20 August 2009

In defense of Press-Ganey

Boy, if there's one thing that ER docs are coming to hate, it's Press-Ganey.  The tales of its misuse by poorly informed managers are legion.  Dr Brenner had another frustrating one yesterday : Dr. Brenner's Thoughts on Healthcare: My own private Press-Ganey Hell
I started a new job in January, and from the get-go had great PG scores. Of course, the sampling was low, so nothing was statistically significant. Once I got one unhappy patient, it killed my score. So 4 excellent scores and 1 bad one = Very bad PG score. But despite that, my scores were still in the top 80%. And stayed that way until June.

All of a sudden, in June my scores dropped to 1%. I naturally assumed I must have gotten a bunch of really bad reviews. Bad luck? Bad day for me? I didn't know. We have a binder that has the recent PG reviews for the department, and looking in there, all the reviews were 5's. The highest. I didn't get it.

The inevitable happened. My administrator saw my scores and insisted I be rehabilitated.
Boy, that's painful.  And I won't reveal the kicker, but it gets worse.  So whose fault is this?  Is it the fault of Press-Ganey?  Well, maybe.  Data collection is a finicky business, and the results are only as good as the process that brings them forth.  But I would contend that the fault lies not in the data itself, but in that of her medical director and hospital administration, who seem to be afflicted with that common disease of statistical innumeracy.  Can an "n" of five give valid information on an individual practitioner?  Of course not!  It's stupidity itself to try to break down the results to such a level of detail with such a low sampling model.

We use P-G ourselves, and with 110,000 visits and a relatively high sampling ratio, we still don't get enough information on each doc to provide meaningful practitioner-level ratings.  We distribute them, for informational purposes, but we don't use them in any way at that level.  There's been talk about incentivizing docs to provide exceptional service by incorporating P-G into the compensation system somehow.  I'm a huge believer in the theory that you get the behavior that you incentivize, so I am interested in the notion.  But it's a ludicrous impossibility without cleaner, more valid data that quite honestly does not exist.

There's a clear sentiment in Dr Brenner's post, as well as the rantings of multiple other ER bloggers out there, that the whole notion of "patient satisfaction" is wrongheaded and perverse.  For example: How Press-Ganey is changing medicine
I've always practiced that educating your patients in the ER is the best medicine. Whether on nutrition or the nature of their disease process, my patients always appreciate it. Or so I thought. Now I'm being told that my patients don't want to hear that. They don't want to be told to quit smoking. [...] They want that prescription for a z-pack. They want their vicodin. They want that head CT or that MRI and especially that foot xray for that stubbed toe.
Sorta.  I agree that patient's agendas when they come to the ER can be ill-informed, and we make it clear to our ER docs that we do not want them handing out inappropriate prescriptions (etc), and that we will back them up if we receive patient complaints that pertain to that sort of thing.  However, when you look at P-G feedback in large quantities, the typical complaints or illustrative comments reveal that other factors are the critical elements in patient dissatisfaction.  I've reviewed hundreds, if not thousands of these comments, and several themes have emerged that provide very useful information on how we can serve out patients better.

To answer the question: What are the key drivers of patient satisfaction?  These elements seem to matter most:
  • Patients want to be placed in the treatment area promptly and seen by a provider in a timely manner.
  • Patients want their doctors and their nurses to be polite and respectful.
  • Patients want to feel that their physician listened to them.
  • Patients want to feel like their caregivers cared about their comfort.
I don't think there's anything controversial on that list.  But how do you use it?  You design processes and procedures that reflect the patients' priorities as well as the medical necessities of the ER.

The Bed-to-door time and door-to-doc times correlate dramatically with the top-level "likelihood to recommend" patient satisfaction score.   Patients hate waiting, and I do too, when I have been a patient.  Further, this is not an unreasonable expectation on the part of patients.  If the wait times are averaging an hour or more, then your ER is underperforming (dramatically) in this arena and it's predictable that the P-G numbers will reflect that.  Whole books have been written about optimizing ER patient flow, so I'll not belabor the point.  Still it must be noted that this alone is probably the single most important factor in overall satisfaction. 

The other elements relate more to the human factor: how does your staff interact with patients?  It's pointless and wrongheaded to single out and stigmatize individual providers for "failing" their P-G, but it is useful and productive to emphasize to all the staff, from Doctors to Unit Clerks and Registrars, that these factors matter, and that patient satisfaction is important.  Providing education and reinforcement to all staffers for such things as "active listening" techniques, developing scripts to standardize certain communications, and teaching your staff what sort of things patients tell us they care about all are fundamental to improving your department's scores.

Remember that when patients talk about their "comfort" that they are not necessarily talking about narcotics.  That's a common assumption in this age of frequent fliers and drug-seekers.  To the average patient, the ER is a bewildering and uncomfortable place to be.  Little things like getting the patient a warm blanket, a pillow, pulling the curtain for their privacy, or finding a chair for their family member are incredibly important to patients.  Telling them your name, or reminding them of their doctor's name.  Again, when you train your staff in these things, when you let them know that they matter and you get buy-in from the caregivers in the ER, then you start to see cultures change, and scores improve.

