1. Another reason Health Care organizations need the Baldrige framework

    March 12, 2016 by BPIR.com Limited


    Origanally posted on Blogrige by Christine Schaefer

    A panel of patient safety experts recently found that a “systems approach” is necessary to ensure patient safety in hospitals and other health care organizations. An article published late last year in the industry newsletter FierceHealthcare summarized findings of a new report from the National Patient Safety Foundation (NPSF). The December 2015 report, follow-up to the NPSF’s groundbreaking 1999 report “To Err is Human: Building a Safer Health System,” publishes findings of an expert panel on patient safety convened by NPSF early in 2015 and co-led by Dr. Donald Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement.

    The panel’s charge was reportedly to “assess the state of the patient safety field and set the stage for the next 15 years of work.” Summarizing the findings, FierceHealthcare Executive Editor Ilene MacDonald writes that the new NPSF report finds necessary “a total system approach and a culture of safety” to combat medical errors and adverse events.

    A total system approach. Surely that resonates with those of you who are already adherents of the Baldrige Excellence Framework (which includes the Health Care Criteria for Performance Excellence).

    Systems perspective is the first of 11 core values and concepts described in the Baldrige Program’s 2015–2016 Health Care Criteria for Performance Excellence. Those core values and concepts serve as the “foundation for integrating key performance and operational requirements within a results-oriented framework that creates a basis for action, feedback, and ongoing success” (page 39). The Baldrige framework’s other 11 foundational and interrelated core values and concepts are visionary leadership, patient-focused excellence, valuing people, organizational learning and agility, focus on success, managing for innovation, management by fact, societal responsibility and community health, ethics and transparency, and delivering value and results.

    The Baldrige Performance Excellence Program, author and publisher of the 2015–2016 Baldrige Excellence Framework (health care version)—as well as the next revision that will be issued early in 2017—defines systems perspective as “managing all the components of your organization as a unified whole to achieve your mission, ongoing success, and performance excellence.” According to the full definition in the booklet’s glossary, “Successfully managing overall organizational performance requires realization of your organization as a system with interdependent operations. Organization-specific synthesis, alignment, and integration make the system successful.”

    As described further in the Baldrige framework booklet, when a health care organization takes a systems perspective, its senior leaders focus on strategic directions and on patients and other customers. They monitor, respond to, and manage performance based on the organization’s results. With a systems perspective in place, a health care organization uses its measures, indicators, core competencies, and organizational knowledge to build its key strategies, link these strategies with its work systems and key processes, and align its resources to improve the organization’s overall performance and its focus on patients, other customers, and stakeholders.


    So health care organizations that have adopted the Baldrige Excellence Framework to manage their performance in and across all areas already have “a total system approach” in place. Baldrige organizations are thus in optimal position to achieve good and ever-improving patient safety results.

  2. Mosaic Life Care: Transforming Health Care to Life Care

    September 6, 2015 by BPIR.com Limited

    Originally posted on Blogrige by Dawn Marie Bailey

    Since its Baldrige Award win in 2009, Mosaic Life Care (formerly called Heartland Health) has continued to be nationally recognized for quality, value, and the patient experience. In 2015, Mosaic Life Care was named to the Truven Health AnalyticsTM 100 Top Hospitals® list, given an “A” rating by The Leapfrog Group, identified as a HealthStrongTM Hospital by IVantage® Health Analytics, and named a “Most Wired” hospital by Hospitals & Health Networks magazine. Based in St. Joseph, Missouri, Mosaic Life Care remains a nonprofit, community-based integrated health system serving the residents of northwest Missouri, northeast Kansas, southeast Nebraska, and southwest Iowa—the region’s largest health system and employer. Since its Baldrige win, it has expanded its geographic reach into Kansas City north.

    But it’s the name that is a significant change for the health system, which is making a transition from providing health care to life care. In a virtual interview, I asked Martha Davis, Institute Leader at Mosaic, about the significance of the name change and how Mosaic is transforming health care. She gave me a sneak peek into her presentation for the upcoming Baldrige regional conference in Nashville about the importance of this transformation.

    How would you describe the transformation from health care to life care? Why has this been important to your success?

    We are an Accountable Care Organization and, as such, have recognized the need to move from a patient to consumer-centric approach. We’ve traditionally built service offerings around the acute and chronic health care needs of patients, but we haven’t always done a good job of engaging consumers to prevent or slow the effects of lifestyle, stress, aging, and other factors that impact one’s long-term health. Consumers are shouldering higher insurance plan deductibles and expect more cost transparency and better care experiences. We are also seeing great opportunities to partner with employers to help them lower cost through improved employee health support. Our life-care model is holistic and focused on health, wellness, and wellbeing.

