Patient Satisfaction

Patient Satisfaction

CHAPTER 18 Patient Satisfaction KRISHNA JAIN, MD, FACS We are witnessing rapid changes in healthcare. The healthcare expenditure continues to outpac...

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Patient Satisfaction KRISHNA JAIN, MD, FACS

We are witnessing rapid changes in healthcare. The healthcare expenditure continues to outpace general inflation. The Centers for Medicare and Medicaid Services (CMS) predicts annual healthcare costs will be $4.64 trillion by 2020, which represents nearly 20% of the US gross domestic product. The nation is looking toward a more fiscally responsible healthcare system. The patient has become a client, customer, or a consumer. The patient expects success after every intervention, while rest of the parameters that go into determining patient satisfaction are maintained at an optimal level. There is a high correlation between meeting the patient expectation and patient satisfaction.1 CMS is tying payment to physicians based on quality matrix, and patient satisfaction is a part of it. There was a time when all that mattered was that the patient had a satisfactory outcome after a surgical procedure. The landscape has changed dramatically. There were excellent surgeons with pristine reputation for their surgical skills but not necessarily for their bedside manners. In today’s environment they will not do well. There are surgeons with a beautiful office, excellent staff, great communication skills but marginal surgical skills. Their overall patient satisfaction scores are likely to be great, and they will do well with the regulatory agencies and payers alike. It is not given that a satisfied patient receives the best medical care. One of the risk factors for vascular disease is obesity. Discussions with the patient about weight loss are not always perceived by the patient to be of a friendly nature and may result in lower patient satisfaction. In general, the office-based endovascular center (OEC) should strive to have patients who are satisfied with the care provided to them in the OEC. Happy patients are the best ambassadors of the practice. There are two terms used to describe patient interaction with a healthcare system: patient satisfaction and patient experience. These two terms have different meaning. They are not interchangeable. It is difficult to define patient satisfaction. In general, a satisfied patient has a feeling that the patient was respected, had

a good outcome, and overall the doctor and staff showed empathy and the patient expectation were met or exceeded. In comparison, patient experience is defined differently. The Agency for Research and Quality defines patient experience as follows: “Patient experience encompasses the range of interactions that patients have with the healthcare system, including their care from health plans, and from doctors, nurses, and staff in hospitals, physician practices, and other healthcare facilities. As an integral component of healthcare quality, patient experience includes several aspects of healthcare delivery that patients value highly when they seek and receive care, such as getting timely appointments, easy access to information, and good communication with healthcare providers.” Most of the published patient experience data comes from the hospital system. In an OEC, patient satisfaction is paramount to its success. High patient satisfaction results in patient retention as well as increased referrals from the patients and referring physicians. This also prevents medical malpractice lawsuits. Healthcare delivery system is changing. With the corporatization of medicine, the individual touch patient expects and aspires for is rapidly disappearing. The delivery of care is becoming much more impersonal. The care provided by physicians is measured in relative value units and to some degree by patient satisfaction surveys compiled by outside consulting firms. OEC provides an opportunity for the healthcare team to deliver the highest quality of care without losing the personal touch. In 2001, Institute of Medicine (IOM) published a report titled,2 “Crossing the Quality Chasm.” In this report, IOM set forth six goals for a quality healthcare system. The care provided to the patient should be (1) safe; (2) equitable; (3) evidence based; (4) timely; (5) efficient; and (6) patient centered. If these six aims along with three others described later in the chapter are met, it is very likely that patient satisfaction will approach 100%. In reality, in the OEC,

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patient satisfaction did reach 99%.3 Let us look at the process of applying these six goals in an OEC.

