Monday, May 11, 2015

A very bad nut

Veruca Salt is the poster child for spoiled kids. With her demands, manipulative behavior, and spineless father, she's one of the most hated children of all time. Certainly, any parent (except her daddy) was thrilled to see her dumped down a garbage chute.

That's what you get when you give children everything they ask for. Trying to raise them to be responsible adults involves saying "no." A lot.

But, in today's world of health care, spoiling patients is apparently the goal. Even when it's against their own best interests (such as keeping them alive).

In case you haven't been near a hospital recently, "Patient Satisfaction Scores" are now the big thing. This isn't just some bullshit public-relations crap. Under the Medicare guidelines, 30% of a hospital's reimbursement is based on them. As opposed to, say, surviving brain surgery with a good outcome because of excellent care.

30% of Medicare money is a pretty decent chunk of change for any hospital. So they go along with it.

Because, ya know, if you hit the ER with crushing chest pain it's more important that someone immediately offers you a light snack than slaps an EKG on you and calls a cardiologist.

Of course, patient surveys don't ask questions about "are you happy that you had a complete recovery after your cardiac arrest/massive stroke/traumatic high speed rollover accident?" They ask if you were pleased with the food service. Or if the nurse smiled enough. Or if the call light was answered quickly.

Perspective is important. If you've suddenly lost vision in one eye, or can't move your leg, I'd hope they answer the call light quickly. If you're ringing it because you can't reach your iPhone, or your roommate is snoring too loudly, then a prompt response isn't as critical. But try telling that to the whiny person who's upset that no one answered her 5th call light in an hour (this time to ask when Survivor comes on) because the staff has been running a Code Blue across the hall. Minor things like someone elses health, or even their own, are beneath them.

The question about call lights is, really, on the survey. According to a recent article in the Atlantic, patient comments about "quality of care" have included:

"My roommate was dying... his breathing was very noisy.”

“The hospital doesn’t have Splenda.”

"I didn't get enough pastrami" (from a guy recovering after coronary artery bypass, FFS)

"This is a hospital, and you can't have it your way."

This experience was drilled into me over 20 years ago. I was a 4th year medical student doing an ICU rotation at a VA hospital (not known for having a big budget). One patient who'd been brought in for unstable angina the night before was yelling at me and a nurse because - get this - he hadn't gotten enough eggs for breakfast, and wanted more sausage links, too. My resident, a guy named Ivan, came over and said "this is not a hotel. We're trying to keep you from having to eat through a tube."

Of course (as is common at the VA) the guy yelled back that he was going to write to his congressman, and left AMA. But I digress.

The goal for us (the people on this side of the bed rail) is that you leave the hospital as reasonably intact as possible. This isn't always possible, but we do our best. But that doesn't mean you're going to get cronuts. Or HBO. Or someone to fix your TV at 2:00 a.m.

Getting you better (at least enough to go out and destroy your health again on your own watch) is our long-term goal. The guy recovering from diabetic coma may be pissed we won't give him cake and ice-cream, but that's not in his own best interests. So we have to say "no." He can go hit Baskin Robbins after leaving, but we can't control that. Like any parent trying to raise a child into a decent adult, saying "NO!" is critical here. As opposed to Veruca Salt's sniveling daddy who gives her whatever she wants and is raising a horrid brat.

Sadly, with patient satisfaction surveys, care takes a back seat. The guy who made it through a messy brain surgery may not be in a condition to fill it out, even though he had excellent care. But the junkie who didn't get Dilaudid as often as he wants? You can be sure he'll be ripping the hospital and nurses a new one.

"Look, bozo. You can't always get what you want."

Of course, the sword swings back at us, too. Let's say I give in to the "customer is always right" attitude they're pushing and let the patient have a little more bacon, or Morphine, or a cigarette. When they have another stroke you can bet they (or their heirs) will come after me with a lawsuit.

Patient satisfaction isn't necessarily the same as good patient care. In fact, it may be the opposite. One study found that the patients who were the most satisfied also had higher rates of medication use, hospital admissions... and death.

"Botched my surgery, but at least they had Splenda."

