Saturday, May 24, 2008

Things that crack me up about Press-Ganey

Many other nurses and docs have blogged about Press-Ganey and the appropriateness of the measuring sticks the organization has chosen to evaluate "good" care in the hospital. Sane people want accountability in health care, and JCAHO does not provide that sanity. Patient satisfaction surveys were inevitable. However, choosing useful measuring sticks for 'good' can be problematic.

What is a 'good' hospitalization from the patient's perspective? A patient with a total knee replacement has a wildly different view of 'good' hospitalization than the patient with an acute psychotic break.

You will not find a serious discussion on this in my post today.

Instead, the following chosen criteria cracked me up. Hospitals are evaluated on the following:

* Percentage of patients who thought their nurses "Always" communicated well.
* Percentage of patients who thought their doctors "Always" communicated well.

There is a world outside of Oz. In this world, my patients look like this:

Sidenote: We had a guy two weeks ago who threw a snowball of poo 15 feet outside of his room. What was most impressive about that is that his hands were tied down at the time.

* Percentage of patients who "Always" received help as soon as they wanted.

Nurses love this measuring stick. I understand the need to ask a question like this on a patient satisfaction survey. However, the gap is that the question does not account for the fact that the patient is not the best evaluator of the professional RN or MD's priorities. Jane and John Doe are so ignorant of the workings of the health care system and the professionals within that system that they simply don't know how much they don't know. They do not understand how insignificant their desperate need to pee becomes in comparison to the often more critical needs of other patients. Most patients will desist on the call light if they hear the loud noises and see flashing defibrillator paddles, because that's what tv tells them saves lives.

But most will still answer the surveyor's question with 'No, I didn't actually get to pee the second my bladder twitched cos there weren't enough nurses to help me get up to pee and while the other nurses were tryin to get a pulse on that other guy.'

Some great rant examples...please see: Madness of an ER nurse, ERNursey, ERMurse, my friends in the UK at Mental Nurse, a new blogger I found at ER-Life.

Personally, I don't know what the big fuss is about. I always put mints on my pillow, bring fries with that and ask grieving families whom I have counseled through the death of a loved one if they'd fill out a satisfaction survey to let my boss know that they liked me.

* Percentage of patients who thought their pain was "Always" well controlled.

I love that one. Open-heart surgery won't hurt a bit, sir. We will keep you totally pain-free all of the time. All this making you not dead won't hurt a bit.

And as a NOC-shifter, I love this one, too:

* Percentage of patients who reported that their room was "Always" quiet at night.

I had a guy once who was pissy about all the "damned noise happening down the hall." I admit I was fried, having just come down the hall from the ugly code that was happening. It wasn't my best night. So instead of being all soothe-y and pillow-fluffy and sympathetic, I was human. I snapped at him: "I'm sorry, did that woman dying DISTURB your beauty sleep?"

I'm sure he complained about me on his patient satisfaction survey.


What's stunning about this website isn't that such a tool should exist to evaluate hospitals. After all, baby boomers want to know the cushiest hospital in which to receive their joint replacements because their bottoms have gotten too large for their knees to support any longer. I'm really okay with that, with economic natural selection.

It's the choice of some of the measuring sticks that Press Ganey utilizes.

It's the lack of context in which real illness actually happens. We in health care know that it's nothing like on tv. The public really doesn't.

It's the clash of capitalist economics and socialist economics: we want competition to weed out the better provider of service, but we also need to take care of the elderly, the drug- and alcohol-addicted (and their children), the sick who belong to a low-income tax bracket, the middle income bracket who can't afford the copays until it's too late.

Press Ganey's survey is not a bad idea. It chose some strange rulers. Today, I'm only ranting.

The real issue is that I'm wondering what some better rulers would be.


Anonymous said...

You're talking about the CMS-sponsored HCAHPS survey here, not about patient satisfaction surveys. This data is publicly reported on

RehabNurse said...

Oh, I work for the feds and no one cares about patient satisfaction at all...even though we're constantly threatened by exposes by Nightline, Dateline NBC, and everyone else. You say Press-Ganey and the kids say, "Huh?"

If we used a little common sense and did our best instead of worrying how much time we'd have sitting down in the break room or in the nurses' station, it wouldn't be so bad. (I ain't killin' myself most days like I was in my private hospital job...and they had Press-Ganeys)

Pissed off patients in the VA system call Congressmen. This starts the domino theory and things go downhill from there.

Press-Ganey crap was so much simpler than government mumbo-jumbo, believe it or not!

RehabNurse said...

Oh, I work for the feds and no one cares about patient satisfaction at all...even though we're constantly threatened by exposes by Nightline, Dateline NBC, and everyone else. You say Press-Ganey and the kids say, "Huh?"

If we used a little common sense and did our best instead of worrying how much time we'd have sitting down in the break room or in the nurses' station, it wouldn't be so bad. (I ain't killin' myself most days like I was in my private hospital job...and they had Press-Ganeys)

Pissed off patients in the VA system call Congressmen. This starts the domino theory and things go downhill from there.

