It seems that the new buzzword in health care is “patient satisfaction.” The Affordable Care Act allows Medicare to tie a portion of a hospital’s reimbursement money to patient satisfaction. Patients are mailed a survey after discharge called the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), and depending on their responses, Medicare can withhold up to 1% of that hospital’s reimbursement.

At first glance, this measure of accountability makes sense; the HCAHPS rewards hospitals whose patients report receiving a high level of care. The problem, however, is that the survey’s standard of care is very high, and patients’ perceptions are not always an accurate representation of the clinical care that was delivered. The responses are too subjective, and there’s no real data to be measured or evaluated.

The HCAHPS questions cover nursing, physicians, communication, cleanliness, and an overall rating. Most questions have four possible answers: never, sometimes, usually, and always. The only answer that counts toward a hospital’s rating is “always.” For example, one question asks patients how often they received help as soon as they wanted it after pressing their call light. Even if the patient responds “usually,” this is a fail. (I’ll spare an enumeration of the possible reasons a nurse may be unable to deliver a blanket within two minutes, and simply point out that this question doesn’t differentiate between an emergent request or a routine one.)

Because of the monetary incentive to keep patients satisfied, many hospitals have changed their model of care delivery to one that, well, keeps patients happy. Customer service training has become a part of many orientation programs (some hospitals go as far as to script patient dialogues), and in many places, you may find a standard that the patient, and not the doctor, is always right. 

But the patient is not always right. One example is the over-prescription of antibiotics for viral illnesses. I triage patients all the time who are prescribed antibiotics for rhinovirus, because they demand them, and providers know a refusal will cause low scores on the question, “How often did doctors listen carefully to you?” Or consider the patient with an ankle sprain who requests narcotic pain medication. A satisfied patient in this case may become a drug-dependent, narcotic-addicted one. Is this really what we want health care to look like?

For now, let’s set aside the issue of whether patients are able to separate the evaluation of their actual care from a rating of the food in the cafeteria or noise in the hallway, and move to the larger issue: Patient satisfaction does not equal patient safety. In fact, they seem to be inversely related. According to several recent studies, high patient satisfaction leads to higher health care costs, to increased nurse burnout and nursing job dissatisfaction, and most alarmingly, to higher patient mortality.

I understand the pressure to increase patient satisfaction not just to maximize reimbursement but to keep patients coming back through the doors. Health care is changing: Patients have a say in where they are treated and by whom. We live in an age when people write Yelp reviews before they even leave a restaurant, and the same is happening to health care (websites such as Zocdoc or come to mind, and the purported purpose of the HCAHPS survey is to allow consumers to compare hospitals and evaluate their quality).

Patients have rights, certainly, but the highest emphasis should be on their safety and not on their satisfaction (and it is infuriating that the answer of “usually” on a survey doesn’t count as a high score). Some patients, after all, will never be satisfied, and will not like the answer that they cannot eat, cannot get out of bed, or cannot have six people in their hospital rooms all in the name of their safety. Linking hospital reimbursement to safety measures, such as rates of infection or hospital readmission, seems reasonable. Core measures exist for this very reason, to quantify performance in areas of patient safety. Instead of spending money on mobile charging stations or Keurig coffee makers in each room, investments should be made in hiring more nurses—recent studies have demonstrated that nurse-patient ratios are crucial to both patient satisfaction and safety.

(For more information about HCAHPS, visit

Laura Kinsella

Laura Kinsella, BSN, RN, CEN, is an emergency room nurse in Washington, DC.

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