The hospital CEO's in their 25,000 square-foot offices, however, don't see it this way. They usually don't care about anything but revenue and getting that 30% out of Medicare's coffers. So a nurse who provides excellent care and catches early stages of an MI is going to be worthless compared to one who mixes up the wrong medications but has a nice smile and gives the diabetic extra ice cream. THAT'S the nurse who'll get the hospital a good survey score.

I suspect that, when this was written into Medicare law a few years ago, no one saw this as the end result. They likely believed patients (or "health care consumers") would be able to see the difference and judge accordingly. Unfortunately, human nature dictates otherwise.

I've bitched about this before, how completely worthless these online rating services are. Granted, the patient satisfaction surveys aren't quite the same, but they make the same mistake. Confusing personal satisfaction (which is subjective, variable, and wildly different from person-to-person) with good outcomes and quality of care (which can at least be somewhat more objective).

Your doctors, nurses, and all the others involved in your hospital care, are doing their best to make sure you get out of there in as good a condition as possible. But, like saying "no" to Veruca Salt, that doesn't mean it will always make you satisfied with us. But, for her own good, it would have made her into a better person. Or, in this case, a healthier one.

Thank you, SMOD!


Anonymous said...

A standing ovation to you, good sir!

You are a good golden egg.

Anonymous said...

Welcome to our world! You'll be really thrilled when they add the question that asks the patient to rate their doctor's knowledge of medicine on a scale from 1 to 6.


The Professor

Loki said...

One needs only to look at reviews for books to see just how insane a fraction of the population is always going to be on customer satisfaction surveys. I have seen book reviews given a one-star rating, not because of any flaw with the book, but because the book shipped in a separate package from the rest of the customer's order.

With a book review, this is asinine, but relatively harmless. (Though I'm sure the author would love to strangle that person - with good reason.) With healthcare compensation being weighted that much by such things...that's horrifying to me.

Anonymous said...

Same in Australia... food quality and TV availability easily trump quality of care. As long as the patient satisfaction surveys are ok, management keep their jobs. And don't get me started on Doctor tracking...

Ivan Ilyich said...

Are you not allowed to say its name (P-G, and I don't mean Proctor & Gamble)?

Candi said...

I have major opinions that ask for subjectives to issue payments rather than objectives.

The questions should be of the "Did you leave the hospital alive?" rather than the "Did the nurse fluff your pillow enough?" type.

And the CEOs need to get out of their ivory towers and do janitorial work or something in the ER or ICU once in a while. Something where they can see what's going on.

Anonymous said...

As a co-worker nurse friend says "We might kill you, but at least we did it with a smile"

Anonymous said...

Thank you, thank you, thank you. As a bedside nurse (NICU and PICU), I have not gotten a raise because our unit's Press Gainey scores were low. Comments included things like, "the parking lot is too far away, " and "the food in the cafeteria is of poor quality." None of the comments had anything to do with my quality of nursing. I'm about to leave the bedside and start my new role as a nurse practitioner, and I'm sure it won't be any better.

Packer said...

Strange , I recently took a patient survey and it asked questions about sanitary conditions of the facility, and went on to explain that once goal was to limit spread of hospital infections. Further it went on to ask about outcome of treatment. It asked about professional demeanor of staff. Not a think about pastrami, tv or splenda.

Anonymous said...

I'veyet to be handed a patient satisfaction survey at any healthcare facility I have had to deal with for my grandmother recently. I however will be contacting state regulatory agencies based on medication errors that occurred repeatedly. And no we arent talking not handing out morhine Quite the contrary. Overdosing patient's, lack of medication reconcilliation, and being refused a consultation pharmacist when requested.

As you said the hospital was great with keeping room looking clean (npotived I said looking- when ou carry a toilet brush across the room dripping that aint clean no matter how you slice it!), serving meals on time etc, but those kind of things just dont matter when someone almost dies because of the errors that have occured.

Anonymous said...

Same goes for student evaluations of college courses. While these are of some use for detecting unexpected problems, a high level of satisfaction can't be the goal. The students don't know if they've been taught well until they get to the next course and see if they were prepared. At evaluation time, all they want is for the course to have been easy.

Anonymous said...

As a patient I would like nurses who don't make up vital statistics for me because it's too much bother to take a blood pressure reading... but I guess that'd slow 'em down too much. (And, good lord, if you're going to lie about what you told me over the phone, at least make sure I'm too drunk or stupid to notice first. Chances are I won't complain effectively enough to make you lose your job anyway, but my opinion of you is going to go way down.)