Press-Ganey crap was so much simpler than government mumbo-jumbo, believe it or not!

Anonymous said...

I love it..I'm sorry, did that woman dying disturb your peace?

on the tele unit, where rooms are still semi-private, i had a less than pleasant patient who was s/p bilateral above knee amputations refuse to have her curtain closed. she exercised this right mid-code on her roommate. when i pulled her curtain the whole way shut, she began screaming "it's my right to refuse that curtain being shut! you can't do this to me!"

I shouted back "This patient deserves privacy right now and you're gonna knock it off! If you want the curtain open you get up and open it yourself. Until then, be quiet and have some respect for the dying."

She didn't have much to say after that. I realize it was less than tactful of me...but I'm sure she reflected that on her press ganey survery :)

Anonymous said...

I'm 50 years old and I don't want to ask your permission to go pee. I don't want to have to ask or beg you to come in once in an 8 or 12 hour shift and empty the damn hat so I can go pee. It's your job, do it. If I get up and dump the hat that you never got around to emptying, don't be mad at me.

hamlette2002 said...

This is what I sent to my congressman, the President, the Vice-President, and Medicare:

Dear Sir,

I am very concerned with what is happening to our hospitals. As a healthcare worker, I am increasingly finding that the standard of basing reimbursement from Medicare on a survey that patients are completely unaware of the consequences of not giving the highest score on is, to say the least, disheartening. We do our best to ensure that every patient leaves the hospital in better condition than when they arrived. Yet we are all constantly under the microscope, so to speak, about how we can 1) ensure that each and every department makes itself memorable and 2) the patient is absolutely happy with every little detail of his/her stay.

We are not running hotels. Room service is simply not an option for all patients. There are medical reasons why a patient may not be permitted to eat or drink or have a nice warm blanket. A person who comes to the hospital and is admitted is sick or injured. Chances are that they are not going to enjoy the necessary procedures to restore them to health and wellness.

Instead of an opinion poll, we need a survey that addresses facts. Please, feel free to ask if the patients' meals were nutritious and edible. If a patient requires a machine-soft diet due to their medical condition, chances are that if you ask how much he liked the food, his opinion is not going to be very high. I encourage you to ask if the patients' blood draws were successful. If you ask how courteous the person who took his blood was, he's not going to actually answer that question - he's going to give his opinion of how he feels about needles and how much it hurt. I beseech you to ask the patient if his health or wellness improved from the time of his admission to the time of his discharge. Asking the patient how friendly everyone who encountered him does not answer the question of how efficient his care was.

These surveys, their weight, and the pressure they are putting on our already strained healthcare force, are damaging morale. We are starting to focus so much on how happy the patients are that we're placing their health second. Please help us bring health back into health care, and change or eliminate these patient satisfaction surveys.



Anonymous said...

As a Press Ganey employee, I feel the need to chime in here. Satisfaction is rarely about your medical prognosis. It is how these people were treated. I am looking to my doctor and nursing staff for their expertise. When I walked through the door, my expectation was a team of knowledgeable, professional, and dedicate individuals. What grade do I give for this? A "C"! Think about going into a McDonald's. When you get to the counter you expect the person behind it to be able to take your order, process your payment, and give you your food in a prompt manner. Are you wowed by this? I doubt it. Does the fact that the garbage can behind you is overflowing or employees are acting like children detract from your experience? I would certainly say "yes". As a care provider, remember, these people are all having what could be considered the worst day of their life. Remember that when you interact with them and their families. The way you deliver your opinion matters. Next time you speak with a patient, even if it is only for a few moments, sit on the end of their bed, make eye contact and connect with them. It makes a difference. Remember the old addage, "it's not what you say, but how you say it". It's not about room service. That is the true basics here.

Now to hit on a real area of concern, your survey sample population. In terms of evil, greedy corporation, Press Ganey is the poster child. For facilities that use them, they are being soaked. PG is committed to a 40%+ gross margin on all products. In fact, to maintain this, your facility's costs for their products increase by at least 4% every year. When was the last time CMS allowed you to increase your reimbursement? Their new capital partner, invested over $600MM in the company and is expecting significant returns. In fact, they are mandating that this company grow from $150MM to $500MM within 5 years. They cannot do this by looking out for the interests of healthcare. The average facility really cannot afford to be able to survey a large enough sample of it's ED population to truly have meaningful data that is insulated from outliers (high and low). The greater the number of visits, the harder this becomes.