    What are your top tips (e.g., 3 to 5 suggested practices) for using Baldrige to support such a transformation?

    We have built solid disciplines around planning and deployment of the Baldrige Excellence Framework, which has been invaluable as we’ve expanded into new geographic areas with very different competitive factors. Some of what we’ve learned follows:

    • While our strategic priorities have remained the same, we’ve established reasonable but stretch measures given the startup of new offerings and services in our expanded geographic service areas. The linkage between measurement and results is critical during times of transformation and innovation—we have to be discerning about what services resonate with our consumers and which ones don’t, regardless of how great of an idea we think an offering is! Maintaining process focus is also essential to this work—not only to improve efficiency and lower cost, but also to improve the provider and consumer experience.
    • In our customer focus, we are moving beyond patient satisfaction surveys to gain new insights into what our customers value. During the September session, we will talk about what we’ve learned about customer sacrifice by studying out-of-industry exemplars and adapting those learnings to our strategies. These new insights are helping us to develop life care offerings that engage and activate consumers in their own health and well-being.
    • We’ve relied heavily on the People Framework we developed as a result of our workforce focus—especially in our new markets and expanded offerings. It is imperative that we hire and onboard the right people, provide the right learning and development opportunities, and provide the right feedback and recognition—whether it is with our leaders, providers, or workforce members. We constantly battle change fatigue and continually look at ways to positively engage our providers and workforce members.

    What are a few key reasons that organizations in your sector can benefit from using the Baldrige Excellence Framework?

    Two key reasons: first, there is enormous disruption in our industry—huge pressure to lower costs and improve the patient experience. With reduced reimbursement, organizations can’t waste precious resources on non-value-added work. The Baldrige framework is an excellent way to prepare for this disruption and upheaval. Second, a population health focus requires great change in the workforce composition: acute care services must leverage technology and tightly control labor costs; clinics need to do the same and be proactive at keeping patients healthy and out of higher-cost venues; and we need to offer scalable, virtual, and other forms of services to consumers who are mostly healthy. This requires that we rethink the skill sets we will need in the future and how we will attract, prepare, and retain the best workforce members. We like to think of the framework as a huge accelerating factor!

  3. A Comprehensive Excellence Framework for Post-Acute and Long-Term Care

    July 17, 2015 by BPIR.com Limited


    Originally posted on Blogrige by Christine Schaefer

    Following is an interview with Baldrige alumnus examiner Christopher E. Laxton, executive director of AMDA–The Society for Post-Acute and Long-Term Care Medicine (formerly the American Medical Directors Association). Laxton compares the Baldrige Excellence Framework (which includes the Health Care Criteria for Performance Excellence) to two other approaches used in his sector today to improve the performance of post-acute and long-term care organizations: Quality Assurance and Performance Improvement (QAPI) and Advancing Excellence in America’s Nursing Homes Campaign (AE).

    Christopher Laxton, CAE

    Christopher Laxton, CAE

    Tell us about recent developments in your industry and how those impact the focus on improving the performance of care-providing organizations.

    I work in post-acute and long-term care. This sub-sector of the health care field has gained a great deal of visibility and importance lately as many Baby Boomers move into retirement—by some estimates (Pew, AARP) at the rate of some 10,000 a day for the next 18 years.

    It is not surprising, therefore, that those who work in this sector and its federal and state regulators are looking for ways to improve the performance of post-acute and long-term care (PA/LTC) provider organizations.

    The Baldrige Excellence Framework is a helpful guide for organizations that are pursuing performance improvement. At the same time, there are other performance-improvement approaches in use across the multiple sectors of the U.S. economy. For PA/LTC organizations, two programs that have become more prominent because of their systems approach (like that of the Baldrige framework) to performance improvement are (1) AE, which comes from the provider side of this industry; and QAPI, which comes from the main federal payer and regulatory agency: the Centers for Medicare and Medicare Services (CMS).

    Would you please explain first how QAPI is similar to the Baldrige framework and approach?

    Yes. I think it is useful to look at how the QAPI and AE programs align to the Baldrige framework, both to understand their many points of connection to Baldrige Criteria categories, as well as to discern what may not be explicit in them.

    The CMS’s QAPI program was introduced in 2013 for nursing homes to voluntarily adopt a systems approach to improvement (http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/nhqapi.html). The program describes QAPI as “the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). QA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care.”

