“Nothing that has value, real value, has no cost. Not freedom, not food, not shelter, not healthcare” – Dean Kamen
A young woman presented for a thoracotomy to remove a mass in her right chest. On my way to see her, her nurse accosted me and told me of the patient’s demands. She didn’t want to wake up in pain – fair enough – but she didn’t want an epidural either! It went on – no ribs were to be broken, she didn’t want a foley catheter and she wanted to be discharged the next day. I actually laughed out loud when the nurse told me this.
I walked up to the patient with a smile on my face that got wiped off by the chilly reception. I tried to explain to her that her demands were unrealistic. She wouldn’t hear of it. I called in the surgeon for reinforcement. We lost the battle. She walked out.
Now imagine there was a tool online that allowed patients to rank the quality of care they received at a hospital based on several questions about interacting with the doctors and nurses, like “Were they responsive to your needs?”
How do you imagine this young woman’s ranking will look like?
Oh yeah, there are already such online tools and it is interesting to read through them.
Which brings me to today’s question – “Using the responses from patients about their care in an inpatient setting, can one really extrapolate the quality of care received?”
My answer to that is big NO!
In medicine (and probably other professional fields too), there is always this big disconnect between physicians who actually take care of patients and those experts who hardly take care of patients so have time to make policy.
Irrespective of what so-called policy makers in some big institutions might preach, using patient satisfaction surveys as a window into the quality of care received in the inpatient setting is going down a very slippery slope of subjectivity.
Even surveys about patient satisfaction in the outpatient setting have been shown not to capture the real issue at hand but rather how long patients waited!
Healthcare is a huge sector. Certain sections can be evaluated using consumer feedback e.g nursing care, drug development, emergency care, public health, the control of chronic diseases. However, when it comes to inpatient care, do you honestly think you can get a patient to objectively tell you through a questionnaire how well a surgeon took out a tumor or replaced a heart valve or a knee or treated pneumonia or a heart attack?
How many of us know the surgeon with the hands of Asclepius but the demeanor of Sergeant Hartmann from the 1987 movie “Full Metal Jacket”?
What is mostly obtained from these patient surveys is the quality of nursing care and the human-to-human interactions. They also capture complications and I’ll come to that later. The reviews however miss the meat – the quality of medical care or surgical interventions.
Now, is it necessary for the public to have an idea of the quality of care they’ll get from a hospital? YES! Healthcare is a service industry and I think it is important for patients to have such a tool.
Let’s say you need to have a hip replaced. Imagine you could go into a tool that showed you each orthopedic surgeon in town, how many hips they did a year, which age group, which ASA class, length of a procedure, number and nature of complications, incidence of transfusions, length of stay and cost. Wouldn’t that be a much better tool than patient surveys?
Now how would such a tool be set up and populated? Setting it up would be the least of any developer’s worries. Populating it is the problem. The only way to get that information is to make hospitals report outcomes for each physician who works at that hospital. That way, consumers can compare. No hospital in the US is going to do that! They collect it but they aren’t sharing it!
And so policy makers grasp at straw by designing surveys based on patient experiences that seek to eke out the quality of care.
However, I think hospitals should publicize this data. It will allow competition in the marketplace, weed out the bad practitioners and lower costs. It will allow patients to choose the best surgeon for their needs. An ASA Class III or IV patient can look for a surgeon who does mostly ASA Class III and IV patients.
It also prevents doctors and hospitals from having to deal with policies that make practicing more difficult but do not really improve quality of care. I think we in healthcare should be more proactive in measures that bring patient care to a pact between a doctor and a patient, excluding insurance companies and government.
So next time you fill out a patient satisfaction survey, ask if it really captured the quality of care? It probably did not but these surveys can capture outcome in terms of complications. The question then is, “Are complications an indicator of quality of care?” To that I’ll respond with yes and no. Complications can be a window into quality of care or also very much patient related. Going back to hip surgery, if a surgeon does 350 hips in a year and out of that 50% have infections, there is a problem. However if a patient after valve replacement surgery with a mechanical valve goes home, forgets to take his warfarin and the valve clots off, that is on the patient.
As a consumer of healthcare, I’ll like to know what I’m getting when I walk in for a procedure. I wish there was a better way to tell than through subjective responses.