How do I know this?  We've lived it.  A number of years ago, I'm not proud to say that our ER was the worst in the nation in P-G scores: the 1st percentile.  Rock bottom.  Nothing like sitting down with your CEO and explaining why you're the worst ER in the whole country to give you some incentive to improve.  So we set about a comprehensive improvement project.  It has taken years, but we've turned the corner.  It also takes partnering with the hospital administration.  There may be a need for additional resources: If the ER is so understaffed that nurses can barely provide safe patient care, it's going to be hard for them to spend time getting warm blankets.  If half the beds are full of boarded patients, then wait times will remain long and scores will never improve.  And so on.  And it also takes an understanding of how to read and how to use the data.  A few years back, we hired a doc whose individual P-G scores at his old hospital were always in the 99th percentile.  When he came to us, his scores plummeted to near our physicians' group average.  The moral to that it that it's the institution as much or more than the individual that determines how a provider will be ranked.

"You can't manage what you can't measure," is the old management aphorism.  P-G is imperfect in many ways.  But it's a useful yardstick for comparing one ER to another, and more importantly for comparing your ER today to your ER last year.   Ultimately, Press-Ganey is just a tool, one among many.  It can be used well, poorly, or not at all.  My experience, from a management perspective, is that it can be a valuable part of an overall process improvement initiative in the ER. 

56 comments:

Reality Rounds said...

I don't know. I work in OB and we also use Press-Ganey, but we have different key drivers. It just seems so weird to me when we have management telling us to "script" how we talk to patients to improve our PG scores. We are scripted to say "I hope your care has been EXCELLENT today," so the patients will mark excellent care on the survey. I feel like a Stepford Nurse.

Dr. Brenner said...

Thanks for the detailed comments on my post. I have added many things in my comments section that reflect much of what you say here: that efficient throughput is essential for good patient (and staff) satisfaction.

I do have a problem with how the PG is compiled. And even the questions. I too assume that pt comfort meant pain relief. After all, what do I have to do with the temperature in the room. Believe me, I've tried to make it warmer in the ER since I am always cold, but I lose that battle. Perhaps comfort should be better defined. Or multiple choice selections could be used for more uniformity.

And besides the PG flawed nature, I believe it is misused by administration. Poor scores are an indicator of a problem, certainly as an overall trend. If half the docs in a group are in the 90s and half are <20, and that is consistent month after month, there can be some basis to find out what the 90s people are doing right and what the <20s docs are doing wrong. But when my numbers fluctuate wildly from month to month, it is useless.

Nurse K said...

We started doing things to improve door-to-bed times, patient rounding, and even staffed up an additional nurse, etc, and our Press-Ganey scores went DOWN. The faster you put people in beds, the slower the slow docs seem. We're taking people from the waiting room with the flat screen TV and putting them in a room with no entertainment to be in the queue to be seen by a doctor only seeing 1 patient per hour, sometimes waiting there to ruminate on their pain for 2 or more hours. Then they start hitting the call light over and over bothering the staff asking repetitive questions and assume we're just ignoring them even with repeated assurances to the contrary.

No one cares about physician speed. At some point, people are going to have to get off their ass and see the patients and not keep them there for 12 hour work-ups, etc. I think if the docs are behind, we should keep 'em in the waiting room with the TV personally unless it's a truly urgent problem.

shadowfax said...

K,

This is weird for me to say: you are totally right. We track the door-to-bed time and the bed-to-doc time so we can identify the bottlenecks in patient flow. But to the patient, what they care about is the door-to-doc time. If the docs are the rate-limiting step, then putting patients in the room faster doesn't help. (TVs in the room do help, I suppose.)

Sounds like your medical director needs to either do some coaching or do some firing.

Anonymous said...

my hospital is now taking in new clientele after two local hospital closures in the past 6 months. these new patients are generally speaking more underserved, hostile, get-your-primary-care-in-the-ED types and predictably our hospital scores have plunged.

the ceo responded by telling our dept chair to fire anyone that can't get their score (averaged over a year) over 80%. the chair told him that's five of his docs... the place will collapse if he fires 5 FTE's.

his compromise was a mass email sent last week telling us if our scores for '09 don't average 80% or higher at the end of the year, we get no raise. no mention of satisfaction scores in our contracts.

care to defend that?

Nurse K said...

Sounds like your medical director needs to either do some coaching or do some firing.

Please come work for us. Please. Turn this shit around. I'll make your job easy and you can take all the credit: (1) Don't pay the docs by the hour (2) Give raises since they aren't paying ER doc market rates at my hospital and have no chance of replacing the ones they'd fire if they did (3) Don't schedule the docs 220 hours/month (4) Instead of giving the slow ones bullshit office jobs (32 hrs/week doing the doc schedule for 10 doctors?!???), fire them, and use the saved money to hire new doctors that don't suck. (5) Go private instead of being hospital employees so that there is an incentive to save money and work harder (6) Ask me who we should hire!!!!

Silvertop said...

We know (hugely big urban ED)if we "inform our patients about delays" our scores will improve. Getting the doctors' cooperation in any scheme to inform patients has been like climbing Mount Everest. To the rest of us who are trying to improve the whole patient experience, it would seem doctors don't want anyone expecting them within a defined time period. Is it the loss of autonomy?

Dr. Brenner said...

K, I am astounded at how your ER runs. I didn't know there were ERs like that anymore. You are right, a part RVU model would change things immediately. Clearly the docs have lived in a world that does not exist anywhere else and should start pulling their weight.

Anonymous: you feel my pain. What the administrator is asking is unreasonable if you are seeing 1.7-2.5 patients per hour. As movin meat posted, there are processes that can be put into place to improve scores. Docs have their role, but the Hospital needs to take responsibility for their part too. Your situation is the reason why I wrote my blog.

