The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital (34 page)

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.

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.”

“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.

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.

“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)

“It’s insanely easy to steal medications. There have been plenty of times where I’ve emptied my scrub pockets at home and found ketamine, Dilaudid, morphine, and Ativan.”