering the “no”. People don’t respond well to a hard “no”. Sit down and explain why the patient’s belief about what they need may be misguided. And then give an alternative. For example,“I understand why you think you need an MRI for your shoulder pain, but it’s really not indicated right now and here’s why. What I’d love to do though is to get you in with my colleague who is a shoulder specialist.”

Salvaging the situation when a patient threatens to call the nurse administrator or an attorney [39:10];

Some patients will remain angry no matter how savvy you are with your communication. These patients are sending out a message that they have not been heard. Whatever emotion they’re experiencing has not been validated in a way that has effectively defused the situation.
It’s worth asking, “What is it that is making you this upset and what can I do to help?” If the patient asks for something you don’t feel comfortable providing (such as antibiotics for a viral illness), explain why their request is not appropriate.
If needed, provide contact information for the charge nurse or service excellence department. It is wise to report the issue yourself as well, so they’re not blindsided by the complaint.
Document well, in a non-judgemental way.
The Happy MD’s Universal Upset Patient Protocol gives a good framework for interacting with angry patients.