SAFETY The care provided in the OEC is as safe as in any hospital setting. Jain et al., in 6458 cases performed in the OEC, reported overall complication rate of 0.8%. Arterial procedures with intervention had the highest complication rate (10 of 368 [2.7%]), followed by venous ablation procedures (22 of 1019 [2.2%]). In 5134 consecutive cases, Lin4 et al. published progressive decrease in complication rates from 3% to 0.7% in the latest period. Once precautions are taken to avoid complications (Chapter 14) and the selection of patients is appropriate, the complication rate should be the same or better than the hospital. The risk of nosocomial infection is eliminated. In the OEC, the same team works in the preoperative area, procedure room, and the postoperative area on a daily basis. This helps decrease lack of communication and inherent risk of complication caused by miscommunication.

EQUITABLE Based on the geographical area and the socioeconomic status of the community where the practice is located the practice would be serving the community at large. Majority of patients seen in a practice dealing with vascular disease come from referrals from the local physicians. If the physicians in the area are serving the community well, it will be reflected in the practice, and since OEC is an extension of the practice the OEC will be serving the patients in an equitable manner. Medicaid in general plays less than Medicare for any given procedure. The reimbursement varies from state to state. In our experience we did not loose money for any procedure performed in the OEC while taking care of patients on Medicaid. Though, the profit margin was minuscule to nonexistent.

EVIDENCE BASED Medicine continues to be an art as well as science. There are guidelines for management of most of the diseases being treated in the OEC. However, the guidelines written by different societies for the same disease process may differ from each other. There are intersocietal guidelines that are usually more comprehensive and should be followed as much as possible. Since the medicine is still an art to some extent, there may be an

occasional patient that falls outside the guidelines. The interventionalist should follow the guidelines as much as possible. There is no peer review process in place for the OEC. This makes it even more crucial that the care being provided in the OEC is evidence based. Every interventionalist should take the “Mirror test,” When looking in the mirror in the morning one should think of the patient as their immediate family and ask the question, “Will I operate on this patient if the person was my mother?”

TIMELY One thing that is very evident is the timeliness of care in the OEC as compared with the hospital. Think of a patient admitted through the emergency room by a hospitalist with a gangrenous toe. Usually it will take a couple of days for medical workup. At some point, vascular consult will be requested. Depending on the hospital, the procedure for endovascular revascularization may be scheduled in the hybrid operating room, cardiac Cath lab, or an interventional radiology suite. Depending on the procedure, room schedule, and the interventionalist’s schedule, a procedure may be performed anywhere from 1 to 3 days after the call is made to schedule the procedure. Depending on the time of the day when the procedure is performed, patient may have to wait another day to be discharged. If the same patient comes to the office, patient can be examined, assessed, have the noninvasive vascular imaging of the lower extremity arterial system and blood work to check the kidney function on the same day. On the next day patient can have total revascularization of the extremity with critical limb ischemia and go home. In follow-up, patient may have debridement in the office or minor amputation in the hospital on an outpatient basis. Since the interventionalist controls the schedule in the OEC, it is a lot easier to provide care for the patients in a timely manner. For patients on hemodialysis, OEC is the ideal place to maintain their dialysis access. Number of missed dialysis can be minimized and patient can have more catheter-free days. Failing access can be easily managed using endovascular techniques on nondialysis days. In case of thrombosis of the dialysis access percutaneous thrombectomy can be carried out on the same day and patient dialyzed. If the hemodialysis catheter is not needed any more, the catheter can be removed on the same day. In a study by El-Gamil et al.,5 patients being treated in an OEC had lower annual mortality,


Patient Satisfaction


lower access-related infections, fewer hospitalizations, and lower total per member per month payments as compared with hospital outpatient department. Patients with retrievable inferior cava filters need to have the filters removed in a timely manner. This can easily be done in the OEC. In one study,6 it seems to improve the retrievable rate of these filters. Patients needing ports can have the port inserted on the same day as they are seen in consultation in the office so long as they are not on anticoagulants and white count and platelet count is normal.

on Medicare may be barely managing their lives on social security checks. The office should work with the patient and the family if necessary to make sure that there is a financial plan in place before the procedure is done. There are strict rules laid out by CMS that need to be followed in billing and collection for patients on Medicare and Medicaid. As per the rules the patient balance can only be written off if proper procedure is followed. A payment plan can also be agreed upon before the procedure is performed on patients with any kind of insurance or self-paying patients.