Silvertop, why do you need to give a defined period of time when informing pts of delays? Simply inform the patient that it is busy in the ER and the doctor is involved with another patient and will be in as soon as they can. Giving them a specific time sets the doc up for failure if they get tied up with other patients. Use the Disney way as a model. When u go to disney, you expect to wait on line. They post an expected wait, but it can be more or less than that. Usually less. You feel like you make some progress, so you are not upset. If it takes less time than expected you are happy. If it take more time, you are upset. If you have to be specific w/patients, I would err on the side of a much longer wait, to lower expectations, and allow your docs to meet them.

shadowfax said...

Anon 5:33,

No defense. Sounds like terrible management (also endemic in healthcare).

Silvertop,

You're right that it helps if patients are informed of expected delays (and I agree that "underpromise and overdeliver" is the right strategy there. A bigger problem is that if the docs are not on board. Getting buy-in from the staff at ALL levels is essential to making change. When you have docs who question whether patient sat is even important, it undermines the whole team's efforts.

Leigh said...

Honestly, using the PG percentile rankings for individuals is not useful. I've even educated the Trustees at my institution on this. The percentiles are only useful in terms of seeing what's happening in the external environment.

I stress mean scores with all staff. We use mean scores to measure improvement. I'm my hospital's resident quality geek. I'm a nurse who can do stats and explain them.

Now, Press Ganey gets a bad wrap and frankly I think it's because caregivers and administrators don't take the time to really understand what information Press Ganey is really supplying a facility. It's not supplying an evaluation method for caregivers, it's supplying information on how the community in general views the facility and it also gives information on certain systems issues (door-to-doc time for instance).

Feedback from our patients, in whatever form, is fundementally good. Our patients shouldn't be expected to understand "us," we need to strive to understand "them."

If Administration is coming down on you for PG scores, then engage your quality folks to help explain the stats to administration. I know I finally made a convert of a neighboring hospital's quality person and now her hospital is engaged in active improvement around PG scores and not just beating people over the head with them.

There is a lot that can be done with data provided by PG. It just has to be kept in the right perspective.

Leigh

Catron said...

Having worked in two hospitals with the poor judgment to use PG, I have to agree with Dr. Brenner.

PG's surveys are statistically meaningless. For any survey to be representative of any population, the respondents must be chosen randomly. And PG's surveys fail that test.

The initial patient selection process is allegedly random (though I have my doubts), but the actual respondents constitute a self-selected subset of the original group.

PG is the Milli Vanilli of patient satisfaction surveys, and it is idiocy for any hospital to use its data as the basis for the formulation of policy.

shadowfax said...

Milli vanilli? ten points for the obscure reference.

Anyway, I agree that the response bias of P-G precludes using it as any sort of objective yardstick (especially, as I have said, of individual performance). However, it's safe to assume that the respondent bias will be stable over time and as such it becomes an extremely useful tool to compare your performance today to that of last year (and next year).

Also, it's reasonable to assume that the respondent bias will be similar from community to community (so long as you compare like facilities -- suburban to suburban, academic to academic, etc) and so you can compare hospital X to its peers reasonably well, too.

pdx rn said...

What I find irritating is its usually the doctors that are causing the long waits that get the best scores. Even if people have waited hours in the lobby, if they end up with the doctor that does the 12 hour work up they're thrilled. They love all the unnecessary tests etc. So everyone else's scores plummet while Dr Can't Dispo a Pt's scores are the best in the department.

This works for nursing too. The nurse that can only look after one patient at a time gets a glowing letter about how caring she was while the nurse that took up the slack gets three letters criticizing how "hurried she was".

And of course there is the issue of patients not always wanting what is best for them. Dr Murray would have gotten excellent P-G's from Michael Jackson.

Regarding time estimates: At triage especially I always give people an inside and outside estimate. "Your wait at triage will be about 1/2 to 1 and 1/2 hours, hopefully closer to 1/2." That way you're not discouraging them by intentionally giving them longer than you think its going to be and risking them eloping. Nor or you going to have them angry if you don't tell them long enough.

Silvertop said...

The single most issue correlated with satisfaction in an ED is time information. One can argue about the beauty of PG data, but if you look at PG's own studies of all their ED contracts (called Pulse report..find on PG website) you will see with an n of millions, if you inform patients about delays, you can even wait up to six hours and still receive the sought after "5" Just this week (My system actually has 3 adult ED's and one PEDS) a man was told it looks about 3 hours before you will see the provider. He said, and I quote "That sucks, but I'm sure glad you told me." We can compare the EDs by service date once we began a process to inform..the one ED where the leadership MDs wouldn't buy in are still in the single digits, but the other 3 are experiencing lift off.
I've been doing this work for many many years, and I watch staff go through, almost like the 5 stages of dying, all sorts of defense mechanisms until they settle down and believe this survey is a legitimate pipeline for patients to let you know how they are being treated. If you want to improve your reputation in the community you serve, and want to be a "player" in the marketplace, you will use the data wisely and not personally..what other sources do you have other than your own sensibilities and egos.

pdx rn said...

My question is, since we all know its waiting and time that improves patient satisfaction, why don't we take the hundreds of thousands of dollars that we pay those P-G people and instead of paying them, use it for additional staffing to improve flow?

Or to study flow? So we can improve it.

