Common Sense

The Beatings Will Continue Until Morale Improves

Issue: May/June 2022

Author: Andrew Mayer, MD FAAEM

Every hospital has their own system of dealing with complaints and also of scoring and rating patient satisfaction. The intention of examining complaints and patient satisfaction scores is on the surface a reasonable one if done properly. Who would say that they do not have room for improvement and that there are not patients who did not receive good service or have a legitimate complaint? Every one of us would like to make our patients happy along with improving their health and quality of life. However, we have gone astray. Sadly, in reality, many systems and programs used to collect and analyze data related to “patient satisfaction” and those used to deal with complaints are severely flawed. The results of these patient satisfaction surveys are often statistically insignificant and the complaint resolution system simply fulfills a federally mandated requirement to deal with complaints without actually making any improvement in the “patient experience.” Conversely, the negative impact of this system on the morale of physicians and nurses in our emergency departments can be significant and further weaken our spirits. The new pandemic facing our emergency departments and the medical system overall is burnout. You can call it “moral injury” but the end result is the same. Unhappy and burned out providers are unlikely to be beaten into better attitudes. Remember the old adage that “the beatings will continue until morale improves.” Telling a burned-out doctor to be nicer is usually counterproductive.

I am the medical director of my group and I have the dubious honor of dealing with the complaints and examining and digesting our patient satisfaction scores. I just spent the last half hour speaking to the mother of teenaged patient with several different chronic pain syndromes. She called to complain that one of my partners refused to give her daughter intravenous morphine to help relieve her daughter’s pain. She insisted that only morphine and only IV helped. She could not understand how any doctor could refuse to give medicine that she knew was the right medicine. She bemoaned modern medicine and that doctors had too much power and in this instance refused medicine which her daughter “needed” to get well. We had a more pleasant conversation than I thought and I gave the usual explanation related to chronic pain in that it is a difficult condition to treat in the emergency department and that it was up to the treating physician which medication to order. We discussed the opioid epidemic, etc. This call eventually ended and I leaned back in my chair and looked out of the window onto a beautiful afternoon on my day off wondering how we had gotten to this point? I would never get back that 30 minutes of my life and also knew that this incident was not over as the wheels of the hospital’s grievance process needed to grind on until all of the many steps had been completed. I decided to close the curtains and not go outside and enjoy the beautiful weather. I forged on with the complaint process. I decided to go ahead and write the response to the complaint in our grievance system and write the initial grievance letter. I would need to produce this letter for our Grievance Committee when I had to go in person and explain the complaint and the “service recovery” which I had undertaken.

This type of complaint can be such a morale sapper for a doctor. I had to reach out to my partner and ask him about the patient interaction. Who enjoys this conversation? It is not that he sent a sick patient home who had a bad outcome but simply the insanity which we are required to deal with despite the costs in money or morale. I always share my responses to the grievance process with the involved physician even if it is ridiculous to let them know about it. Hiding these types of issues from a doctor has a downside as there are things to learn from many of these situations and many times the doctor is surprised by the complaint. However, I think in many instances it would be better for them not to know about many of the more ridiculous complaints as I think it will only cause pain. Certainly, there are real complaints with real issues which need to be dealt with but this was not one of them. Even something as ridiculous as this leads to hours of wasted time and efforts and often leads to more burnout and discontent with our health care system. Unfortunately, somehow our health care system has been subverted to this level of insanity.

The reason I mention this is to ask if there is a better way to deal with the issue of patient satisfaction. Please consider how much money is involved. Your hospital most likely pays large amount of money to some company to survey your patients to provide a ranking of how you are doing compared to everyone else. This of course is a zero-sum game as there has to be winners and losers using our current ranking system. Every hospital or hospital system wants to proudly display billboards with whichever quality, safety, or satisfaction ranking or award which they have “won.” The hospital has to also have some sort of grievance process which involves many standing members and also the invited guests who are in the hot seat during any particular meeting. All of these people are usually highly paid individuals who are not providing health care during all of the time required for this process. How many nurses at your hospital are involved in this process? Nurses play many roles in the satisfaction and quality process and are on the various safety and quality committees dealing with any complaint or quality issue. Would your hospital be better off and the patients more satisfied if these same nurses went back to actually taking care of patients?

I have felt frustrated especially during Covid to sit in large meetings (many virtual) which include up to a dozen nurses who no longer nurse. Large committee meetings are held with many well-paid professionals who closely analyze this data and the complaints. They propose ways to improve our patient’s satisfaction. They meet to review every grievance and discuss patient service recovery. They want to encourage every member of the health care team at the hospital to be nicer, faster, and more willing to bend over backwards for any patient or family complaint so that your “net promoter” scores can go up. It can be insanity in the making. The topic of the critical nursing shortage is usually discussed as a factor in all of these quality and satisfaction issues. I often sit wondering to myself what would happen if we could just put all of the nurses sitting in the meeting back into direct patient care?

The current system of rating patient satisfaction is percentile based which means there has to be winners and losers. Each of us is compared to other members of our group and also to any other hospital which bought whichever expensive satisfaction monitoring tool which your hospital executives or system purchased. This data is often statistically insignificant but hospital executives like numbers. They want a number to “work” on. This also has led to a large and expensive army of consultants which your hospital probably has hired over the years to help the hospital improve their scores. These consultants advise executives in means of motivating the nurses and physicians to improve. These suggestions are often monetized leading to significant pressure on you to row harder and faster despite staff shortages, boarding, Covid, and low morale.

Drs. Thom Mayer and Arjun Venkatesh in an article published online in JAMA on December 2, 2021 titled “Criterion-Based Measurements of Patient Experience in Health Care- Eliminating Winners and Losers to Create a New Moral Ethos” (doi:10.1001/jama.2021.21771) suggest a possible change which may warrant consideration. It is certainly not a panacea but may change the focus of this system to actually improve things instead of the current more punitive form which we deal with on a daily basis. They propose switching to a criterion-based measurement system from our current norm based system. Currently, there are winner and losers and in many systems, the importance of ranking scores are highly monetized and have led to a toxic environment of pay for performance. This can have a significant negative impact on physician burnout and led to overall dissatisfaction with the clinical practice of emergency medicine. Shifting to a ratings system instead of a ranking system could be a small step in the right direction.

The authors point out that “there are 2 truths using measurements to improve patient experience. It is essential, and done poorly, it does far more harm than good.” They point to the current “metric madness” as the opposite of what is needed. They propose using a simple criterion-referenced ranking system in which everyone could succeed. If a specific criterion was reached then everyone could be “winners.” I certainly do not know the answer but somehow the focus of these systems has to change for the better. Society wants the whole system to improve and for us all to learn better and more adaptive ways to improve patient care. However, new attention needs to be paid to doing this while still protecting the mental and physical health of the dedicated physicians and nurses who are providing this same care.

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