Timeliness and efficiency go hand in hand. The OEC usually opens before the main office and closes at the same time as the office. This would be a 10-hour day. There is no provision for overnight stay in the OEC. That means all the work needs to be done during these hours. Since the physician owners have a vested financial interest in the center, every effort is made by the team to eliminate wasted time. The techniques will include, a) doing cases in the morning that will require longer time in the recovery room, b) turnover time between cases being 6e15 min, c) working through the lunch break with appropriately trained people, d) availability of all procedure-related data before the patient arrives in the OEC etc. During the course of the day of the procedure, patient does not have to go through more than 30 touches by different people, quite common in the hospital even for outpatient procedures.

The thought of having an invasive procedure is scary for everyone. Timely communication plays a great role in alleviating anxiety in the patient. Since OEC is an extension of the practice, the practice should have the policy of open communication with the patient. Every employee should be able to communicate with the patient and share information pertinent to their level in the organization. Physicians should be able and willing to discuss all aspects of care with the patients and family members designated by the patient.

PATIENT CENTERED Patient comes for the procedure at the same place, where the patient has received nonoperative clinical care. The culture of the office should be patient centric. The only reason the practice exists is because it cares for the patients. If there are no patients there is no practice. It behooves the owners of the practice to make the patient comfortable and be treated with respect during every encounter with staff as well as the medical personnel. This culture permeates into the OEC. Patient’s privacy and confidentiality should be maintained at all times. In addition to the goals set by IOM there are other factors that impact patient satisfaction in an OEC.

FINANCIAL In today’s healthcare environment, patients carry insurance policies with very large deductibles. The patients

EMPATHY In Merriam-Webster Dictionary, empathy is defined as “(also the capacity for) the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner.” Any invasive procedure causes anxiety in the patient and the family. To have a good doctor-patient relationship, it is crucial that the doctor and the whole team has empathy toward the patient. It lays the foundation for high patient satisfaction. In the functioning of the OEC, patient satisfaction is driven by three factors contributing to their care. Doctor Organization Office environment

DOCTOR For patient to be fully satisfied the patient must feel that the patient got undivided attention of the doctor. Usually, it is the same doctor who has been managing the patient in the office who will carry out the procedure in OEC. Sometimes, another doctor in the practice may carry out the procedure because of scheduling reasons, or different skill sets possessed by doctors in the practice. In case another doctor is going to do the procedure, the



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operating physician should meet the patient in advance and build a relationship. There should be frank and exhaustive discussion about the pros and cons of planned procedure. Alternatives to the invasive procedure should be discussed. The appearance of the doctor is important. A chronically tired looking doctor in shabby clothes does not build confidence in the patient. Without violating the HIPAA rules, it is important to have good relationship with the patient’s family or the caretaker. They are concerned about the care the patient will get as well as they will be responsible for the care after the procedure, and many times will be bringing patient to the follow-up appointments. Doctor is the leader of the organization and needs to lead by example.




The whole organization needs to be quality driven. In today’s environment, the office is exposed to the world even before the patient comes to the office. Majority of patients or the relatives of the patient are looking up information about the OEC on the Internet. They are doing independent research about the doctor and the practice. They are looking for a practice website, researching on social media and other Internet sites. The OEC website should be pleasing, informative, and updated as necessary. The patient should feel welcome starting from the time a call is made to make an appointment and throughout all encounters. Wellinformed patient is a happier patient. There should be clear-cut delineation of duties. Since the OEC is an extension of the office practice, if the patients are unhappy in the office it is most likely that they will be unhappy in the OEC. Beyond the usual office staff, the patient will interact with the OEC staff which will include the scheduler, recovery room staff, and procedure room staff. All these staff members need to be courteous, respect patient privacy, and answer questions appropriate for their level. Organization should make sure that the staff members are happy doing their job. Happy staff members make the patients happy. There should be clear-cut chain of responsibility. There should be a mechanism to answer patient concerns and complaints in a timely manner. According to the joint commission a mechanism must exist for receiving complaints, and patients should be informed of this mechanism and their right to complain. The organization should respond to the complaint, take appropriate action and share the outcome with the patient.

