Patient satisfaction and high-reliability organizations: what's the connection?

Dermatology Nursing, April, 2008 by Karlene Kerfoot

TRANSPARENCY IS THE WATCH-word of the day as we enter the new era of public reporting in health care. The public wants to know our outcomes before choosing a provider and a facility, and the government and other payers want to know if we are providing value for the dollars spent. We have moved from carefully concealing information about quality to the new era of quality outcomes data posted on a variety of Web sites. And now with the federal initiative, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) which will provide a standard national survey instrument for measuring patients' perceptions of care, we will have public ally reported comparability between health care organizations. A public light will shine on the very important component of quality health care, the patient's perception of care.

In reality there is no such thing as truth. It is merely one's interpretation of a particular reality. Patients' perceptions of their care are extremely varied based on their expectations and the actual variability of the care provided to them. The key to attaining excellence in patients' perceptions of their care is to first describe carefully the process of what their care should be, insure that the processes are carefully replicated correctly throughout the course of their stay, and any variation from the ideal measured in real time so corrections can be made quickly during the stay. This sounds like a simple process, yet is very complex as we consider the variability of the patients, employees, and processes within the health care facility that are dramatically altered by shifts in census, consistency of available qualified staff, etc.

High Reliability and the Patient Satisfaction Experience

High-reliability organizations (HROs) strive to replicate the same "best practice" over and over again in spite of any extenuating circumstances (Gaba, 2003). We expect that a code will be performed exactly the same way if it happens on Saturday at 4:00 am or on Monday afternoon at 6:00 pm. To allow variability in this process can mean the loss of life. We practice in classroom simulations until we get it right and then repeat the practice at defined time intervals. To achieve excellence in outcomes for patient satisfaction, we must apply the same principles in spite of the complexity of the interaction between patients and the people within the organization. One antagonistic person in the admitting department can create an unforgettable experience that will tip the entire perception of a patient's experience with the facility.

The Six Sigma process focuses on eliminating the variation around conformity to requirements as a way to improve performance. If we take this measurement tool and apply it to our challenge to attain excellent HCAPS scores, we have some things to consider. In an attempt to apply Six Sigma to the patient experience, Fleming, Coffman, and Harter (2005) make the case that customers fall into two categories: those with strong emotional connections and those without these connections. Customers with strong emotional connections contribute the most to the bottom line and recruit new customers. In a HRO, the drive to standardize "best practice" to create this high level of engagement of patients is present in the DNA of the organization's structure and processes. These authors note that the "..unmanaged variability in the quality of the customer experience represents a significant threat to the enterprise's sustainability because customers experience variation, not averages" (p. 111). One irritable nurse or one physician who cannot make a connection with the patient represents the variation from the ideal that will taint the patient's total perception and ability to engage with the organization.

The Signature Experience

One of the hallmarks of the Six Sigma process is the mapping of desired processes and measuring the variation from the expected ideal. This is hard to do unless there is a clear view of knowing what is expected (Wagner & Harter, 2006). You can't effectively measure variation from best practice if people are unclear about the expectations. Erickson and Gratton (2007) suggest that every company needs a "signature experience" that sets it apart and explicitly communicate what makes the organization unique. For employees, this significantly improves employee engagement and performance and ultimately customer satisfaction, which is directly related to employee engagement. Starbucks, Disney, Ritz-Carlton, and other organizations strive for a standardized signature experience that guides their staff and sets up expectations for their customers. When variation around the expected process occurs, the disconnect with the customers' expectations and the failure to deliver correctly on any of these signature expectations creates a failure in execution of the desired customer experience. In hospitals and health care organizations, we are just beginning to learn about the absolute essential need to reduce variation around these processes in order to create the outcomes demanded by the public reporting of data.