We all know who it is that's causing back-ups in our departments. We all know who the buttheads are that don't have good bedside manor. We don't need to pay P-G to tell us. Its money that could be spent elsewhere.

How many nursing FTE's go to pay for that P-G BS?

Silvertop said...

You can't manage it if you can't measure it..throwing more staff at the problem can intensify the behaviors that are getting you in trouble in the first place..it's often not the number of nurses, but the recognition that clinical skill MUST be coupled with humanistic, service behaviors. The kid with an earache is bread and butter, but how do we treat them? We'd rather have a cardiac arrest or multiple trauma..., and that shows, no matter how many nurses you have.

pdx rn said...

Silvertop, you don't need to pay P-G hundreds of thousands of dollars to pay attention to customer feedback. If you're getting complaints about certain nurses and doctors bedside manner or rudeness then you know you've got a problem. If you pay attention to the individual complaints on a complaint by complaint basis you can evaluate their validity. Was the patient upset because Dr X was rude to them or because he wouldn't feed their narcotic addiction.

Study the flow. Are the physicians making patients wait too long or is your lab taking too long for their turn around?

Listen to your staff. Is that Dr Q who all the patients love keeping his beds full with 1 turn around for his entire shift? Yep, his patients might love him but the 30 patients in the lobby that have to wait 3 hours to be seen because he's log jamming don't like the doctor they see.

None of this is reflected in a P-G score.

Listen to your coworkers and see how they interact with patients and what works for them. Learn from them and from experience. Not from insincere P-G scripting.

Tell your patient "i'm glad you came in. I'm sorry you have to wait." And mean it.

Silvertop said...

Wake up..it's not about the validity of complaints, it's always been about the customer's perception. A select few are impossible and bring misery wherever they go, drug seeking, attention-getting...but the majority who come, just have their own points of view.. the PG isn't the bible, but benchmarked measurement is. HCAHPS is now mandatory in acute care..next year is Home Care's turn. Have you seen the website drscore.com?
What you suggest is the age-old practice of "we know best." that's how we got where we are.

pdx rn said...

No, its not "we know best", its use some frigging common sense and judgment.

Why substitute "we know best" with Press Ganey knows best.

Press Ganey is just a fad. Millions of health care dollars that could be used on patient care are being thrown at these guys so they can make charts and graphs.

Its a joke.

Customer perception is not the most important factor when delivering health care. We're not working at Burger King. Our first obligation is to deliver good health care, not hold the pickle, hold the lettuce, special orders don't upset us. We have standards to uphold. We need to do what's right for the patient's health and that isn't necessarily what they want.

And we have to weigh the needs of each individual patient against the needs of every other patient in the department.

What the hospitals should be doing instead of hiring Press Ganey to measure patient satisfaction is perhaps maybe an advertising campaign to educate the public about the realities of modern medicine. Maybe those millions of dollars could be better spent on a campaign explaining to people why their waiting. How about an ad campaign with a theme of "Don't be an ass when you go to the ER"

Silvertop said...

I am sincerely enjoying this dialogue because we believe in the same thing... which is taking care of our patients with clinical and service excellence. Health care systems are forced to measure, there is no escape, and wouldn't you weigh yourself regularly if you went on a diet, or measure your heart rate in cardio fitness? In 40 years in hospitals, I can attest to the complex systems we create for our own convenience and the hires we do without thinking of the individual's ability to "play well with others." I have data to show you the reduction in litigation when we pay better attention to patients and families..so they feel heard and not dismissed. It's good business and good medicine to treat people as they need and want to be treated, regardless of acuity etc. And, the literature will tell you about the bad things that happen while people are waiting, such as the death in a Brooklyn ED waiting room. We now round in these areas. And why not get credit for improving..on measurement...and, there is plenty of proof that staff and patients are mutually dependent on the others' feelings of satisfaction. The money it takes to measure is the cost of doing business.

pdx rn said...

My point is P-G scores are not an accurate measurement of who and what is good customer service.

I will give you an example.

15 bed ER with 2 docs on. Doc A is slow as molasses. He comes on shift and fills his 7 beds up right away and keeps his patients there all shift. His patients haven't had a long wait to see a doctor because the doctor before him was efficient and kept beds empty and kept the flow going. He orders every test known to mankind on them.

Doc B has the other 7 beds in the ER. He turns his beds over 3 times but his patients have been waiting 2 and 3 hours in the lobby for his 7 beds while Dr A's patients are in his 7 beds waiting for MRIs that could be done on an out patient basis or some obscure test for symptom they've been worked up 20 times for.

When it comes time for the P-G scores Dr A is going to get excellent scores because his patients are happy with being treated like their nonemergency was some big deal even though it meant some other patient had to wait 3 hours out in the lobby vomiting with 10 out of 10 gallbladder pain.

Dr B is going to get crappy P-G scores because the patient is going to perceive him as the one that kept him waiting for 3 hours for the pain medicine, not Dr A who was doing an MRI and lumbar puncture on the guy who has had them all 10 times for migraines before.


We all know which doctors and which nurses are good for patient flow and which ones aren't. All the bedside manner in the world isn't going to help if you've left someone with a kidney stone or gallbladder puking in your lobby for 3 hours because your doctors will not admit or discharge patients.

Not to mention the inhumanity of this kind of treatment.