But, ummm... anyway. Yeah, badly written quality surveys are a stupid way to figure compensation.

Anonymous said...

I continue with the standing ovation!! As a neurotrauma nurse, I get so many complaints when I won't let the family feed a stroke patient a big fat burger or something. Do you not hear him gurgling and choking?? No matter how many times I explain that they will probably go to ICU since they can't even manage their own secretions, the response is "But they haven't eaten since last night!" The fact that I spend most of my time setting boundaries like, the night stock of food is NOT for people that had three dinners does not seem to register. I do love my job but sometimes I wonder when I went back to serving people, not saving them.

Officer Cynical said...

The nurses NEVER smile at me when I drag in some combative, .25 BAC DWI for a blood draw. Who do I complain to about that???

Tsunoba said...

I'll admit, I'm guilty of not filling out those surveys.

With the knowledge you've provided in this PSA, though, I'll fill one out if I end up in the ER again.

bobbie said...


HeroHog said...

Same goes for other industries, most notably, your local cable "provider." Take, for example, ComCrap. Every call about the horrendous service and constant unresolved issues is a craftily worded "survey" about my "service" for that call's "TECHNICIAN." None of the questions involve satisfaction with weather the issue was actually resolved or the same one I have called about every month for 2 years about. It's all "was the person polite?" Yes, no help! Arrrrgh!

Anonymous said...

Yep! After hospitalization, I got that survey form. There was no place to tell about the 14 hours in ER on npo orders and the nurse kept trying to give me a cup of water-which she had contaminated by sticking her fingers inside the rim. Or the fact that it took 10 hours for my meds to come from the pharmacy and when they did, there was no heart pill which I should have taken about 4 hours prior but there was the medication I take only 4 times a year.

But I could tell them about smiles and greetings by name.

PGYx said...

+1 million. Now if we could just force news networks to read this aloud around the clock as "Breaking News." For a month.

Anonymous said...

Retail pharmacy is the same way. Nobody cares that they received the correct medicine for the correct patient with the correct directions printed on it. They complain that it took 30 minutes to prepare, or that we didn't address their presence within 2 seconds of walking up to the counter.

Anonymous said...

I did an in-patient survey once. The first question they asked was, "What is the most important thing to you in this hospital?" and I answered, "Communication. I like when my doctors to talk to me about what is going on, what i have, how long I'll be here for, and what the plan is."

And they stopped, and looked at their list, and turned red. So I said, "What? What's wrong?"

And they said, "Um, there's no box for that. But you can say things like, cheap parking or variety on your menu!" FFS.

But seriously, please don't blame the patients because the administration sucks balls. That's like blaming the cashier because head office changed the secret sauce recipe on your Big Mac.

Anonymous said...

I am going to get a "bad rating" from the patient I had the other night. She had been extubated that day and kept pulling her O2 off. And fighting me claw and tooth every time I tried to put it back on. So I tied her hands down. I told her I wasn't trying to be mean, just trying to keep her alive. She didn't care and just gave me a look from hell. And there is where ethical care will get me. I feel like she wasn't with it enough to make rational decisions, but you can be damn sure she will tell case management that I tied her down against her will. She was still alive at the end of my shift and if I get in trouble, at least she lives.

Anonymous said...

I was in the hospital twice in the last year and did not get a survey for either hospital. I am in NYS, I don't have medicare, and I have bipolar disorder. I bet I could gave a very useful information and be able to identify positive and negatives accurately. Do you suppose I did not get a survey because of my mental illness diagnosis?

Anonymous said...

First, I always thought Verruca Salt was a particularly apt name for a disgusting little twerp, although I do know someone named Candida. However, I do not know anyone at all whose name is Chlamydia.

Second, the idea of these surveys that one finds regularly on the internet is boorish in intent. Even I have a patient satisfaction survey about me, and no one who's ever been a patient in the hospital has ever met me. But, still there I am, and people can say whatever they want at the patient satisfaction survey site because my name has been pulled from a hospital employee database.

