Improving Quality Through Satisfaction: A Four-Part Series

Part 1: A New Way of Thinking About Quality Improvement
Part 2: A Happy Patient: What Drives Patient Satisfaction?
Part 3: A Happy Provider: Strategies to Increase Employee Satisfaction
Part 4: Communication Approach: Using Best Practice

Introduction
In our last article, we supported a patient-centered way of thinking about quality improvement. More specifically, we addressed how a shift in focus to improved patient interaction and communication standards can impact the patient experience and, thus, influence patient satisfaction of care. We also mentioned that higher scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) are positively correlated with cost savings and staff engagement.¹ As patient satisfaction is one of the two measurements for quality care, determining what drives patient satisfaction is a strategic place to start.

Positive patient experience metrics also have an association with more objective clinical quality measure scores like improved health outcomes.² Enhanced patient satisfaction is shown to have better patient engagement and therefore greater adherence to treatment plans and follow-up. Satisfied patients are more likely to come in for visits and trust their providers. Furthermore, healthcare organizations with higher measures of patient experience scores are associated with a stronger sense of teamwork and commitment to improvement.³

Influences on the Patient Experience
There are several factors that affect the patient experience and resulting patient satisfaction. In addition to the interpersonal relationship between a provider and patient, there is also technical quality, environmental quality, and administrative quality. These additional factors might include the perceived atmosphere of a clinic, perceptions of expertise and outcomes, and timeliness involving wait times, hours of operation, and appointment waiting lists.⁴ While these factors should be considered, in this article we will focus on the effects of the interpersonal relationship as studies have found that the strongest impact on patient satisfaction is the care provider’s interaction with the patient.^{5, 6}

In a Stanford Healthcare article titled, Press Ganey again? Strategies for improving the patient experience, the Author Ann Weinacker, summarizes patient’s priorities in this passage:

“Nearly a decade ago an article in the Wall Street Journal said that "people place more importance on doctors' interpersonal skills than their medical judgment or experience," and a Harris Poll showed that the main thing patients want from us is to be treated with dignity and respect. Other characteristics on the list are that we listen carefully to patients' health concerns and take them seriously, that we are easy to talk to and are willing to spend enough time with them and that we truly care about them.”⁵

In a more recent study that analyzed patient satisfaction surveys to determine which attributes most affect patient satisfaction, authors concluded that the care provider’s interaction with the patient was the most impactful.⁶ Patients are most satisfied when their provider’s communication style supports their needs for active listening, support for autonomy, and demonstration of an empathetic perspective. All in all, a satisfied patient is one who is adequately informed but also adequately validated. Moreover, when active listening and displays of provider empathy are present there is less resistance and an improved sense of collaboration and positive rapport.

In a classic study that supports a Motivational Interviewing and Rogerian Psychotherapy emphasis on empathy and reflective listening, researchers evaluated the impact of two counseling styles: one emphasized providing information (Teach) and advice (Direct) and one focused on reflective listening. They concluded that Teach/Direct increased client resistance by 70% in contrast to empathic listening.⁷ We will address more specifics on the importance of using evidence-based communication strategies, such as motivational interviewing, in our upcoming Part 4: Communication: Where It All Begins (and Ends).

Importance of Empathy
Empathetic or reflective listening is a therapeutic skill that involves a commitment to understanding the patient’s personal worldview and perspective, then accurately reflecting its meaning back to them. With a focus on what the patient is saying and experiencing the conversation becomes less of a “teach and direct” session and more of a collaborative conversation where the patient is more likely to be engaged. This type of listening is pervasive in balanced, collaborative provider/patient relationships and can effectively improve the patient experience and patient satisfaction. One study found that perceived provider empathy led to better exchange of information, partnership, increased perception of physician expertise, increased interpersonal trust, and a positive correlation with patient satisfaction.⁸ In another study, clinicians who were more empathetic had more patients with better results and less medical complications than their less empathetic colleagues.⁹ On the flip side, authoritarian confrontation – essentially the foil of an empathic listening style – has consistently been associated in clinical trials with no change or adverse outcomes in addiction treatment.⁷

Summary
Most of the research in empathy has been done in the addictions and counseling world. In short, high-empathy counselors appear to have higher success rates regardless of theoretical orientation. Low-empathy and confrontational counseling, in contrast, has been associated with higher drop-out and relapse rates, weaker therapeutic alliance, and less client change. Because of the importance of improving the patient experience and the clear link between patient satisfaction and an empathetic approach, this topic merits both scientific investigation and greater emphasis in healthcare treatment endeavors. If empathy can be designated as an evidence-based element of the therapeutic relationship in healthcare, it makes sense for training programs to implement competence-based criteria for educating practitioners in relationship and communication elements. Patient satisfaction increases if they feel they are listened to, respected, and valued as individuals. Lastly, it’s important to remind our stakeholders and management that these are more than just warm and fuzzy peripheral efforts; the measure and management of patient satisfaction has become a top priority at health systems across the country and multiple studies have demonstrated that clinicians with higher rated levels of empathy have markedly better outcomes than other clinicians.¹⁰

References:

¹ Hospital Consumer Assessment for Healthcare Providers and Systems. Centers for Medicare & Medicaid Services, Baltimore, MD. Accessed November 16, 2016. Available at: http://www.hcahpsonline.org

² Manary MP, Boulding W, Staelin R, et al. The Patient Experience and Health Outcomes. New Engl J Med  2013;368(3):201–3.

³ Mehta, Shivan J. Patient Satisfaction Reporting and Its Implications for Patient Care. AMA J Ethics 2015; 17(7):616-21.

⁴ Dagger TS, Sweeney JC, Johnson LW. A Hierarchical Model of Health Service Quality: Scale Development and Investigation of an Integrated Model. J Service Res 2007;10(2):123-142.

⁵ Ann Weinacker. Press Ganey Again? Strategies for Improving the Patient Experience. Stanford Health Care. Accessed on October 11, 2016. Available at: https://stanfordhealthcare.org/health-care-professionals/medical-staff/m...

⁶ Johnson DM, Russell RS. SEM of Service Quality to Predict Overall Patient Satisfaction in Medical Clinics: A Case Study. Qual Manag J. 2015;22(4):18–36.

⁷ Moyers TB, Miller WR. Is low therapist empathy toxic? Psychol Addict Behav 2013;27(3):878–84.

⁸ Kim SS. The Effects of Physician Empathy on Patient Satisfaction and Compliance. Eval Health Prof 2004 Jan;27(3):237–51.

⁹ Del Canale S, Louis DZ, Maio V, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med 2012;87(9):1243-9

¹⁰ The Rising Importance of Patient Satisfaction in a Value-Based Environment. API Healthcare. 2015. Accessed on November 16, 2016. Available at:https://apihealthcare.com/sites/default/files/MC_CL_PAS_PPA_0000000001.pdf

¹¹ Allen ML, Cook BL, Carson N, et al. Patient-Provider Therapeutic Alliance Contributes to Patient Activation in Community Mental Health Clinics. Adm Policy Ment Health 2015:1-10. doi: 10.1007/s10488-015-0655-8

¹² Mosen DM, Schmittdiel J, Hibbard J, et al. Is Patient Activation Associated With Outcomes of Care for Adults With Chronic Conditions? J Ambul Care Manag 2007;30(1):21–9.