P-G doesn't measure a physicians natural ability to recognize and treat illness. That's what we need from an ER doc. Not some bozo who picks up a chart, reads the diagnosis and starts ordering lab before he ever sees the patient. Chief complaint-headache and fever. Okay that means he needs and LP. No it doesn't, the patient has strep throat. I see this kind of stuff on a daily basis. Until P-G measures that kind of crap I'll believe its crap.

shadowfax said...

The point, I think, of the original post was that we should not use P-G to evaluate individual docs. So in the above example, the P-G scores for the whole department will be low to middling, and can be used to track the improvement process. You identify the folks that need improvement by another means (as an ED Information System that tracks doc-specific turnaround time), remediate as needed, educate everybody about customer service, and the P-G scores for the whole department will tell you if your management plan is working.

Silvertop said...

I agree..we shouldn't lose the forest for the trees. We can nit-pick anything into irrelevance.
And, it is the leadership that must confront the problem of low performers. Clinical quality indicators need to track outcomes. Service quality and clinical quality both must be pursued. I could name a couple of providers that I would love to send to work for our competition.

It is possible to drill down to providers and then run a correlation with the observation of who works faster/slower/better etc, in the staff's eyes. Boy, would that be interesting.
We must always test our assumptions.

pdx rn said...

But how much does P-G cost? It cost tens if not hundreds of thousand of dollars. Give a decent admin asst your pile monthly pile of survey responses and she can do the same work for her usual salary.

Anonymous said...

If you are concerned with your PG percentile scores or oversampling to receive nothing butinsufficient data I would recommend looking at NRC Picker! They are an amazing vendor who truly knows what's going on in the market place. They are not measuring to measure they are measuring for outcomes and have been a great example for healthcare providers to learn from.

Silvertop said...

NRC is a for-profit just li8ke PG, and don't forget Gallop and Avatar, PG's database is the biggest and their consultancy the broadest, and for no extra charge,

Anonymous said...

That's what you'd like to think about PG and that's where you end up wracking up all the costs. PG has hidden fees everywhere. You are right though they do have the largest benchmarking database. We just recently made a switch b/c of NRC's philosophy and survey style. I'd rather be looking at one consistent measure across every service line than looking at "top box" vs PG's mean scores. I found huge gaps between our HCAHPS scores and our PG scores. NRC is known to help hospitals improve by asking quesitons similiar to the HCHAPS questions. It's a completely different way of looking at data but I am finding it more and more benficial to me and I am not a statistical person. Gallup is a great organization especially for consulting; however, they have stopped paying attention to their clients that are less than $100k. Avatar another for profit organization is basically just a data collection vendor they have no idea where to help hospitals improve. There are many others out there in the industry, but looking at which vendor has the most impact on your hospital's patients' experience & how it effects your bottom line I think NRC and PG are the top two to be looking at.

Anonymous said...

A few things to keep in mind when looking at satisfaction vendors. NRC has put all their eggs into the HCAHPS basket, yet, their facilities are the lowest performing in the national and regional databases. Press Ganey does have the largest hospital database at this time (1971 facilities, approx.) but by far the highest cost. In fact, they have a commitment to ALL products achieving a gross margin in excess of 40%. This is not speculative, I work for Press Ganey and am constantly horrified by the treatment of our clients. In particular, taking 23-25 year old college grads, placing them in customer service rolls and passing them off as "healthcare consultants". Over 70% of these folks have never set foot inside a hospital, been on rounds with a nurse manager, have a clue as to what daily huddles are, or have any healthcare back ground what so ever. It gets better. One of these so called consultants will be speaking this year at their National Client Conference. In fact, this individual is considered to be at the highest level of consulting available to hospitals from Press Ganey. What credentials? This time last year, this individual was working at the mall. Amazing what one can learn in 365 days. Press Ganey will continue to use statistics and its overpriced system to hold healthcare hostage. Ask your "consultant" exactly how much this company earned off its mailing process. Here is a hint, it was in excess of $90 million! Now they want to change in excess of $1 million an engagement to fix the flow in your ORs. How? Blocked schedules! Now that is a million dollar idea. All vendors provide data and it is nothing more than a commodity product. My advice? Find a less expensive vendor and use the cost savings to work on real improvement.

shadowfax said...

Fascinating peek behind the curtain. Thanks for sharing.

Anonymous said...

For those that are not aware of this, HCAHPS scores will NOT help you to improve. Let me make this as simple as I can. As a PG employee, I feel compelled to give something back that will not cost an arm and a leg. HCAHPS focuses on frequency, or how often something happened. Why did CMS take this route? To see if hospitals are doing what they say they are doing. You say you cover discharge instructions with the patient but we want to know if the patient agrees with you. If not, your reimbursement could be at risk. Look at the 8 global ratings and the 2 overall ratings. I can tell you from vast experience that the only HCAHPS questions your C-Suite cares about is Overall Rating and Willingness to Recommend. These two are ratings of outcomes. The other 8 are frequencies or how often something happened. The frequency does nothing to predict the outcome. As an example, your hospital scores very high in responses to call lights yet, you still have a low recommend score. Think of this from the patient's perspective. You may be working with staff to respond promptly, but until you work on being more proactive and reducing dependency on call lights, the patient's experience will suffer and so will the recommend scores. Focus on the issues and focus on the patient. If you do that, you will effect the measures that matter. You will also do that regardless of who provides the data. Lastly, benchmarking is effective to see where you stand on the grading curve. On the other hand, it is something you cannot control. Your percentile ranking falls into the "area of concern". Your mean score falls into the "area of control". You can only work on your own facility, you cannot effect the outcomes of another. Administration needs to understand this basic fact and tie performance to that which can be controlled and effected. It is demoralizing to staff when they do not make their percentile rank goal. Take two facilities and say one has more buy in at the top and more resources to make things happen. Both have the save level of committed staff members. Logically, the greater resource facility will improve faster with all else remaining equal. Hence, the other facility see a lowered percentile ranking in comparison, even with the same amount of effort. Be aware of the benchmark, but focus on you!

