“Belief” is the pivotal word here. Those laminated cards that collar Massachusetts nurses include the phrase “I have the time” not because the nurses necessarily have the time, but because, consultants told The Boston Globe, “patients are more satisfied with their care when they believe nurses made time for them.”
UTMC is a good example of how an emphasis on patient satisfaction does not make for better care. Remember, this is the hospital that also spent $50 million on superficial changes (such as changing valet service vendors) and evaluates staff on “customer satisfaction.” At the time of this writing, according to government data on hospitals’ rates of readmissions, complications, and deaths, UTMC appears to be among the worst performers in the state, if not the country. UTMC has higher than average rates of serious blood clots after surgery, accidental cuts and tears from medical treatment, collapsed lungs due to medical treatment, complications for hip/knee replacement patients, and, more generally, “serious complications.” In addition, UTMC made headlines in 2013 when, during a transplant operation, hospital staff threw away a perfect-match kidney that a patient was donating to his sister. Instead of focusing so intently on “satisfaction,” UTMC should have spent those millions of dollars on improving its actual healthcare.
Many hospitals seem to be highly focused on pixie-dusted sleight of hand because they believe they can trick patients into thinking they got better care. The emphasis on these trappings can ultimately cost hospitals money and patients their health, because the smoke and mirrors serve to distract patients from the real problem, which CMS does not address: Patient surveys won’t drastically and directly improve healthcare—but hiring more nurses, and treating them well, can accomplish just that.
Nurse satisfaction
It turns out that nurses are the key to patient satisfaction scores, but not in the way that these hospitals have interpreted. When hospitals do hire enough nurses and treat them well, patient satisfaction scores intrinsically rise. A study comparing patient satisfaction scores with surveys of almost 100,000 nurses showed that a better nurse work environment raised scores on every HCAHPS question. Furthermore, the patient-nurse ratio also impacted patient satisfaction scores. The percentage of patients who would “definitely recommend” a hospital decreased with each additional patient per nurse.
There are a few things that good work environments for nurses have in common: favorable patient-nurse ratios, positive nurse-doctor relations, nurses who are involved in hospital decisions, and task-focused managerial support. University of Pennsylvania researchers have found that better nurse work environments lead to improved patient health, too, in the U.S. and in countries as varied as Australia, Canada, China, Germany, Iceland, Japan, New Zealand, South Korea, Switzerland, Thailand, and in the United Kingdom. The researchers observed, “Increased attention to improving work environments might be associated with substantial gains in stabilizing the global nurse workforce while also improving quality of hospital care throughout the world.”
When hospitals improve nurse working conditions, rather than tricking patients into believing they’re getting better care, they actually provide it. Higher staffing of registered nurses has been linked to fewer patient deaths and improved quality of health, according to a study by influential nursing professor Linda Aiken, the director of the University of Pennsylvania’s Center for Health Outcomes and Policy Research. For every 100 surgical patients who die in hospitals where nurses are assigned four patients, 131 would die when they are assigned eight. When a hospital hires more nurses, failure-to-rescue rates drop. Patients are less likely to die or to get readmitted to the hospital. Their hospital stay is shorter and their likelihood of being the victim of a fatigue-related error is lower. Even in Neonatal Intensive Care Units, where medical issues could be disastrous for hospitals’ most vulnerable patients, the fewer the nurses, the higher the infection rates.
Hospitals and healthcare systems view nurses as one of the largest budget expenditures. However, by investing in nurses and treating them so well they want to stay, hospitals could earn millions in Medicare bonuses, avoid costs associated with employee turnover, and save money on healthcare expenses (with lower expenditures per patient, including shorter stays, less pharmaceutical use, and fewer tests).
And they would save lives. A Center for Health Outcomes and Policy Research presentation reported that in poor working environments for nurses, patient falls with injuries are 90 percent more likely to occur frequently (once a month, or more often), medication errors are 73 percent more likely to occur frequently, and hospital-acquired infections are 55 percent more likely to occur frequently than in good working environments. In good working environments for nurses, patients are 19 percent less likely to die after common surgical procedures. The presenters concluded that if all U.S. hospitals improved their nurses’ working conditions to the levels of the top quarter of hospitals, more than 40,000 lives would be saved every year.
The trade-off seems like a no-brainer. Would you rather be bribed during your hospital stay with made-to-order omelets or would you rather be, for example, not dead?
Even Studer Group, the survey “coach,” admitted that nurse communication is “the single most critical composite on the HCAHPS survey.” (Indeed, one of the most effective ways to improve patient satisfaction scores, hospitals are finding, is to have nurses check in with patients every hour.) But Studer Group, which calls nurse communication “The Most Bang for Your Buck,” is thinking backward. Nurses are more likely to communicate well in hospitals that give them the time, energy, and morale to do so rather than in workplaces that spend those bucks on a script.
If hospitals really want more bang for their buck, then instead of splurging on gourmet meals for patients (who don’t select hospitals for the food), they could manage even just one covered meal break per shift for nurses; hospitals say they do this, but many don’t. They could let their nurses park at work for free rather than hire a fancier valet service for patients. They could quit trying to cheat both patients and nurses by diverting funds to superfluous perks instead of investing in staffing, and, therefore, in patient care and well-being.
And if CMS truly wants “to promote higher quality and more efficient healthcare,” as the Federal Register stated, it likely would meet that goal and have more accurate ratings in the process if it based reimbursement on surveys not only of patient satisfaction but also of nurse satisfaction. A simple measure of hospitals that would reflect healthcare quality, patient satisfaction, and nurse satisfaction could be to rank hospital departments by their nurse-to-patient ratios.
Instead, hospitals are responding to the current surveys and weighting system by focusing on smiles over substance, hiring actors instead of nurses, and catering to patients’ wishes rather than their needs. Then again, perhaps it’s no wonder that companies are airbrushing healthcare with a “Disney-like experience,” a glossy veneer. One of the leading consulting companies now advising hospitals on “building a culture of healthcare excellence” is, oddly enough, the Walt Disney Company.
Chapter 7
The Code of Silence
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Painkillers, Gossip, and Other Temptations
“I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug.”
—The Florence Nightingale Pledge (a nurses’ adaptation of the Hippocratic Oath)