Patient satisfaction surveys and care quality: a continuum conundrum

In recent years reporting patient satisfaction has become an important feature of the healthcare landscape. In countries including the United Kingdom, the United States, and Australia, measures of patient satisfaction are increasingly being employed as drivers of quality and accountability. Patient satisfaction has also been tied to value-based purchasing as part of a suite of strategies seeking to drive improved performance and efficiency. In a number of countries investigations into largescale care failures have also reported failure to listen to patients as a key factor in these failures (Garling 2008, Thomḗ 2009), leading to refocused efforts to improve patient satisfaction. As part of this patient satisfaction agenda, nurses have changed leadership practices and re-designed nursing care delivery in efforts to improve patient satisfaction. Yet the merits (or otherwise) of employing patient satisfaction as a measure of care quality remain unclear. Given the continued attention to patient satisfaction it is important to establish whether satisfaction is an adequate or appropriate primary indicator of nursing care quality. Without clear evidence of the link between patient satisfaction and care quality there is a risk of distracting attention and resources from other efforts to improve quality and safety. After decades of research on patient satisfaction there remains little clarity about the associations between patient satisfaction and care quality. In 2008 a report on hospital data collected from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) identified that patient satisfaction was correlated with higher care quality (measured through physician adherence to quality guidelines) for the four conditions examined (acute myocardial infarction, congestive heart failure, pneumonia and surgical care improvement) (Jha et al. 2008). In contrast to these findings, Esposito et al. (2014) note that, in an environment where clinician and provider remuneration is tied to adherence to clinical guidelines, there is a risk of pressure on clinicians to adopt guidelines. Illustrating this point, these authors report evidence that clinical guidelines for some conditions were adopted prematurely and were associated with increased patient mortality (Esposito et al. 2014). Similar perverse incentives may operate with regard to patient satisfaction. When clinician and service performance is rated on the basis of patient satisfaction there is a risk this pressure may influence clinical reasoning, leading to over servicing or changed prescribing practices (Stearns et al. 2009). Further evidence from the United States presents a complex picture of the association between quality and patient satisfaction. In one study of 2953 hospitals reporting data on patient experience and surgical quality, hospitals with higher patient satisfaction were both more efficient and reported higher surgical quality (Tsai et al. 2015). Countering the link between patient experience, efficiency and quality, another study noted that patients reporting higher levels of satisfaction also had more extensive in-patient stays, greater prescription drug expenditure, and higher mortality risk (Fenton et al. 2012). These authors also reported that more satisfied patients had better mental and physical health status at baseline, suggesting patient satisfaction scores may be influenced by variability in patient characteristcs. A further complexity in attempting to understand the contribution of patient satisfaction to care quality is blurring between the concepts of patient-centered care and patient satisfaction. Although patient-centered care was the initial platform upon which patient satisfaction surveys were first employed, widely employed measures of patient satisfaction capture few of the features of patient-centered care (Rozenblum et al. 2013). Eight characteristics are viewed by patients and their family as important indicators of patient-centered care: information and education; respect for values and preferences; comfort and pain management; emotional support; care coordination; care continuity; family or significant other involvement; and the accessibility of care (Gerteis et al. 2002). Together these are taken by patients and their family as indicators of care quality. These indicators of patient-centered care contrast to the narrower set of items employed in many measures of patient satisfaction. Yet, surveys of patient satisfaction are often employed to make claims about patient-centered care. If confusion exists between these concepts among researchers, it is likely frontline clinicians may not distinguish the qualitative difference. It is also important to be mindful that the integration of nurse-sensitive outcome metrics into patient satisfaction surveys is under developed. Although patient satisfaction has been linked to care quality, the nature of the association is complex and poorly understood. Few studies have sought to examine in any detail whether activities to promote patient satisfaction impact the nature of the nurse-patient relationship. Without further substantive work in this field, there is a risk efforts to improve patient satisfaction may result in work intensification for nurses or other unintended consequences (Willis et al. 2015 (early view)). Improving patient outcomes and experience of the care journey remains a central tenet of nursing practice. Few nurses would dispute that quality of care is influenced by nurse-patient relationships. It is also likely that most nurses would agree that patients are good discriminators about the quality of their healthcare experience. In the current environment there is a risk that patient satisfaction will be taken as a proxy measure for nursing care quality. Without careful consideration of the nexus between patient satisfaction and care quality there is a risk that efforts may be directed towards improving scores on satisfaction surveys, rather than improving the patient experience and outcomes from nursing care.