Anonymous said...

I believe the anonymous poster with the inside PG info "used" to work at Press Ganey. At any rate, previous hospital experience is not requisite for knowing how to treat people.

Anonymous said...

It sounds like some of the comments just hit a little bit close to home! There would be a lot more but our Marketing department has put a company-wide ban on ANY online posts. At least, until they can develop the requisite talking points. I would agree, healthcare experience is not required to know how to treat people. But then again, it would be considered criminal if someone from say, housekeeping or HR entered the ED and started diagnosing patients. It takes skill, training, practice, and experience to be able to do that. It would seem to reason that someone speaking at the National Client Conference on Six Sigma and Lean would hold a "belt" other than the one you would find on the rack at the mall. This same "expert" has be tapped to speak at CaPRA on Rapid Response Teams. Now we are suggesting we have some sort of clinical or risk background. If you are not an expert in healthcare, do not lie or misrepresent your credentials. This applies to all the individuals within the company that are being heralded as having "extensive healthcare experience". Those that come from outside of healthcare have a legitimate value to bring to the table. They can contribute a new way to look at an old issue or a new method that may be able to cross over. If that is your case, be proud of it and share that with your clients. Stop misrepresenting the issues. Look at the caliber of consultants provider by organizations like Disney, Baptist Leadership, and The Studer Group. Can you really say most Press Ganey "consultants" are in the same league. I think not!

Silvertop said...

Dear Anonymous:
You are either a very disgruntled employee or very naive. I have been in this biz a real long time and know the "experts" from Studer, PG, Picker (NRC), even Gallop...It is what it is...everybody thinks they have the answers and the cure. Truth to tell, just give us workers a good measurement, and we should be able to do it all ourselves. There is plenty of scientific talk about what is a valid measure of satisfaction..each vendor swears they hold the magic. So chill. Stop sounding so mad at Press Ganey, it only makes you sound "postal." Patients deserve better. Keep your eye on the purpose, not the marketplace. It's business, not personal. You will be a patient too, if not already.

Anonymous said...

Well said Silvertop!

Anonymous said...

I have heard about the amount of money PG makes off hospitals for these simplified surveys and "consultative services". They make their money off of hospital executives wanting to brag about their scores. On the back-end they get enormous discounts from the postal service and paper suppliers for their 19th century style surveys. This really is capitalism at its best and healthcare at its worst. My advice - write your own surveys and use the money on real improvements, like cleaner facilities, more staff or better service. No brainers people. You don't need a company of 600 paper pushers to tell you that - do you really? All for a $200 buck trophy that you could get at the bowling league?

Anonymous said...

These are a few observations from a person that spent two years managing a patient satisfaction program in a large hospital.
I began saying that the idea of tracking patients assessment of the quality of services rendered is a good idea (satisfaction is another thing in psychological terms - it includes more components).
Peter Drucker once said that hospitals are organizations built to deal with emergencies so they haven´t been design in such a way that the principal consideration is the person not the disease. In recent years there has been some progress and more and more professionals are recognizing the need to treat the patient not the disease.

Anonymous said...

However the obsession with following the results of the surveys by week or by month is damaging the objectives of being customer centric.
The biggest error is considering the variability as a consequence of the actions of the hospital personnel and not a change in the psychological characteristics of the patients filling the instrument.
Different people respond differently to the exact same performance and consecuently they rate the quality of the services differently

Anonymous said...

In the services marketing literature is recommended that the assessments of the quality of the services be done administering surveys several times a year not permanently. The reason being the difficult in separating changes in the environment from the characteristics of the individuals responding.
Additionally to this there is another serious problem, it is difficult to measure the attention that each person put in answering the survey. There are plenty of strategies that are followed by respondents when completing a survey (spècially a long one) and it is possible that some of the answers are just the real deal.

Anonymous said...

In regards to the professionalism of PG I agree totally with of some of the comments. I interacted with many consultants they were absolutely clueless about basic principles of survey research, operations management and many other things. The comment about recent college graduates preaching as experts is absolutely true.
The biggest problem is not PG, is the countless executives in many organizations that are also clueless about the science behind survey design.
For those interested there are plenty of many valuable papers showing how the patient satisfaction scores are not a very good predictor of patient returning.

Anonymous said...

I am a former PG employee. I couldn't take it any more. If you had any idea about the unskilled, uneducated, and lazy people that work there, you would use a different vendor. The PG consultants you work with are young and uninformed. The sales teams are greedy. Management is unconcerned. Your PG reports should simply be another tool among your many tools used to help provide better care. Switch vendors first.

Peggy Creany said...

The National Conference is just one of the greatest scams on earth. PG just make some deals with some people so they use their podium time not to help, but the sell their consulting services.
It is just amazing the stuff they can pull. An entire session dedicated to talk about a book that was written not by the speaker but by somebody else (Crucial conversations -2008 national conference). Or in a regional conference talking about the power of stories (the subject of a book from two authors that were miles away from the conference place - Made to stick).
They are one of the greatest scams on earth.