The physical structure of the office should be pleasing and patient friendly. The reception area is usually shared by the patients coming to the office for office visits as well as the patients coming to OEC for a procedure. The OEC facility should not be cramped and be designed in a way to have comfortable space for patients and their families. The procedure rooms should be designed for patient comfort and safety. There should be space for family members while waiting for the procedure to be completed. Since there is no cafeteria in the office, the waiting family should be offered light snacks. The reception and waiting area should have appropriate current reading material.

Satisfaction is part subjective and part based on reality. The surveys are created in an attempt to translate subjective feelings into meaningful, quantifiable data that can be acted upon. The survey can be done via mail, telephone call, or face to face with the patient at the postprocedure office visit. The survey should be short and ask pertinent questions about the care provided in the OEC. Patient interacts with different people in the OEC. Survey can be designed to ask questions about each point of contact and the operative experience. The hospitals have used Hospital Consumer Assessment of Healthcare Providers and systems (HCAHPS) for quite some time. This was the first national, standardized survey of patients that was publicly reported regarding the patient’s perspective of hospital care. The survey is also known as CAHPS. This survey compares the hospital locally, regionally, and nationally. The survey has three goals: (1) provide objective data about patient’s perspective of care at the hospital, (2) public reporting of the results that may help hospital improve quality of care, (3) public reporting increases accountability and transparency of quality of care provided by the hospital. This results in a better accounting of public investment in healthcare. The survey consists of 27 questions and is sent to discharged patients from the hospital. Eighteen questions out of 27 are directly related to patient’s experience at the hospital. Nine questions are asked related to other items. The survey is sent to random patients every month between 48 h and 6 weeks postdischarge. The survey can be conducted by mail, telephone, mail followed by telephone call, or interactive voice recognition.

CHAPTER 18 In addition to authorizing payment for certain procedures in the OEC by CMS, the Deficit Reduction Act of 2005 created an additional incentive for acute care hospitals to participate in HCAHPS. More incentives were created in the Patient Protection and Affordable Care Act of 2010.

ONLINE REVIEWS Online reviews have taken a life of their own. There are countless reviews online. These reviews are on none healthcare websites like Google or Yelp and on healthcare websites like Healthgrades, RateMDs, Zocdoc, etc. In addition, many healthcare organizations have their own websites. A significant number of patients look at online reviews in making healthcare decisions. The negative reviews cause stress among physicians. In a study published by Holliday et al.,7 53% of physicians and 39% of patients reported visiting a physician rating website at least once. The physicians trusted data on health system patient experience surveys more often than the data on independent websites while the opposite was true for the patients. Widmer et al.8 compared Press Ganeyeconducted patient satisfaction survey with the online review by patients of physicians who had a negative review and the ones who did not. In Press Ganey survey, there was no difference in patient satisfaction score in the two groups. However, when comparing none physician-specific factors in those with negative online reviews versus the ones without negative online reviews there was a significant difference. This has implications in the OEC. Despite the patient being satisfied with the services provided by the physician there may be other factors in the OEC that can result in a negative online review. The online reviews are here to stay and the OEC should make an active effort to address any issues that may result in negative reviews. There is a debate as to how to handle a negative online review. Some experts recommend addressing the negative review while others do not. If there is merit in the negative review the issue should be addressed. For example, if the review says the staff is rude, staff may need further training. I would recommend a strategy that is proactive. If any member of the practice sees a negative comment about the practice or the OEC, the patient should be contacted observing HIPAA rules. Do not post comments on the website. Once the problem is resolved, the patient is very likely to take down the negative post. Comments on social media stay forever and it is in the best interest of the OEC not to have any negative comments on social media.

