Patient satisfaction at the 75th percentile

This week we celebrated impressive improvements in Community General Hospital's patient satisfaction scores . . . across the board.

There were free sundaes in the cafeteria on Wednesday, and Chris Stryker, Chief Nursing Officer, and her Directors Nancy Thompson, Lyn Pittinger, and Cathy North brought ice cream to night staff in various departments.

The graph shows Community's overall patient satisfaction rating, as posted in the hospital this week.

The Press Ganey survey scores (second quarter, 2010) show patients overall rating of the hospital at 86.4%, a statistically significant improvement over previous scores. That score puts Community at the 75th percentile for hospitals of our size nationally and for hospitals in our Central New York comparison area.

The overall rating reflects improving patient satisfaction in all areas, including these statistically significant gains:

▪ Satisfaction with nursing care and communication -- 89.9%, up over two percentage points
▪ Satisfaction with doctors care and communication -- 88.7%, up over two points
▪ Satisfaction with the handling of personal issues -- 87.0%, up over two points
▪ Satisfaction with hospital accommodations -- 81.4%, up over four points

We've seen the improvements coming as we track the changes from week-to-week and quarter-to-quarter.

Improved patient satisfaction has also been evident in the HCAHPS* scores the federal government posts on its Hospital Compare website. I talked about the HCAHPS improvements in employee meetings last May.

It's great to know that patients see improved value from our caring and in our hospital environment. Congratulations to Community's employees, to our management team, and to our medical staff.

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* HCAHPS stands for "Hospital Consumer Assessment of Healthcare Providers and Systems." HCAHPS track and report the opinion of Medicare patients at hospitals across the nation.

The pneumonia deaths

A recent news report cited Community General Hospital for pneumonia death rates above the national average. The story was based on mortality statistics published by the Centers for Medicare and Medicaid Services (CMS). The mortality rates were mathematically adjusted for differences in patients' medical conditions, but the rates did not adjust for differences in mortality due to patients’ own do-not-resuscitate (“DNR”) orders.

The Post-Standard reported that for Medicare-covered pneumonia patients “the national mortality rate was 11.4 percent. Community General Hospital… had a pneumonia death rate above the national rate 15.1 percent.” In paragraph eight, the story appropriately quoted Fred Goldberg, MD, Community’s Chief Medical Officer, explaining that “these report cards do not account for...end-of-life preferences."

The distinction may be too subtle for headline writers.

Last year I wrote about CMS’ plans to add pneumonia mortality rates to its Hospital Compare website. I discussed Community’s past investigations into pneumonia deaths with respect to patients’ DNR orders – and I quoted “Mortality as a Measure of Quality: Implications for Palliative and End-of-Life Care” from the Journal of the American Medical Association (JAMA):

Mortality is a good quality measure for individuals with acute illness who are not supposed to die…However, mortality is a poor quality measure for the majority of patients with multiple chronic diseases who are near the end of their life, and may be engaged in…decisions that result in an earlier (or less delayed) death.

Following the recent news story, I again looked up the JAMA article. It said:

Treatments provided to seriously ill patients are often inconsistent with patients' underlying preferences….[T]here is a 10-fold variation in the rates of early do-not-resuscitate (DNR) orders across hospitals and dramatic variation in the proportion of all intensive care unit deaths preceded by withdrawal of life support….Such decisions may be relatively more common in the 600,000 hospital deaths that occur each year (over 50% of all hospital deaths) in patients aged 75 years or older who are at increased risk for accumulating multiple chronic illnesses.

During the period of time reported in the CMS data, the average age of the pneumonia patients who died at Community General was 83. As Dr. Goldberg reported, 93% of them had do-not-resuscitate orders.

Hospital mortality rates

A wry pathologist once explained to me the reason for post mortem examinations. “Patients die,” he said, “for one of two reasons – patient failure or doctor failure. We ought to know which.”

Today we understand that many factors contribute to hospital outcomes. It is not just what a doctor orders or what a doctor does. Hospital outcomes are affected by the doctor working with the entire caring team, as well as by the effectiveness of hospital processes and support systems. Hospitals are complex places.

Last June the federal government's Hospital Compare website began reporting risk-adjusted 30-day mortality data for hospital heart patients.[1] The government’s report shows that 98.5% and 99.5% of all hospitals treating heart attacks and heart failure, respectively, had mortality rates that were consistent with the national rates.[2] Community General and the other Syracuse hospitals were all within the mortality rate mainstream of the nation’s hospitals.

The government’s website does not show hospital-specific mortality rates, and this lack of detail has been criticized by some. USA Today said that, by not listing hospital-specific death rates, the government’s web page “leaves 98% of the hospitals in the USA statistically indistinguishable from one another.” The newspaper also quoted a source at the Robert Wood Johnson Foundation as saying, “I would want to know if my hospital has higher death rates than the hospital across town.”

But others worry that mortality rates, even after statistical risk-adjustment, do not capture underlying differences that may be affected by patients’ own decision-making, particularly the end-of-life decisions made by the sickest patients. The authors of a recent article in the Journal of the American Medical Association (JAMA) suggest that the public reporting of hospital mortality rates might actually encourage the “overly aggressive treatment” of patients in their final weeks of life at the expense of effective pain control.

Several years ago, an insurance company published misleading mortality data about the pneumonia patients cared for at Community General Hospital. As reported, the pneumonia patients’ mortality was significantly higher at CGH than at other area hospitals. After investigation, we determined that the company did not take into account patients’ advance directives.[3] An examination of the records of the patients found that that 90% of the pneumonia patients who died had a DNR order.[4] In other words, most of the pneumonia deaths occurred among patients who had decided they did not want extraordinary measures used to prolong their lives. Of the non-DNR pneumonia patients cared for at CGH, the death rate was less than one percent. I discussed this situation in 2005.

Interestingly, JAMA reports that the federal government will likely add the mortality rates of pneumonia patients to its website in the future. According to the commentary in JAMA:

“Mortality is a good quality measure for individuals with acute illness who are not supposed to die…However, mortality is a poor quality measure for the majority of patients with multiple chronic diseases who are near the end of their life, and may be engaged in…decisions that result in an earlier (or less delayed) death.”

Hospital report cards are good things, and they will improve over time. As patients and families learn to use these report cards, they will become more informed about differences among hospitals – as well as about limitations of the report cards themselves.


[1] Risk-adjustment is a complex statistical process that takes into account differences in the complexity of patient conditions and differences in hospital service programs so that the mortality rates are, in fact, comparable among hospitals.
[2] The data reflect patients discharged from hospitals from October 2005 through September 2006.
[3] Advance directives are the written instructions patients give to doctors and hospitals that specify the care the patients want to receive (or don’t want to deceive) in the event they cannot make future medical decisions for themselves.
[4] DNR (“do not resuscitate”) is one form of advance directive.