Julia said...

When discussing issues of satisfaction, I am put in mind of Maslow's hierarchy of needs: at the base of the pyramid are basic physiological needs (food, drink, shelter, clinical health), then come needs (in ascending order) like safety/security, affection/acceptance, approval/recognition, beauty, order/symmetry, knowledge, justice and finally, ONLY when all the lower-level needs can be met, self-actualization.

It seems as if tools such as PG are asking patients to assess how well the healthcare setting contributed to their self-actualization without the healthcare setting even being in the business of providing for their lower-level needs. If a patient is starving, for example, no amount of pillow-fluffing is going to lead to a good PG score.

Ramblin Rich said...

I see the effect of PG medicine everyday. With our employer your PG score determines salaries and budgets for each clinic. The response , short of malpractice give the patient what they want. MRI for minor back pain - yes sir, newest PPI for slight indigestion this morning, no problem. BMI of 40 - don't mention it unless they ask for dietary assistance. Don't say or do anything that might upset the patient and practice medicine as best as you can as a secondary issue.
I also would like to know how administrators justify publishing and posting PG scores of individual providers. . The only rationale I can come up with is that the fear of public humiliation will keep those in line that monetary threats don't effect.

Anonymous said...

Nurse B... Im no manger and i can only speak as one who had been literlly traumatized by this press ganey bit. As you know the survey mailed does not tell the pt what percentile they are marking!!! they think 4 is very very good. NO WONDER! Also it is a TOOL! It does not cover all the actual NURSING that is done. I know nurses, as a reuslt of press ganey mania who have lost their jobs for no real good reason. it is focused on customer service. That is only one piece of the pie. I was confronted by a manger whose primary concern is scores. Some nurses are great at cusotmer service but i often wonder if they know the blood flow through the heart? Yet these who get lots of high scores are the nurse of the month. My experience has been literally like a stepford nurse, we have created a monster! My expereince has been that Press is now beign used as a disciplianry tool and leverage for mangers who may not like you or only care about the scores so they can boast to the DON. This has got to stop! The worst thing a nurse cna hear is not your patient has stopped breathing but you have a complaint! Most of it is no more than he said she said. My goodness of course sick, scared and cranky patients complain, we try our darnndest to help them but some things are just absurd then we top it off with AIDET! and then bedside report. this is great in theory but i know it does not work and think that it is demenaing to our profession. Even when I followed the chain of command and had two doctores witness an out of control patient , i was still disciplined. This is a question of our integrity as professionals. Then the families and pt wonder why we are scared to death to speak to them too much...its no wonder. In any other profession being suspended or fired soley based on what a pt said would not even be considered legal. Ive heard it all from nurses...one so called complaint was she seemed disorganized, I at one point thought i was going crazy and called all types of other professional friends they have all be in shock! Why? one answer... Press Ganey! It is literally ruining nurses job stability. Ive been an RN for 16 years and I am no slouch! Although i have worked with several ...but becasue their patients called and talk about how sweet they were they keep a job. the focus is very frightening! We have lost our focus! It is amazing that when a nurse manger rounds and hears anythign even remotley negative she writes it up, we are disciplined but when she rounds and hears good it is never plsced in our files!!! I think this is mentally abusive. No wonder nurses are leaving.

Anonymous said...

nurse b again...I wonder if this is indeed legal? Has anyone researched that? To be disilpine in the fashion I mentioned? The hos-pitlas bought into i tnad now cnat get out? what could we as HC pros DO aobut it? that is the solution! I would be honered to speak at any engagements they may have and bring my file of what nots wiht me. I called lawyers and they were applaed! I never had a case due to the dman at will garbadge. I have been destroyed by PG! My aunt was an ICU nurse in the smae unit for 15 years...PG cmae along and she was suspended for 2 days soley based on some family and the he said she said game! Years ago a prudent manger would ahv easked her about things...those days are over...WHY??? PG!!!!! someone help us!!!

Anonymous said...

I've worked in hospitals for over 43 years, and I am glad nurses, doctors, therapists, etc are called out on their behavior. This is here to stay..It's not Press Ganey..The Feds will penalize your hospital (resulting in your salaries etc) when patients reveal nurses aren't helpful, they don't help them toilet, and are waqy too noisy at night. A good nurse is one who is sensitive to the emotional needs of their patients and families as well as a clinical expert. Some complaints are baloney..but they are the exception. Patients are learning their power and exercising it. When you say you are too busy, short staffed, and will be back in a minute, your scores go down. Get over it.

Anonymous said...

The problem with PG is it is all about customer service and not about quality and administrators and politicans are treating customer satisfaction with quality.
The other problem is that hospital administrators and politicans misuse it to reward preffered groups/providers and punish unpreffered groups/providers.

In my area the hospitals with the best scores have 50 inch plasma TV's in every room, single rooms, waiter service and have some of the worst quality of care. This is what these surveys have brought.

Anonymous said...

You can have all the dilaudid you want, and I will smile and tell you that I care about your health and jump through the stupid PG hoops while I plan my escape. You guessed it! My PG scores are high.

All the smart doctors are leaving/retiring and you will be left with the slackers that can't get a job elsewhere. Tying PG scores to medicare reimbursement was a bad move. If anyone in your family is considering a career in medicine, tell them don't do it. The money is no longer worth it and physician autonomy and respect are a thing of the past. Tell them to go to law school instead. It is shorter, easier and they are the ones writing the new BS healthcare legislation so they aren't affected negatively.