Patient Satisfaction


MIPS and MACRA The Medicare Access and Chip Reauthorization Act was passed in 2015. In the act, Merit-Based Incentive payment (MIPS) system was created. As per CMS website, in MIPS, “Performance is measured through the data clinicians’ report in four areasdQuality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. We designed MIPS to update and consolidate previous programs, including Medicare Electronic Health Records (EHR), Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the ValueBased Payment Modifier (VBM).” In addition, an advanced alternative payment system (APM) was also created. As per CMS website, “An APM is a payment approach that gives added incentive payments to provide high-quality and cost-effective care. APM can apply to a special clinical condition, a care episode, or a population.” Physicians working in the OEC are ideally suited to participate and take advantage of these programs. When the physician is in charge of the total care being provided to the patient in the OEC, variables can be controlled and improvements made to deliver quality care at the highest level. If the practice wants to participate in an APM, it may be possible to create a model to take care of patients on hemodialysis and patients with critical limb ischemia. OEC is ideally suited to take care of these patients. Participation in a quality clinical data registry can help meet some of the requirements of MIPS.

Survey Tool The OEC may contract with an outside agency to carry out a survey. This kind of survey may be acceptable to payer, but is expensive. If the goal is to assess the quality of care being delivered for internal use the survey can be developed by the practice (Table 18.1). Patient satisfaction is important to the patient, patient’s family, and the physician alike. Every doctor wants the patients to be happy with the care they receive. When the physician provides care in the hospital there are many factors that are not in the control of the physician. However, when the care is provided in the office and OEC, almost all foreseeable aspects of care are controlled by the doctor and the staff. In this setting if patients are unsatisfied by the care they are receiving, the doctor and the team needs to analyze the cause of this dissatisfaction and correct the deficiency. There will be an occasional patient who will



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TABLE 18.1

Sample Survey Questionnaire (on the Scale, 1 is Poor and 10 is Excellent).





Was the staff courteous

1 2 3 4 5 6 7 8 9 10

Communication with staff

1 2 3 4 5 6 7 8 9 10

All questions about procedure answered

1 2 3 4 5 6 7 8 9 10

Satisfied with results

1 2 3 4 5 6 7 8 9 10

Will you come back for a procedure if needed


Will you recommend the center



be dissatisfied despite the best efforts on part of the practice. Even that patient needs to be treated with respect and compassion. OEC is the site of service which lends itself to strive for 100% patient satisfaction.






REFERENCES 1. Hamilton DF, Lane JV, Gaston P, et al. What determines patient satisfaction with surgery? A prospective cohort study of

4709 patients following total joint replacement. BMJ Open. 2013;3(4). Crossing the Quality Chasm. Washington, D.C.: National Academies Press; 2001. Jain KM, Munn J, Rummel M, Vaddineni S, Longton C. Future of vascular surgery is in the office. J Vasc Surg. 2010. Lin PH, Yang K-H, Kollmeyer KR, et al. Treatment outcomes and lessons learned from 5134 cases of outpatient officebased endovascular procedures in a vascular surgical practice. Vascular. 2017;25(2):115e122. 10.1177/1708538116657506. El-Gamil AM, Dobson A, Manolov N, et al. What is the best setting for receiving dialysis vascular access repair and maintenance services? J Vasc Access. 2017;18(6):473e481. VanderVeen NT, Friedman J, Rummel M, et al. PC190. Improving the retrieval rate of inferior vena cava filters: impact of inferior vena cava filter retrieval in the office endovascular center. J Vasc Surg. 2018. 10.1016/j.jvs.2018.03.339. Holliday AM, Kachalia A, Meyer GS, Sequist TD. Physician and patient views on public physician rating websites: a cross-sectional study. J Gen Intern Med. 2017;32(6): 626e631. Widmer RJ, Maurer MJ, Nayar VR, et al. Online physician reviews do not reflect patient satisfaction survey responses. Mayo Clin Proc. 2018;93(4):453e457. 10.1016/j.mayocp.2018.01.021.