Monday, August 24, 2015

The Patient Experience

Why is it important to provide patients with the best experience we can?

The most obvious and noblest of reasons is because it is the right thing to do. We should be treating our patients, caring for them in a manner that we would want for ourselves, our families and our friends. As Michael Dowling, President and CEO of the North Shore-Long Island Jewish Health System often reminds staff, many of our patients are us, our relatives and friends. We should be treating all patients as such (Author’s attendance at Mr. Dowling’s presentations.).

A second reason focuses on the theme of choice as related to how our patients view the quality of care we provide. Deming tells us that quality is meeting or exceeding our customer’s needs and expectations. Deming also tells us that loyalty is achieved when we exceed those expectations (Aguyao, 1990; Deming, 1982). Changing how health providers view their patients as customers continues to have its detractors, but few would argue, that increasingly patients have choices, and all in health care now have multiple competitors. If our organizations are to become and continue to be facilities of choice, there is a need to be distinguished from our competitors.

            Pyzdek (2001) in his description of the Kano Model of Customer Expectations explained that meeting basic levels of quality is something that is taken for granted. Meeting them does not result in satisfaction, but not meeting them is a source of dissatisfaction. There are expectations that customers believe are important and the more they are met the more satisfied the customer. The provision of providing exciting quality occurs when the customer receives more than what was expected and this level of quality becomes increasingly important as competitive pressures for nurses present internal customer problems with dissatisfaction with peers or supervisors. Similarly, Bertel (2003) referred to events and practices that dissatisfy customers as the must-haves, which if unfilled would serve as sources of dissatisfaction. Bertel used the term delighters which would not cause dissatisfaction if not present, but when they are present serve to truly satisfy or delight the customer.

A third reason and most recent interest in the patient experience came from HCAHPS, a CMS-developed patient satisfaction questionnaire. In October 2012, HCAHPS’ (Hospital Consumer Assessment of Healthcare Providers and Systems) patient satisfaction scores were utilized by CMS in the calculation of reimbursement for patient stays HCAHPS is not only an instrument that affects reimbursement, its results are publicly reported, permitting comparisons by the public (CMS, 2015).

Creating and Managing Expectations

            Creating expectations initially derives from the informed consent process. This process should have included communication regarding diagnosis, agreed upon course of treatment following an explanation of alternatives, with risks and benefit (Bord, 2014). Patients must have an opportunity to pose questions and to have those questions answered in a manner they can understand. The process must also include an awareness that the patient understands what has been conveyed and an agreement by the patient for a course of care. The process occurs between the physician and the patient.

Once hospitalized, patients are obviously “managed” much more by other hospital staff who have a responsibility to make patients aware of what to expect during their stay. With their experience, other hospital staff have greater expertise regarding what is likely to happen to and for patients, and in what sequence, than patients could possibly have. Initial expectations also derive from past experiences with the facility, discussions with others, experiences with other facilities, and information derived from the media, “report cards,” various web sources etc.

Likewise, mindful that effective communication must be a two-way process, staff have a responsibility to seek out questions and comments from patients regarding their needs and expectations (similar to a consent process), and to appropriately respond to these, both in terms of words and actions to best meet those needs and expectations. The voice of the patient-customer regarding their expression of needs and expectations is often critical to how quality is perceived by the patient (Stroud, n.d.). Bertel, (2003) described the centrality of meeting customer needs in the Six Sigma model with: “Failure to listen to and understand the Voice of the Customer can be fatal” (p. 171). Further, Solomon (2015) stated: “If you want to stem patient dissatisfaction, stop giving off cues of indifference and uncaring.”

             Managing expectations, requires transparency of information between staff and patients on an ongoing basis. Treatment plans may have to be altered due to either patient condition, physician direction or hospital “circumstances.” Solomon (2015) provides the following additional items regarding how to improve the patient experience (Bullets rather than numbers have been utilized here):

 Get every employee thinking about purpose, not just functions… To create successful medical outcomes and hospitable human experiences for our patients’ is a purpose. 

‘Sorry’ may be the hardest word, but it’s a word that everyone on your team needs to learn.  Resolving patient issues means knowing how to apologize for service lapses…It means getting rid of the defensiveness …when confronted by a patient upset with what she perceives to be a service gaffe. Instead, take your patient’s side in these situations, immediately and with empathy, regardless of what you think the “rational” allocation of “blame” should be. And spread this approach throughout your staff through role-playing and other training devices, so it will serve you fully every time a patient hits the fan.

Teach your employees – every single one – how to handle a patient or family member’s complaint or concern.  

 If you want to improve, strive to create a blame-free environment. 

Understand that improving patient satisfaction is about systems just as much as it is about smiles.

Cultural Change toward a Customer Approach

Increasingly patients don’t want to be considered as patients; they want to be considered customers. They want to know and agree to how they will be treated, what should happen, what are the outcomes, what to expect when they leave the hospital, what to expect about their health. We cannot effectively respond to these expectations with a departmental/silo mentality. We must break down these silos, learn to work as interdepartmental, inter-professional teams, although past models of professional education did not foster this approach, and change in these educational models is needed (National Center for Healthcare Leadership, 2011).

 Contributed by Dr. Walter Markowitz, Adjunct Faculty 


Aguayo, R. (1990). Dr. Deming: The American who taught the Japanese about quality.
            New York: Simon and Schuster.

Bertel, T. (Ed.). (2003). Rath and Strong’s Six Sigma leadership handbook. Hoboken, NJ: John Wiley and Sons, Inc.

Bord, J. (2014). Informed consent. Retrieved from

CMS. (2015). HCAHPS factsheet. Retrieved from

Deming, W. E. (1982). Out of the crisis. Cambridge, MA: MIT Press.

National Center for Healthcare Leadership. (2011). Michael Dowling accepts 2011 Gail L. Warden Leadership Excellence Award. Retrieved from

Pyzdek, T. (2001). The Six Sigma handbook: A complete guide for greenbelts, blackbelts, & managers at all levels. New York: McGraw-Hill.

Solomon, M. (January 11, 2015). 8 ways to improve patient satisfaction, patient experience and (by the way) HCAHPS scores. Retrieved from

Stroud, L. (n.d.). Defining CTQ outputs: A key step in the design process.

(Note: Dr. Markowitz was the Director, Strategic Planning, North Shore-Long Island Jewish Health System.)

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