Molly was floored. Priscilla gave Juliette the impression that she loved her. Juliette was a hardworking nurse who always tried to do right by her patients, and she was assembling a strong portfolio for her clinical ladder application. “If she feels this way about Juliette, she should tell her, and her performance evaluations should reflect it,” Molly said. She struggled with whether to tell Juliette because she knew it would hurt her feelings. But Juliette needed to know that the private information she shared with Priscilla might not be remaining confidential.

Staff politics were only one of many reasons that Molly was glad she had left Pines. Pines had the best educated and best insured patients that Molly had seen; they were probably among the smartest and wealthiest in the area. They were also the most demanding patients Molly had ever met.

Recently, the Westnorth Corporation announced to staff that care should be tailored to the patient surveys that were administered randomly after discharge. Thanks to the Affordable Care Act (also known as “Obamacare”), hospitals took their patient satisfaction surveys very seriously because their scores affected the amount of federal money they received. Since Westnorth had taken over the hospital, patient satisfaction scores had dropped. Administrators now were scripting nurses’ discussions with patients and ordering them to use memorized key words in what the hospital called “guided conversations.” For example, the survey asked, “Did your nurse educate you on your condition?” Patients tended to answer no, despite receiving discharge instructions about their diagnosis and treatment. Therefore, Westnorth now instructed nurses to say, specifically, “I am going to educate you on your diagnosis.”

At Pines, the patients could be difficult to please. “You can come in with appendicitis and we fix you but your room was cold, so you’re pissed off and give us a poor rating,” Molly said. “I don’t care whether the patients are ‘satisfied.’ I care that they get the treatment they need.” A patient once found Molly in a room performing CPR and yelled, “I ASKED YOU FOR A PILLOW FIFTEEN MINUTES AGO!” During CPR!

Too often, Pines patients demanded specific procedures, after speaking with doctor friends or searching for ideas on the Internet. If the patient’s orders didn’t match the doctor’s orders, the patient might leave the hospital dissatisfied, even if he was cured, simply because he didn’t receive the treatment he demanded.

One of the worst patients Molly could remember was an annoying woman who pressed her nurse’s call light every few minutes. “I’m cold,” she’d say, so Molly would cover her with a blanket. Molly would just be sitting down at the nurses station when the woman rang again. “I want some water.” Molly brought her the water. Five minutes later: “I don’t like it with ice.” Molly brought her water without ice. Another few minutes, then: “It’s too warm. I want one piece of ice.”

Thinking the woman should have to “work a little harder” to contact her nurse, Molly moved the call light out of reach. The woman called her on the room phone, asking for another blanket. Molly complied. Three minutes later, the patient rang her again. Molly was wise enough to know that some patients were difficult because they were lonely and scared. But she had four other patients just as lonely and scared as this woman, who was taking up way too much of her time. Nurses flipped coins to avoid patients like her.

Those were the kinds of people who answered the patient satisfaction surveys. Not the man to whom Molly gave her own meal because he missed putting in his dinner order and hadn’t eaten all day. Not the little old lady who had taken her first-ever airplane flight, fallen at the airport, and needed a CT scan that messed up her intricately braided cornrows. She’d had her hair done because she was meeting her great-granddaughter for the first time. Molly spent 45 minutes rebraiding the woman’s hair into its updo. As an out-of-town resident, the grateful woman wouldn’t receive a survey. Instead, Molly got in trouble with the charge nurse for braiding hair.

And no one would hear from the 30-year-old man who was dying of AIDS. He had been estranged from his family, and had just reconciled with his mother when his condition deteriorated. While Molly was triaging him, he begged his mother, “Please don’t leave me. I don’t want to die alone.” Soon afterward, he became unresponsive.

At 2:00 a.m., the patient was admitted to a medical floor for end-of-life care. When Molly wheeled him upstairs, his mother turned to her in tears. “I can’t stay here and watch my child die.”

“I understand this is very painful, but he specifically said he didn’t want to die alone,” Molly said.

When Molly left the man’s room to return to the ER, the mother left, too. At 7:00 a.m., when Molly’s shift ended, she called the floor to ask if the man was still alive. “Yes, but barely,” came the answer.

“Is anyone with him?” Molly asked.

“No. His mother never came back.”

Molly had just finished an exhausting twelve-hour night shift, but she wanted to honor the man’s last wish. She clocked out, took her things to his room, and sat next to him, holding his hand for two hours until he passed away.

“Of course,” Molly said later, “since he was an admitted patient—and dead—he couldn’t be polled about his hospital experience.”

Patient Satisfaction, Tricking Patients, and the Stepford Nurse

When Department of Health and Human Services administrators decided to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores, they likely figured that transparency and accountability would improve healthcare. Centers for Medicare & Medicaid Services (CMS) officials wrote in the Federal Register, rather reasonably, “Delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.” They probably had no idea that their methods could end up indirectly harming patients.

Beginning in October 2012, the Affordable Care Act implemented a policy withholding 1 percent of total Medicare reimbursements—approximately $850 million—from hospitals (that percentage will double in 2017). Each year, only hospitals with high patient satisfaction scores and a measure of certain basic care standards will earn that money back, and the top performers will receive bonus money from the pool. Private health insurance companies, such as Blue Cross Blue Shield of Massachusetts, are reportedly following the lead of what the government calls the Hospital Value-Based Purchasing Program.

Patient satisfaction surveys have their place. But the potential cost of the subjective scores are leading hospitals to steer focus away from patient health, messing with the highest stakes possible: people’s lives.

The questions and the problem

The vast majority of the thirty-two-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” There is no similar question regarding speed of doctors’ or other staff members’ response times.

This question is misleading because it doesn’t specify whether the help was medically necessary. Patients have complained on the survey, which in previous incarnations included comments sections, about everything from “My roommate was dying all night and his breathing was very noisy” to “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.” An Oregon critical care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple bypass surgery). “Many patients have unrealistic expectations for their care and their outcomes,” the nurse said.