The Perception of Care Versus Quality of Care

Recently, I received a letter “Thanking me” for servicing my car at a local dealership. Scripted words stated how they were looking forward to my having a “fantastic” ownership experience indicates that I will be receiving a survey in the mail. It is obvious that the dealership, based on guidance from the outside survey firm, hopes that these key phrases will become embedded in my mind as I fill out their forthcoming mailing. I believe that I am like most people and throw most of these surveys away. The real motivators for my paying attention to these flyers and letters is either boredom, frustration or, rarely, anger. The later usually generates from me a letter and a phone call.

The reason for bringing up this topic of surveying and scripting has to do with how their use has permeated hospital care. The staffs in most ERs are now taught to use scripting during all patient encounters to help boost scores on subsequent third party surveys. The phrases sound artificial and forced to my ear. I was raised by my parents with the adage that “actions speak louder than words”. Hence, with the amount of effort my colleagues, staff and I display in our patient care, have to state these phrases (referred to in the lexicon of these companies as “key drivers”) seems very disingenuous. I use them as has been requested of me. However, this is not my prime concern with the current means of surveying acute hospital care. Being polite and courteous is something that everyone should expect. I try to be such in all my endeavors, including my work as an Emergency Medicine physician. In this regard, I absolutely agree with these surveys. There are a variety of issues which I see developing from the over reliance and misapplication of the survey data

Roses and gift baskets often stream past me in the ER to the nursing station in the ICU. In a recent case, a 45-year-old father of three that we sedated and intubated on arrival in fulminant cardiac failure remembers nothing of his ordeal in the Emergency Department. Near death, my colleagues and I performed as we were trained and delivered excellent care. This patient woke up in the intensive care unit. No survey for the care we provided in the ER will be generated for this individual. Any collected data will reflect strictly the care provided in the Intensive Care Unit. Interestingly, this is precisely the type of patient that is central in the curriculum in Emergency Medicine residencies. In other words, the Emergency Department is ignored in surveys for providing the type of care the physician staff is most qualified to provide.

Recently, a physician assistant confided in me that her department head at another emergency department chastised her. She explained how she was trying to explain to a young, otherwise healthy patient with a viral illness that antibiotics are thoroughly ineffective for her and can actually be harmful. Apparently, a negative survey or phone call was the product of her trying to practice good medicine. She was told that in the future she was to provide these medications whether indicated or not because that is what the “customer wants”. The “hospital is running a business”. Her experience is not a unique vignette. This type of patient represents the focus of many of these surveys. Urgent and nonemergent patients, often with an expectation of rapid “one stop McDonald’s shopping” for care and an expectation of an immediate “cure”, often receive these surveys in the mail. Combine the acquiescing to patient demands for unnecessary tests and medications despite it being poor medicine, with the push to rapidly see and discharge low acuity patients, inappropriate and substandard care is often being provided. Unnecessary and repeat studies involving ionizing radiation, especially to children, often occur.

Television shows have given the public the belief that Emergency Departments have specialists just waiting to come out of the back room to solve any problem at a moment’s notice. Not only is that not true, but also patients have no idea what Emergency Physicians are trained to do or their fund of knowledge. It is not a uncommon experience for a patient with a chronic, nonacute illness to show up in my emergency department which has confounded their specialist. Obviously, my two weeks of residency training, for instance, in dermatology, is not going to swiftly provide an answer for such a patient. After potentially multiple hours waiting to be seen, these patients are often unhappy being informed that I will not be able to answer their concerns.

To push up satisfaction scores, narcotics are being administered and prescribed with increasing frequency regardless of the true nature of the injury or complaint. I have witnessed my colleagues prescribe Percocet and other narcotics often without checking to see how many times in the last six months an individual showed up with the very same toothache. Addiction is a large enough issue already. As mentioned before, the push to move patients through rapidly and to drive up survey scores is only adding to this problem.

Another failure of the current hospital survey system has to do with morbidity and mortality reports published in various magazines and newspapers. To the layperson, one surgeon may inappropriately be seen as a “butcher” or a hospital may seem “like a death trap”. Not taken into account is how many of the more aggressive, higher quality surgeons will take on more difficult case with, as a result, higher morbidity and mortality scores. Usually, these highly skilled individuals are located at teaching and university hospital settings. Often, they do not have a choice to accept these transfers from community hospitals. These surgeons and institutions end up being penalized in the public’s eye in published websites and print media. Their community based potentially less skilled counterparts appear better in the public eye in these publications.

An entire industry has been erected to measure the public’s perception of services offered by various forms of business. Unfortunately, the survey industry’s product doesn’t translate well for specific niches in healthcare. Emergency services selects for a unique “customer” base. This customer base is comprised of the truly ill and the desperate, those who have no where else to turn for care, as well as those with poor coping skills and a naiveté regarding emergency care realities and, on occasion, those with secondary gain interests. What is being measured is the perception of quality in care and not quality of care. The survey industry has duped the hospital administrators who are trying to promote their “businesses”. Kind, considerate, thoughtful care, with a focus on the patient is absolutely paramount. Inappropriate prescribing of antibiotics and addictive narcotics, exposure to potentially harmful unnecessary studies, especially in developing children, as well as further straining an already economically burdened health care system are just some of the products of blinding following these surveys. The survey industry has duped hospital administration into believing that the same system used to evaluate customer service at my auto dealership translates to all niches of hospital care. Obviously, it doesn’t. Blind focusing on these surveys without true reflection on their source and meaning will lead to many patients becoming victims.


  • Every time that I see hospital security toss a belligerent drunk out of the ED I remind the staff that this will not help their Press Ganey scores one bit. For some reason, none of the ED staff thinks that’s funny.

  • I don’t believe the surveys usually hit this type of individual. There is another issue with what you brought up.

    There is also a liability in “tossing out that belligerent drunk.” Not too long ago, a pair of paramedics for whom I have the utmost appreciation for walking the “regular drunk” to the ambulance. Turns out the drunk had a cervical fracture and pithed himself.

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