Trust — At the Core of the Patient Experience

How do patients evaluate the "patient experience?" Not like providers do. Various studies have pointed to the challenges inherent in attempting to determine patient satisfaction with their care in meaningful ways. For instance, as far back as 1999, an article in the Journal of Advanced Nursing noted difficulties with patient satisfaction surveys due to the "limited theoretical underpinning of satisfaction" (e.g. what does "satisfaction" really mean?) and pointed out that "the difficult in defining expectations and satisfaction and the methodological problems associated with their measurement have cast doubt on the validity of studies."

Flash forward 14 years and healthcare administrators across the country will tell you the same thing with regard to their Hospital Consumer Assessment of Healthcare Providers and Systems survey experiences. What we see as the result of surveys simply doesn't yield the rich information required to identify and address issues at the core of the patient experience. The numbers clearly indicate the percentage of respondents giving a certain rating to a specific question, but the data doesn't explain why.

Experience is built on relationships

Healthcare is, at its core, based on relationships. And, as with any relationship, trust is foundational to building and maintaining a strong relationship. The very personal nature of healthcare relationships supports the importance of trust. So does the research. In "The Patient-Doctor Relationship: a Synthesis of the Qualitative Literature on Patients' Perspectives," study authors reviewed data on qualitative studies examining the patient-doctor relationship and identified two key aspects impacting the relationship: "factors that develop or maintain the relationship (longitudinal care and patients' consultation experiences) and factors that characterize an ongoing depth of relationship (knowledge, trust, loyalty and regard)."

Building trust is critical for the patient experience. Unfortunately, trust can be fragile and fleeting. It can be either eroded or enhanced in an instant. Determining what it takes to erode these fragile relationships can be challenging and not generally appropriate for quantitative assessment. Quantitative surveys are not the best choice when evaluating attitudes and feelings — qualitative assessments are widely felt to be of far greater value — methods like depth interviews or focus groups are among the most widely used qualitative research methods. They are valuable in revealing the patients' perceptions, expectations and desires.  

These types of assessments, though, can be taken even further to yield far richer results. Ethnography studies or, in-depth mystery shopping assessments, evaluate the layers of the emotional experience in context of the facts to explore expectations versus experience and how any gaps between the two can impact trust and, ultimately, the relationships. In ethnography studies, the trained researcher works with the patient and is presented to staff as a family member or friend. This individual documents information regarding the series of specific events and encounters while gleaning the patient and family reaction and emotional responses to the encounters. For instance, after the physician, nurse or tech leaves the room, the observer (who has taken note of the facts surrounding the encounter) will ask the patient about his/her thoughts and reactions to the encounter. Sharing the patients' direct quotes and stories from mystery shopping can shed light for staff and providers which engage the heart. Mystery shopping assessments can provide revealing insights about the things that diminish trust for patients in their care providers as well as their healthcare organizations.

Mystery shopping and the healthcare experience

Despite the privacy issues inherent in healthcare, mystery shopping is becoming increasingly prevalent and is conducted in several settings with distinct goals:

  • Phone calls. Mystery callers assess phone encounters through the use of previously determined scenarios. Callers score staff on multiple areas based on customized surveys. These scenarios and surveys can be designed to target particular problem areas that may have been identified through surveys or patient comments such as friendliness of staff or ease of access. In some cases, mystery calls are invaluable in identifying loss of market share due to poor first impressions. Some of the objectives for phone mystery shopping are to assess appointment access, friendliness of staff and knowledge of providers and services.
  • Walkthrough visits. Mystery visitors posing as hospital or practice visitors gather general impressions about the experiences with wayfinding, the overall atmosphere, environment and employee encounters. They spend time in public areas listening and observing the environment, staff — and other customer reactions. They do photo documentation of things that they feel add to their impressions. Pictures paint a thousand words!
  • Patient visits. Using real-life situations with predetermined scenarios, mystery patients present with symptoms of an urgent, but non-life-threatening matter. This allows them to provide information about the total patient experience, including interactions with all staff, as well as experiences in the waiting room and exam rooms. These visits can take place in urgent care/ER, clinics and outpatient settings. Photo documentation is an important part of the report. For example, one patient showed a photo of blood smears on the floor of the ED along with an un-capped, used syringe left on the counter. This, paired with his comments that, "They are sloppy and don't pay attention to detail. It makes me feel like I have to be on the look out to be sure they don't give me a wrong medication or something. I wouldn't recommend this place because of it, nor would I return." Leaders are often shocked to see the photos provided by patient mystery shoppers especially when they see how specific items erode trust.
  • Care partner observations in inpatient settings. Often referred to as ethnography studies, these visits offer direct and indirect observation with documentation. Care partner observers are mystery shoppers who are introduced to the hospital staff as a family friend, neighbor or relative there as a companion to the patient. The CPO is able to witness firsthand what the patient is experiencing and to gather patient reactions and feedback. These interviews and observations often connect the dots to explain why they respond the way they do on surveys. These studies also include photo-documentation.

Hospitals — even very good hospitals — are often stymied by HCAHPS scores that are lower than anticipated. Often, based on these scores, leaders may take actions that really do little to address the crux of the issue. For instance, consider a hospital whose scores suggest that cleanliness is an issue. The administrative team immediately identifies this as an opportunity for improvement and all eyes are on environmental services. But the survey may not reveal what's at the heart of the matter.  

Getting to the heart: Building trust

In one situation, we found that although the environmental staff were doing a great job of cleaning, other staff members were creating clutter which led patients to feel that their rooms were not clean. For instance, a nurse would start an IV and a tech would do an EKG and both would leave wrappers behind on the bedside table. Every time food was delivered and placed on the bedside table none of the old, half-full, warm beverages were removed. In another situation that our CPO observed, a nurse helped the patient change his gown and then dropped the soiled gown on the floor where it remained for two shifts. When the patient was asked what he thought about the environment he said it was dirty — not because of the efforts of environmental services, but because of the actions of other staff. The patient described his feeling that staff members were careless because of these behaviors and his trust in the care was diminished because of it. When the staff saw the photos and heard the patient comments they became much more engaged in taking action. Why? Because stories (and photos) move information from the head to the heart.

This is just one example of how qualitative feedback delves deeper into issues related to the patient experience. The result: clarity for both hospital staff and administration as they work hard to address issues their HCAHPS scores.

Another interesting point: many of the issues that are uncovered through qualitative patient encounters have nothing to do with what clinicians might typically view as "care" — they have to do with issues related to trust. Healthcare organizations are only as strong as their weakest link and often don't know what these weak links are. They are the people, processes and environmental issues that diminish trust.

Identifying the real drivers of patient satisfaction at your organization can help you focus on those things that most impact the trusting relationship you seek to build with your patients and their families. Then the real work can begin.

Getting there does not necessarily require hiring an organization like ours to do the work. Many organizations incorporate interviews and patient advisory groups very successfully. When it comes to ethnography studies, the key is to work with someone who can provide an objective opinion and, who can interpret the information to provide solid recommendations. Too often, immersed as we are in the work that we do as healthcare providers, we have trouble seeing what is really behind those vexing scores.  

With over thirty years of experience in patient care, healthcare marketing, business development and administration, Kristin Baird is a talented speaker and consultant with a passion for service excellence. President of the Baird Group, Ms. Baird earned a bachelor of science in nursing from the University of Wisconsin-Madison and a master's in health services administration from Cardinal Stritch University in Milwaukee.


More Articles on Patient Experience:

Survey: Patient Satisfaction May Depend on Bedside Manner More Than Medical Skill
Healthcare Emotional Intelligence: Its Role in Patient Outcomes and Organizational Success
Study: Physicians Less Likely to Bond with Overweight, Obese Patients

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