Here is the truth, these measures matter and the way we interact with patients matters. Want to effect wait times, try a liaison to update people on what is going on. Even if there is nothing to report to a patient, it has an effect that they are cared for and about. Give it a shot! As far as measurement tool, it DOES NOt matter. Data is commodity. Your facility will never use 80% of what their tool does so why pay for it? Save money, find a cheaper provider, raise your sample sizes, and invest in improvement efforts & initiatives. Satisfaction and interaction matters. You do not need a gold-plated ruler to do it effectively. The old wooden one will do just fine. In the end, you can cut costs and raise service levels. They only way this company will change and do the right thing is if you as customers make them do so. Vote with you wallet. Do that and you win. Press Ganey can only continue to hold hostage and pillage if you let them! Best of luck.

Anonymous said...

I have heard about the amount of 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. 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. This is a no-brainer to me - and my friend who quit there.

Lauren said...

I am a recent ER patient and I currently have a survey that I can not possibly wait to submit!

I love how you have examples of ignorant patients who complain about trivial issues while the nurses and doctors are busy trying to save a seriously injured patient who is dying.

I had a positive pregnancy test even though I had my tubes tied 5 yrs ago. After several blood tests of low hcg levels; my doctor gave me a Methotrexate injection to attempt to abort an ectopic pregnancy. We then scheduled a time for an outpatient surgery to remove my tubes completely. In the mean time, I was to report to the ER if I had any severe pains.

I presented at the ER with a rapid heart rate, severe abdominal pain located in a specific area on the right side, tremors, dizziness and severe shoulder pain. I explained to the triage nurse about my current OBGYN situation, the Methotrexate given 4 days prior, upcoming outpatient surgery scheduled. They rushed me to a room and gave me a cup for a urine sample. Then I waited and waited and waited.

FINALLY, a doctor came in, keeping his distance as if I had some sort of deadly virus; asked me to recap my story, then told me my urine sample was negative for pregnancy. He said it was a highly sensitive test and I was definitely no longer pregnant. He asked if it burned to urinate... nope.

Lauren said...

Then he said my abdomen did not look swollen; couldn't be my appendix. He said gas could cause severe pain, but once you pass it, you'll feel better. I asked if it could be a side effect from the Methotrexate. He said he wasn't really familiar with it, but possibly. He said wasn't sure what the cause was but he'd get me discharged with pain meds and come back if I develop a fever.

He walked out, stood five feet from my door and complained to one of the nurses to page the other doctor, because he'd been seeing 4 patients per hour and that was just too many!

Hour passed; a nurse came, asked me if the doctor had come in, asked ME - what did he say - and asked me to explain what the issue was. After explaining this a 3rd time, she said... ah, now I understand. Then she left to go find the doctor because she thought they should do a blood test.

After 1/2 hr I could hear a male voice complaining about his car and a female voice asking him about the 1 he talked about buying. He started on and on about it being out of state, his wife asking why wouldn't he just keep the 1 he had. He went on for at least 15 minutes; why he didn't like the car he had, what he wanted in a new vehicle, important points were vs items he was flexible about, color he liked best, colors he hated and why, and why his wife shouldn't have any say in him buying a new car. This lead to how his wife doesn't work and how he pays all the bills, etc. The female voice chimed in here and there.

Naturally, I had to pee after waiting for 3 hrs, and I knew the bathroom was down the hall.

As soon as I got out from behind the curtain, I was SHOCKED to be staring at MY STUNNED doctor and MY nurse (who went looking for him) and I asked to use the bathroom. They said, sure it's down the hall.... oh... by the way, we're printing up your discharge papers right now!

When I came back, I was handed (by a different nurse) a form to sign and a generic print out regarding possible (harmless) reasons for abdominal pain and follow up with my doctor.

I went right home and called my OBGYN, told this entire story to the nurse, who had the doctor call me immediately asking for every detail and was furious that they turned away a person with a possible ectopic pregnancy, recently given a powerful toxic drug without any type of examination or blood work. He sent me for another hcg blood test.

At my surgery a few days later, my doctor said my hcg test showed levels had gone from 96 to 115. He said he called the ER and spoke to the supervisor (who defended his employee). My OBGYN told him to check the expiration date on his urine pregnancy tests. I had a positive result on a store-brand test purchased the day before a blood hcg test showed my level was 71 and the ER claimed their "ultra-sensitive" test was negative when the next day my blood test showed my hcg level at 115!

Then during my outpatient surgery, my OBGYN located the fetus in my RIGHT tube (EXACTLY where I had been complaining that I had pain) and it was still "alive" and trying to grow. He removed it.

I had a serious medical condition which could have resulted in a ruptured tube and hemorrhaging if I had not been lucky enough to schedule a planned surgery for tubal removal in which we stumbled upon the reason for the severe pain and the ER had just turned me away.

I would not choose my hospital based upon survey responses from patients I don't know and without knowing the circumstances around "what they considered a bad experience." AND - This experience did not keep me from going back to this hospital for my outpatient surgery.

I do like the fact that I get to express my frustration with the DOCTOR AND NURSE in the ER and hope that they actually use this feedback to prevent someone else from ending up back at the ER with more serious complications, or even dead!

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