An entire industry has sprouted, encouraging hospitals to waste precious dollars on expensive consultants claiming to boost satisfaction scores. Posters hang in break rooms even in some of the most prestigious hospitals in the country, displaying key words to remind nurses of the specific jargon they must use with patients. Some hospitals have ordered nurses to keep cue cards in their pockets, or, at several Massachusetts hospitals, to wear laminated cards around their necks that remind them to end each interaction with the words: “Is there anything else I can do for you before I leave? I have the time while I am here in your room.’’ And across the country, administrators are telling nurses to use a patient’s name at least three times per shift.
One of the most common scripted interactions is the AIDET, developed by Studer Group, a company that works with more than 800 healthcare organizations worldwide and refers to its services as “coaching.” AIDET stands for Acknowledge, Introduce, Duration, Expectation, Thank. Some managers are telling nurses that they must demonstrate “AIDET competency” or they will have to undergo “remediation” or an “improvement plan.” They are assessed by “AIDET auditors.” Of course, patients can appreciate some of the AIDET information. It’s helpful to know how long a wait will be or what a procedure entails. Certain nurses could use the reminder that their patients don’t know and wish to know what is going on. But good nurses explain those things to patients anyway, and the best nurses explain them in ways most suited to each individual patient. Evaluating—and penalizing—nurses based on how well they stick to a formulaic script implies that nurses need a blueprint for basic human interaction.
More disturbing, several health systems are now using patient satisfaction scores (likely from hospitals’ individual surveys) as a factor in calculating nurses’ and doctors’ pay or annual bonuses. These health systems are ignoring the possibility that health providers, like hospitals, could have fantastic patient satisfaction scores yet higher numbers of dead patients, or the opposite.
While role-playing can be an effective teaching tool, some hospitals have gone too far, auditioning and hiring trained actors to perform patient roles in playacting sessions for nurses to rehearse these scripts, including call-backs. That’s right: Hospitals are spending valuable resources to audition and hire professional actors.
If scripting sounds like teaching to the test, that’s because it is. HCPro, a healthcare consulting company, offers a tip sheet entitled “Quick Ways to Improve Patient Satisfaction Scores.” The company calls the survey “an open-book test” and suggests that nurses “ ‘remind’ patients and/or their families of the ‘right’ answers.”
It’s safe to say that the Centers for Medicare & Medicaid Services, the federal agency that utilizes the surveys, does not approve of these tactics. Survey guidelines specifically state, “Hospitals must not use HCAHPS wording and/or response categories in their communication with patients.” But what did CMS expect? That’s like college admissions officers telling high school seniors they shouldn’t get help with their applications. No hospital wants to be the only kid taking a curved test on his own, when other students use tutors who already know both the questions and the answers.
In Massachusetts, a medical/surgical nurse told The Boston Globe that the scripting made her feel like a “Stepford nurse,” and wondered whether patients would notice that their nurses used identical phrasing. She’s right to be concerned. Great nurses are warm, funny, personal, or genuine. It can be hard for nurses, who are not actors, to appear heartfelt and compassionate when they all recite the same script.
At Indiana University Health, a ten-page laminated guide instructs staff to use precise phrases and manipulative strategies. Employees cannot answer patients with “You’re welcome” or “No problem”; they are told to say, “It’s my pleasure!” They are directed to use strategies including “fogging” agitated patients by telling them, “You’re probably right”; “verbal softeners,” which replace “That never happens” with “It’s possible” or “It’s unlikely,” and, an interesting strategy for customer service: “Nod and hum.” The guide even recommends specific nodding and humming sounds: “Mmmm hum, hmmm?” and “Uh-huh.”
Uh-huh. These scripts and strategies assume nurses are unintelligent, lazy, or lacking people skills. Consultants further demoralize nurses when they are condescending and out of touch. Rebecca Hendren, an HCPro administrator, wrote the following in an industry newsletter: “If you haven’t found a way to drive home the importance of patient experience to direct-care nurses, find it now. You know how much reimbursement is at stake, but the rank and file caregivers still don’t get it. I’ve written before that the term ‘patient experience’ has a way of annoying bedside caregivers. ‘We’re not Disney World’ is a common refrain; people don’t want to be in the hospital. ‘I’m here to save patients’ lives, not entertain them’ is another common complaint.”
Oh, they get it. Make no mistake that nurses “get” the finances that hang in the balance. But they also understand that ultimately, the way that both Medicare and hospitals are interpreting patient experience has less to do with patient health than with the image of the hospital.
The assumption that the “rank and file caregivers”—a patronizing term to begin with—fail to grasp the importance of the patient relationship undermines the nursing profession. “In our staff meetings, we’ve had to practice role-playing and scripting to make sure the buzzwords in the patient satisfaction survey are covered,” a Washington, DC, nurse told me. “Rather than addressing the nurses being spread too thin to provide care that is good enough, they assume the nurses aren’t coddling the patients adequately enough.”
What annoys nurses is that the concept of “patient experience” has morphed patients into customers and nurses into “rank and file” automatons. Some hospital job postings advertise that they are looking for nurses with “good customer service skills” as their first qualification. University of Toledo Medical Center evaluates staff members on “customer satisfaction.” Even the AIDET audit forms explicitly refer to patients as customers.
By treating patients like customers, as nurse Amy Bozeman pointed out in a Scrubs magazine article, hospitals succumb to the ingrained cultural notion that the customer is always right. “Now we are told as nurses that our patients are customers, and that we need to provide excellent service so they will maintain loyalty to our hospitals,” Bozeman wrote. “The patient is NOT always right. They just don’t have the knowledge and training.” Some hospitals have hired “customer service representatives,” but empowering these nonmedical employees to pander to patients’ whims can backfire. Comfort is not always the same thing as healthcare. As Bozeman suggested, when representatives give warm blankets to feverish patients or complimentary milk shakes to patients who are not supposed to eat, and nurses take them away, patients are not going to give high marks to the nurses.
The hospital image
Recently, at a hospital that switched its meal service to microwaved meals, food service administrators openly attributed low patient scores to nurses’ failure to present and describe the food adequately. It is both noteworthy and unsurprising that the hospital’s response was to tell the nurses to “make the food sound better” rather than to actually make the food better. This applies to scripting, too: It does not improve healthcare, but makes it sound better.
The University of Toledo Medical Center (UTMC) launched an entire program based on patient satisfaction. iCARE University mandates patient satisfaction course work and training for every university student and employee. “Service Excellence Officer” Ioan Duca told a publication sponsored by Press Ganey, a company that administers the surveys for hospitals, “I am really focused on creating a church-like environment here. We want a total cultural transformation. I want that Disney-like experience, the Ritz Carlton experience, the Texas A&M experience. I want that kind of true belief.”