There's no better way to jump back into work after a long leave of absence (my wife and I recently welcomed our first child, a beautiful, healthy baby boy, to our family) than to have someone else do the heavy lifting for you. That was my first thought last week, when I returned somewhat groggily to H&HN's world headquarters to find a long, impassioned, anonymous and, most importantly, compelling letter on patient satisfaction in my mailbox.


With the impending inclusion of scores from the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS, in the payment formula for Medicare's value-based purchasing initiative, patient satisfaction is a fairly hot topic in hospital boardrooms these days, and strategies abound on the best methods to keep patients happy and HCAHPS scores high.

The patient satisfaction movement is not without skeptics, though; earlier this year, a controversial study, published in the Archives of Internal Medicine, questioned the linkage between patient satisfaction and health care quality. In turn, a panel discussion I attended in May at the National Patient Safety Congress turned into a group therapy session on the alleged failings of the study itself, as a host of high-profile speakers took aim at the findings.

Back to the letter — We don't usually publish anonymous entries, but the author was concerned that the examples provided would reveal his or her identify. And, as you'll see, it's quite the riveting read, whether you agree with the conclusions or not:

"In the minds of managers and supervisors, the overall goal of maximizing patient satisfaction gets operationalized into an unspoken but strongly enforced mandate to minimize complaints at all costs. This distorts the caregiving process in many ways.

A sign appears at the nurses' station: 'Answer any bell from Room X at once.' Is Room X the room with the vent-dependent patient, or the patient on a cardiac monitor? No, it's the room with a patient whose family called administration … ranting about a problem with the TV volume control. The vent-dependent patient and the one on the cardiac monitor have non-complaining families.

At one time, if a nurse had a couple minutes free, she might poke her head into the room of an anxious or medically frail patient and offer emotional support or an extra nursing assessment. Now, she pokes her head into the room of whoever is the most verbal complainer.

Caregiver time management gets distorted. Staffers are continually weighing who really needs them versus who will complain. A respiratory therapist in a general staff meeting said, 'What do you do when you have a patient on a vent who really needs something quickly, but whose family would never complain about anything, and someone else who's demanding a perfectly routine breathing treatment be given right away, but who you know will complain if there's a minute's delay?' Of course, she responded first to the patient on the vent, but staff shouldn't even have to think twice about a decision like that. There are enough legitimate stresses in health care without having this type of worry imposed on everyone.

The assumption that every complaint is legitimate is also a problem. A patient with a well-documented … comorbidity of borderline personality disorder turned an entire nursing unit and treatment team upside down, as we all spent hours trying to figure out how to make her happy despite her distorted view of reality.

In another case, a family member wrote a letter complaining literally about every staff member she had contact with. Two of the complaints were especially ludicrous. She said that one staff member, who is well known for working very late hours to be available for families, kept looking at her watch and was clearly upset at having to stay until 5:30 p.m. to meet with [her]. The letter also included a complaint about a staff member with 20 years of experience on a specialty unit, who has gotten multiple commendations from staff, patients and families. The letter described her as 'hateful.' In spite of the clearly absurd nature of these complaints, the employees and their managers had to draft letters of apology, explaining what they'd do to avoid the employees acting in the same manner in the future.

I want to be very clear: I am not saying legitimate complaints should not be taken seriously. I'm a fierce advocate for my patients. There's nobody faster than I am at dealing with an unanswered call bell, an uncleaned room or a miscommunication. I believe a pattern of complaints about a particular employee needs to be addressed. The incidents [above] are quite different.

I think the patient satisfaction gurus you often interview will respond by saying my hospital isn't applying patient satisfaction principles correctly. I am certain, however, that front-line staff at any hospital that has made a fetish of patient satisfaction will have similar stories to tell."

Whether you're a hospital executive or front-line clinician, I'm interested in your thoughts on this thorny topic. Comment below or send your thoughts to, and I may feature them in an upcoming column.