This is a hospital, not Disneyland

How nursing scripts and patient satisfaction surveys project a fantasy of care, not real care

RoseAnn DeMoro, Executive Director of National Nurses United

By: RoseAnn DeMoro, Executive Director of National Nurses United

“Hello, Mr. Smith. My name is Joanne. I am your nurse. Are you experiencing any pain today? No? That’s good. Do you need help getting to the bathroom?” (check script) “Can I fluff your pillow, bring you a magazine, turn on your TV, move your water bottle closer?”

(check script) “I am so happy to be of service, this is all part of the excellent care we provide here at Happy Homes Medical Center and Resort.”

“We know you have choices when you go to the hospital, thank you for choosing Happy Homes.” (check script) “You will be receiving a survey from us after you leave Happy Homes, and I hope you will remember this excellent service when filling it out. Have a nice day, Mr. Smith.”

If this scenario seems far fetched, you’re probably not a nurse who has worked in a hospital recently. Strict adherence to scripts derived from exorbitantly paid consultants like the Studer Group and Press Ganey for every interaction between the RN and her patient is increasingly a job expectation.

Can’t recall it all? Not to worry, the hospital will provide acronyms and “important key words,” also known as the “Five Fundamentals of Service,” to help RNs remember their script, helpfully reinforced by their managers, as we noted in a 2010 NNU CE home study course and feature story (National Nurse, October, November 2010).

Scripting is one element, another is “rounding,” guaranteeing that every nurse document a visit to every patient at least once every hour, even if the nurse checks on the patient more frequently, as is typically the case, or misses the hour by a few minutes because another patient happens to be coding.

And, what happens if you fail to meet the scripting and rounding requirements? For the nurse, especially in a non-NNU hospital, it can lead to docked pay or other discipline. For the hospital, it can lead to reduced Medicare reimbursement, for which it will certainly exact punishment on the nurses.

Welcome to the not-so-Brave New World of faux patient satisfaction.

About 15 years ago, during an earlier wave of hospital restructuring, we told the story about a hospital where nurses being required to put lip gloss on a patient to improve their color before a family visit so that family members would think their loved one was receiving appropriate care. Even as the hospital was replacing RNs with unlicensed personnel, all that mattered was the perception of care.

As the years have evolved, so have the reengineering methods. And the hospitals have an added incentive to substitute service and the appearance of care for the actual delivery of quality care.

It pays. A lot. The Centers for Medicare and Medicaid Services announced last October that patient satisfaction survey results will be one significant factor in determining Medicare reimbursements, and for those executives lucky enough to meet the contrived guidelines, bonuses.

To make matters worse, patient satisfaction surveys are fully integrated into the 2010 Affordable Care Act, through healthcare quality initiative measures.

Are the nurses, doctors, and other staff constantly smiling? Check. Are there plants in the hospital lobby? Check. Attractive artwork on the walls? Check. Soothing music in the elevators? Check. An espresso machine in the cafeteria? Double check. Free wi-fi in hospital rooms and lounges? Triple check. And are the nurses scrupulously following those scripting and rounding demands? Checkmate.

If this sounds like something out of Disneyworld or the hotel and hospitality industry, that’s not a coincidence. Hospitals now use the same consultants and the same formulas. Call it Goofy on steroids.

Consultant-driven reengineering blueprints are destructive enough in the service and entertainment industry. In healthcare they can be deadly.

Witness a study, “The Cost of Satisfaction,” just published in February in the Archives of Internal Medicine. Correlating patient satisfaction surveys with outcomes, the study said the risk of death for the most highly satisfied “healthy” patients was 44 percent higher than their less “satisfied” counterparts. The article sparked a bevy of medical blogs and news accounts with titles like, “Do you like your doctor? It could be the death of you,” and a furious rebuttal from Press Ganey statisticians arguing the surveys are “here to stay.”

Just making the patient happy, with inappropriate care for example, has no bearing on quality of care, wrote columnist Theresa Brown, RN, in a March 14 New York Times commentary aptly headlined “Hospitals Aren’t Hotels,” and echoed by William Sullivan, MD in a March 20 article in Emergency Physicians Monthly titled, “Dying for Satisfaction.”

Nurses don’t need these high-priced consultants or CMS or the ACA to determine how to improve quality at the bedside. Studies have long documented that safe RN staffing, especially mandated RN-to-patient ratios, and other measures that reinforce professional nursing judgment and the application of an RN’s clinical expertise and experience have far greater impact on positive patient outcomes.

Indeed, nurses increasingly see that the patient satisfaction scam, and the scripting and rounding that accompanies it, are closely associated with hospital industry restructuring aimed at deskilling, displacement of RNs, and automating RN interactions with patients.

They interfere with nursing care, undermine the culture of safety, can lead to increased medical errors, and subject RNs to intimidation, offensive scrutiny, and discipline from managers for not following the consultant’s script and doing enough to artificially inflate patient scores.

It’s a safe bet that when Disney executives themselves are in the hospital, they’d rather have safe nursing care than a potted plant at the bedside.