Hooray. We Stink!

By  |  November 9, 2011 | 

Well, not all of us, but some of us– especially in Manhattan, Los Angeles, and Chicago.

With value-based payments coming down the pike (this calendar year applies toward the 2012 ranking), patient satisfaction and HCAHPS is a priority.  Of the composite score, this element has a 30% weight.

Yesterday, in both the WSJ (gated) and NYT, long feature articles discussed how hospitals are adapting to improve the patient experience.  First, of note, fellow SHM’er (and friend), Kathy Hochman is the star:



The article reviews familiar ground, but what struck me was the lengths to which facilities are upgrading service to obtain scores of 9 or 10.  It felt like Groundhog Day redux, but instead of antibiotic overkill in the instance of CAP, we are now tucking patients in and leaving mints on the pillow.  Will this lead down the same path of resource exploitation in order to play to the measures?  Probably.

Service is great, and we need more of it, but there is a fine line.  When I buy a suit, the sales clerk can say hello, ask if I need assistance, and stand 30′ back if I defer.  Conversely, he can do the same and hover.  A waiter can check in at my table every 5 minutes, or every 10, but either way, the tip is 20%.

Unlike fastidious attention to hand washing and infection control (we cannot employ enough dollars there) or other clinical measures, the service angle can get impractical, and be forewarned, it will.  Will it have positive externalities for the organization and generate good will amongst staff?  No doubt, and Nordstrom or the Ritz-Carlton would not object.  However, this comes at the expense of our other efforts to say, prevent unnecessary readmissions.  Again, it is the five vs. ten-minute thing.

Let us just hope the pieces were featuring extreme instances.

Now, on the “we stink” front, I highlight the Hospital Compare website, and the inserted satisfaction scores excerpted below:

Of the 295 Hospital Referral Regions, Manhattan is dead last, Chicago is #292, Long Island is #288, and Los Angeles is #282.  Why?

It is not one hospital, or one physician group, but an entire locale.  Do we impugn a population, its normative expectations, the homegrown physician training, or something else?  What is going on here, and why are these three enormous cities such outliers (Houston is #133 incidentally).  I believe it is more arcane than staff and patient interaction, and I will revisit this subject in the future with a more in depth discussion, if a publication does not beat me to it.  It is not so simple.

It is tempting to attribute the scores, if you live in these cities, to a faulty instrument.  HCAHPS bashing is a recreational sport nowadays, and we all question its validity, particularly in its application to hospitalists.

This interesting JHM paper, released last week, contrasted HCAHPS scores between hospitalists and PCP’s in three Massachusetts facilities:


There is plenty to garner from the study—with its inherent limitations of course, but my interest rested with uncovering misleading differences between specialties, especially as they relate to HCAHPS.  To my surprise, the groups were equivalent, and at least amongst this sample of 8000, the survey played no favorites.  If validity was an issue, and the survey was “rigged” from the outset, my expectation was superior PCP performance.  This was not the case.  We must await more data.

I crave thoughts on HCAHPS—upsides, downsides, and whines—all are desired, and please sound off.

Mason City, I am talking to you!

UPDATE: Here are additional views on the subject.  Even if care standards are applied identically, and equivalent outcomes are achieved, should hospitals (cities) be penalized if patients of lesser means rate differently, or regional expectations are dissimilar?  Adjusting for these factors then, seems rational, and is not a free pass for the affected institutions.


  1. Bill Rifkin November 9, 2011 at 7:58 pm - Reply

    Good post. Certainly timely. I agree that pursuing satisfaction is a distraction. See Jha Ak, 2009, NEJM. Little to no correlation between high/low patient satisfaction with d/c process and actual outcomes. Lots of people love their nice, idiot doctor. Of course, can go too far the other way, but beyond being “nice”, it seems a waste. They are so desperate to measure/report/rank on something, they grasp at straws.

    As to why cities, especially NY, do worse? This sorts of surveys are notorious for the ceiling effect. Everyone puts 9/10 or 10/10. So a few honest 5’s or 6’s make the difference. As you can see from the chart above, low 60’s is terrible, high 60’s is average and mid 70’s are great. Very small Std dev. So a few honest or chronically unhappy folks can skew. As a New Yorker myself, I would say, we are the ones not easily impressed by new magazines or slightly hotter food.

  2. rachel lovins January 13, 2012 at 6:42 pm - Reply

    It’s New York, New Jersey and New England I believe that have the lowest scores. I do think people complain more on the east coast. I hate that! (see, that’s a joke, I’m complaining).

Leave A Comment

About the Author:

Brad Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.


Related Posts

By  | July 19, 2018 |  0
So out in the varied land of hospital medicine, I have noticed something that I have no clear explanation for. It turns out there is often a gap in productivity between that of NP/PA providers and physicians. The range of the gap varies wildly – I just got off the phone with a HM group […]
By  | June 26, 2018 |  2
JAMA just published the largest trial I have seen on a Hospital at Home (HAH) model to date and the first one out in the last few years. It comes from Mount Sinai in NYC–who have led the pack in this style of care if national presentations are the judge. They launched the program three […]
By  | June 7, 2018 |  0
Everywhere I go these days, one of the top questions on the minds of hospital leaders and hospitalists alike is, “How can we improve hospitalist patient satisfaction scores?” It’s a dilemma. There are people who know way more about this subject than me, but I’m not aware of anyone who has really cracked the nut. […]