-MD

Anonymous said...

Didn't know that MRIs were ER med rad test of choice.... Because they aren't. Please pick other examples. Thanks!

Anonymous said...

Folks - Don't mean to sound like a Mr. Know-it-All...BUT....I've worked for a large patient satisfaction survey organization recently and have dealt with the most demanding ER physicians on earth.

I couldn't agree more with you around the Press Ganey (Milli Vanilli) survey process in general. Those mailed surveys are producing less than 8% response rates nationally (according to PG). Good luck getting any true representation on that.

HERE'S THE SOLUTION: First of all, use a telephone-based survey. The response rates are much higher, the surveys get to your patients before they get their bill, and you can ensure your "frequent fliers" don't get the survey multiple times.

More importantly, why not set individual "quotas" on the # of completed surveys each physician receives on the patient survey? In other words, instead of getting 100 completed surveys per quarter for all ER physicians, why not set the sample size a n=30/quarter for EACH provider, thereby giving them a statistically valid baseline from which to improve upon. Yes, this will cost your CEO some additional dollars with the ole' survey vendor, but its chump change when you compare it against the former approach.

This is quickly becoming the standard among top-performing hospitals nationally. They are applying this same survey technique with hospitalists, clinic-based providers, etc.

Hope this information is useful.

Bryan said...

I retired from the Navy in 2008 and moved from Health Care Management in the military to the civilian sector. I am finding that I have to spend a lot of time working on running my department based on outside agencies, such as Press Ganey. I actually have staff on write ups because they were mentioned negatively in PG.
Coming from the military I was trained as a leader that we make our own decisions and I was trained and have achieved a leadership skill level that gives me the ability to lead and make decisions. I am finding that in the civilian sector management tends to outsource for companies to make decisions and run the company for them, such as PG or the Studor Group. I question why this is, do we not have the leadership skills to run our own company? Are we afraid to make decisions based on our abilities to lead. To top it off we are told to cut costs, we can't hire that extra nurse to support the back office, we can't buy what we want when needed, yet we spend a large amount of money on these outsourced programs or companies. It is not intelligent business, why do we pay our executives so much money when they need management consultants or surveys to run the company for them? Just venting....

Anonymous said...

When will someone with balls stand up and report the truth: the emperor has no clothes?

Press Ganey has ruined medicine. Instead of the real focus on patient care, getting fives on an artificial survey is all that matters.

I know for fact people die because of Press Ganey. Prescription drug addicted mother of two comes in asking for narcotics. She's told no narcs for you but we can get you into rehab. She accepts and is detoxed from narcs, is no longer a frequent flier for months, then returns with her original pain complaint, given dilaudid IM, sent home with an rx for the pharmacologic equivalent of 90 Percocet. Accidentally overdoses at home (was not suicide, she was basing her at-home use of the drug on her prior level of narcotic tolerance.) Is found dead by her husband from respiratory depression.

All in efforts to "win 5's" on the survey. You know, Make.The.Customer.HAPPY!!!

I'm seeing great, talented people at hospitals being railroaded, bullied, threatened and eventually fleeing the field because of this nonsense.

When the $$$$ incentive is removed from survey companies and emphasis placed on surveys that involve common sense, reality based evaluation of emergency departments, and true exclusion of drug seekers, mentally ill attention seekers, and the litigious, only then will I have ANY faith that these will be of ANY use at all.

Til then... I am in the process of fleeing. And by the way. THE EMPEROR HAS NO CLOTHES!!!!

Ahmad Risk said...

It seems to me there is an additional and important component to the patient experience criteria. that of communications. For example, responding to Nurse K's dilemma, how about a simple explanation: "I'd like to move you to the treatment area but expect the doctor will be x minutes/hours behind. What would you rather do, stay here or go to the treatment area?"

One of the commonest causes of patient complaints in UK is lack of or inadequate communications.

By the way, good communications are good to everybody involved: patients, nurses, doctors, management, referrers, etc.

Ahmad Risk said...

It seems to me there is an additional and important component to the patient experience criteria. that of communications. For example, responding to Nurse K's dilemma, how about a simple explanation: "I'd like to move you to the treatment area but expect the doctor will be x minutes/hours behind. What would you rather do, stay here or go to the treatment area?"

One of the commonest causes of patient complaints in UK is lack of or inadequate communications.

By the way, good communications are good to everybody involved: patients, nurses, doctors, management, referrers, etc.

Providing the Facts said...

Press Ganey isn't the problem. The PG data is merely a means to an end. HCAHPS are here and now and CGCAHPS aren't too far behind. Use your Press Ganey resources as a way to improve your scores, as well as your VBP numbers. Press Ganey has not ruined medicine; peoople don't die because of PG; those are very ludicrous claims. Don't shoot the messenger. PG has BY FAR the largest database of hospitals and providers to benchmark against. PG is the ONLY vendor who can provide a holistic view of a hospital's performance data: Patient Experience, Clinical Outcomes and Financial. No other vendor can make that claim...and be telling the truth!

Anonymous said...

You guys are looking at the terms of the survey instead of the actual context within it. The reviews based on the patient's answers are coming directly from experience. I have encountered rude nurses, heartless doctors etc. and they think their job goes unnoticed. The patients are able to give their opinion from a bird's eye of view. for all those slackers in the health care field, you're being watched. simple solution, follow protocol and show some damn respect and sincerity for the patient