Third, it's been long known that these 'so called' satisfaction surveys are tipped to the balance of the default. For example, the word agnostic is derogatorily tipped to the balance of 'believers' and not to atheists to whom the descriptor means nothing if they're a true atheist. People that would fill out a survey are much more likely to respond to a singular insignificant detracting incident than the best, most euphoric response in the world. How many people are going to compliment pain relief to a '3' on a scale of 1-10 when they started at an '8' and think that complete satisfaction is '0'?

But, the worst of it is, how often will the care-provider that is already doing his/her best do something less effective and not additive to 'care' just to recoup a more showy higher number? And, what does the patient think of their care if it arrives unaccompanied by red roses, thornless to be sure, but something ostentatious?

nyllrap said...

Reading all of this made me so sad. About 5 years ago, I spent 6 months in the hospital with severe acute necrotizing pancreatitis. Overall, I had excellent care, because in fact, depsite very low odds, I survived and am doing great now. There were some problems, of course, in such a lengthy hospitalization. One mistake or bad decision by a nurse resulted in a 4 month use of a wound vac, in addition to nothing by mouth for several months. But I realized mistakes do happen and I tried my best to be a good patient, while speaking up when I felt I needed to. The bottom line, as Dr. Grumpy said, was I recovered, and give God, my doctors, and my nurses credit for it. Whether or not the food was all that great didn't mean a whole lot to me.

rapnzl rn said...

It would be terrific to see an 'expose' piece of investigative journalism on just how many hospital employees were sent packing as a result of P-G. However, I would settle for a black box warning on the top of each survey, stating that 'answering these questions may be detremental to your prognosis'.

Thanks, Dr. G. and AMEN!

Kate said...

I'm so glad you wrote about this. I think this article also articulates the problem very well:

Candi said...

Hey, my name's Candida!

Quick name history lesson: In the Latin, Candida is used in the scientific name of a fungus. But in the Teutonic/Germanic ancestry languages, it means "light bright" or "light white".

The hospital where I had my kids tries their best to serve good, appetizing food -but don't you dare try to circumvent doctor's diet orders. The kitchen will check.

Anonymous said...

To one anonymous -- hope you had an order for those retraints!

To another anonymous...I knew a Sue Demonas.

Anonymous said...

You are right, of course. Multiple choice surveys that put the focus on a spa-type experience are worse than useless (unless they are sent out by some spa, of course). But I read this just before heading out to meet with a top hospital administrator about the recent time when I took my friend to the ER, and we spent over 20 minutes in the waiting room before anyone responded - other than to say they couldn't do anything for us - to our clear - and repeated - statement that my friend was suffering from severe chest pains. There's gotta be a way for hospitals to know about those incidents and to be held accountable for them. Fortunately, my friend survived.

Anonymous said...

Sorry about the name gaffe, Candida. I tripped and fell on my own nose. I apologize. Now, you made me look it up. I found that it has a beautiful meaning referring to pure dazzling, glowing white color, like neon white. And, I realize the name Candida came first, before the medical terminology. So, now I am becoming a proponent of more academic names for medical ailments, and wondering why some crank gave a particular organism such a beautiful name. If you like, you may call a chicken pox scar by my name-- Mary.-

Still, however, I cannot completely purge the picture of my ugly plantar warts from my head whenever anyone mentions Verucca Salts. I could try, though, if I met someone who was nicer than Miss V. Salt.

RehabRN said...

Of course (as is common at the VA) the guy yelled back that he was going to write to his congressman, and left AMA. But I digress.

Welcome to my world, Doc.

BTW I worked at a private rehab (Saintarama) where the biggest complaint on the survey was the selection of TV channels. We did manage to bump the "willingness to recommend" scores.

Spook, RN said...

Having supportive management really helps deal with the BS.
I was once called into my managers office for the following:
Manager: Hey Spook. Sorry to bring you in but policy states that all complaints have to be addressed.
Me: Ok, what's up?
Manager: Patient wrote on the survey that she asked for a glass of ice water...
Me: Yeeah. And?
Manager: Well, she asked for a glass with six ice cubes. You brought her a glass with about a dozen ice cubes.
Me: *blink* *blink* Wow! Really?!
manager: *throwing hands up* Just following policy Spook. All complaints must be addressed. Just keep the patients requests in mind next time, huh?

Nope. Not making that up.

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