Unintended consequences of reliance on patient satisfaction measures

In 2013 Hospital Impact published my post “The hidden costs of incentivizing patient satisfaction“.

In this piece I shared the following quote from a physician working within the broken healthcare system …

– “If a portion of my compensation is based on patient satisfaction then to maximize my reimbursement I must provide to my patients everything they want. And if that means services they don’t actually need, be it an antibiotic or x-ray, so be it. If I say no they are mad (unsatisfied) and it will cost me money. These are the rules of engagement the system has created and thus these are the engagement rules I will follow.”

And I concluded …

– To honor our commitment to improving the health of our patients, families and communities, we must be mindful of the complexity of the system, understand the unintended consequences, and focus on those things that bring physicians and patients closer–and rail against anything that hurts the physician-patient relationship.

So I was thrilled to see the article “Bioethicists say patient-satisfaction surveys could lead to bad medicine” by Sabriya Rice in Modern Healthcare this week in which she shares:

– “The bioethicists also worry that focusing on patient satisfaction as an independent goal has made it “ripe for commercialization” and resulted in a boom of profit-making businesses.”


– “… many have questioned whether focusing on those priorities will lead to improvements in patient outcomes such as lower mortality and lower readmission rates or result in unintended consequences.”

With unintended consequences defined as …

– “Pressure to tell patients what they want to hear and accede to unreasonable requests may increase the provision of unnecessary care,” and ultimately “lead healthcare astray, undermining the provision of optimum care for all.”

As healthcare leaders we must remember surveys are simply tools and within the complex adaptive nature of the healthcare system we must focus on both intended and unintended consequences of the reliance on these tools.

We must ensure we are developing healthcare models which optimize these tools without being solely dependent on them.

And most importantly … we must focus on ensuring authentic connection and relationship between patients (and families) and their clinicians which allow for the development of trust and the telling and hearing of the patient’s whole story.  Only then will we truly understand the patient’s experience and satisfaction level through their lens and truly be able to act upon it together with our patients.



  1. Tom,

    Great post about a very confusing subject.

    The recent article in Atlantic Magazine talked about the same issue. The pressure placed upon physicians to strive for high patient satisfaction scores by giving patients what they want but don’t need.

    Interestingly, there is research that shows it is possible for physicians to say NO to unreasonable (and often costly) patient requests without adversely affecting their patient satisfaction scores. Turns out that patients of physicians whom they really trust are quite will to acquiesce to their physician’s denial of the requested service … and not go running to complain on the nearest survey. What’s required is an explanation from the physician to the patient as to why the request is unwarranted (other than just a blanket NO) and the aforementioned high trust level.

    High trust and a willingness to explain their rationale to patients are not traits that do not apply to all physicians however. This is evidenced by the fact that as many as 70% of physicians still employ the same paternalistic, “do what I tell you” communication style when talking with patients … not the patient-centered communications skills that are considered best practice and emblematic of high quality care by the IOM.

    Patient-centered communications is what patients prefer … it is considered a best practice … it is essential to Triple Aims … and physicians get paid more for doing it. Yet 70% of physicians still don’t know how to “speak patient centered.”

    Steve Wilkins, MPH
    Mind The Gap Academy

    • Hi Steve –

      You are 100% spot on that with relationship and trust (and patient-centered communication skills) the appropriate sharing can and will take place, a co-created plan of care will be created in line with patient preferences and there will be a willingness to say and hear ‘no’ when it is the most prudent course of action for optimal care and safety.

      We must focus on ensuring systems which allow for optimal time for relationship and trust and patient centered communication are developed, tested, and successful and in so doing we must remember that tools such as patient satisfaction surveys are just that … tools … for smart caring leaders and care providers to leverage for the betterment of patients, families and communities.

      As always … thank you for sharing your important perspectives and wisdom, Steve.


  2. re: …. focusing on patient satisfaction as an independent goal has made it “ripe for commercialization” and resulted in a boom of profit-making businesses.”

    A little more commercialization and profit-making might help healthcare focus better than ACA mandated surveys.

    That said, my VA experience with these surveys was coordination of care drove satisfaction more than most else. A tough slog for any healthcare entity to improve but, given the recent batch of VA scandals, I wonder if many VA Medical Centers even reviewed.

    • Hi Bill. Thank you for your comment. I greatly appreciate you linking satisfaction with coordination of care. In my experience and based on stories from others … when there truly is an optimal relationship and understanding of patient preferences and needs and the plan is co-created so that care is truly coordinated within this context satisfaction (outcomes and safety) are all greatly improved. And thus it is about system improvement for the betterment of care as it should be. Great great point. Thanks again for sharing. Tom

  3. Let me know if you might want to build out this argument into a full length feature article (1000-1500 words), with a focus on primary care practices, for Medical Home News.

    Raymond Carter

    • Hi Raymond. The idea of building out this piece into a feature article for Medical Home News is very intriguing. I would very much like to discuss further with you. Perhaps a phone discussion? I can be reached at td66@rocketmail.com to schedule a time to discuss. Looking forward to it. Thank you. Tom

  4. Tom,

    Great post! The relevance of what you say extends beyond patient satisfaction to all customer satisfaction scores in my opinion.
    Over-reliance on the score in evaluating performance of the individual or the business can truly create outcomes very different from what was intended.
    One approach that might help reduce the un-intended consequences is to not plug the overall score alone directly into evaluations. Parse the score into its components and use relevant component scores too. Components to use can be picked based on various factors like the role being evaluated or certain categories of `reason for low score’ can be factored out (e.g. patient feels doctor did not order the required tests)
    How practicable is this? Well, I think it will be more time-intensive to administer and analyse but there will ways to optimise this and my feel is it will be time well-spent. It will lead to better, more granular, customer understanding and better alignment between short-term and long-term business and people outcomes.
    After all, when there is much knowledge asymmetry between customer and vendor the vendor needs to bear the responsibility of not just providing what the customer `wants’ but take care of the customers `needs’! Difficult ground.

  5. Thank you for your comment, Deepa. Yes, specific to the use of a patient satisfaction tool … you suggestion makes good sense. In fact, identifying and prioritizing the dissatisfiers will provide great wisdom in which to implement quality improvement processes focused on providing greatest value of impact.

    And your point relative to ‘wants’ and ‘needs’ is so very pertinent. When the patient (and family) and clinician have developed an authentic relationship and trust wants can be shared, challenging (and trusting) discussions can take place, and together what the patient needs (aligned with their preferences) can be identified and focused upon via co-created care plans.

    It is incumbent upon us to develop these care models (healthCARING models) which allow for this relationship centered compassionate care provision. In so doing we must leverage tools while never forgetting they are just that … tools to be used to better care.

    Thank you again for sharing.


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