    QAPI is defined as having five elements (see Figure 1): Design and Scope; Governance and Leadership; Feedback, Data Systems and Monitoring; Performance Improvement Projects; and Systematic Analysis and Systemic Action. These will be familiar to those organizations using the Baldrige approach to improve, since they align relatively well with 2015–2016 Baldrige Criteria categories: QAPI’s “Design and Scope” element relates to Baldrige Criteria category 2, “Strategy”; QAPI’s “Governance and Leadership” relates to Baldrige Criteria category 1, “ Leadership”; QAPI’s “Feedback, Data Systems and Monitoring” relates to Baldrige Criteria category 4, “Measurement, Analysis, and Knowledge Management”; and QAPI’s “Systematic Analysis and Systemic Action, and Performance Improvement Projects” relates to Baldrige Criteria category 6, “Operations.”


    The five QAPI elements have open, non-prescriptive definitions and guidance for applying them. This is comparable to the Baldrige framework’s approach of asking questions rather than dictating particular solutions, based on the understanding that there is no “one-size-fits-all” solution to organizational excellence. This is especially true in the PA/LTC sector, where—despite years of organizational improvement efforts and extensive regulatory oversight—there is wide variability in provider size, scope, capacity, and quality.

    Next, would you please tell us about the AE program and how it compares to the Baldrige framework?

    Of course. Advancing Excellence (AE) was founded in 2006 by a coalition of 28 organizations that included nursing home providers, quality improvement experts, and government agencies (https://www.nhqualitycampaign.org/). The Campaign now includes more than 62 percent of the nation’s nursing homes and has a local presence in every state and the District of Columbia through a network of participants called Local Area Networks for Excellence (LANEs).

    AE has identified nine quality goals (see Figure 2) that describe areas of key importance to good nursing home care that are often challenging for providers. Those areas are where it is likely that nursing homes will find opportunities for improvement, to use a Baldrige term. The AE goals are organized into two groups that will sound very familiar to Baldrige framework users: four organizational goals, which are process-focused; and five clinical outcome goals, which are results-focused.

    The nine AE goals align the Baldrige Criteria in the following ways: AE’s Consistent Assignment goal is a Baldrige Criteria category 5 (“Workforce”) goal, as is AE’s Staff Stability goal. AE’s Hospitalizations goal aligns with Baldrige Criteria category 6 (“Operations”), since it principally relates to item 6.1 (on work processes). AE’s Person-Centered Care goal is clearly a Baldrige Criteria category 3 (“Customers”) goal. And AE’s five Clinical Outcomes goals (Infections, Medications, Mobility, Pain, and Pressure Ulcers) are all Baldrige Criteria category 7 (“Results”) goals, though they each have process elements that are relevant to Baldrige Criteria categories 4 and 6.


    The AE program also identifies a seven-step process that organizations can adopt to systematically address each goal in their organization (see Figure 3). These seven steps have some alignment with the Baldrige process-evaluation factors (approach, deployment, learning, integration [ADLI]) and, to a lesser extent, the Baldrige results evaluation factors (levels, trends, comparisons, integration [LeTCI]).


    With all these similarities, do you see these approaches as competing or complementary with each other?

    While the CMS QAPI program may resonate with those familiar with the Baldrige framework, I believe it would be a mistake to “choose” one over the other. One reason is that the Baldrige framework is very inclusive—accommodating all varieties of performance improvement tools, such as Plan-Do-Study-Act, Lean, Six Sigma, and so forth. Furthermore, when you line up both the QAPI and AE programs against the Baldrige Criteria (see crosswalk of 2013-2014 Baldrige Criteria to QAPI and AE), a comprehensive performance excellence framework for the PA/LTC sector is revealed. It is well aligned with the Baldrige Criteria categories, and it is specifically focused on the highly complex and challenging organizational and customer/patient/resident environment found in this sector’s care settings.

    These are not simply academic considerations for how quality might be improved in this important and previously neglected sector of U.S. health care. The demographic shift to an older population in this country and around the world—sometimes referred to as the “Silver Tsunami”—is producing major changes in public policy and rapid and massive shifts in market forces that will have a direct impact on the care and support available to our nation’s elders.

    What do you believe needs to happen in relation to the Baldrige, QAPI, and AE improvement tools to address the current and coming challenge of caring for more senior citizens?

    It is a basic principle of organizational excellence that systems produce exactly the results that they are designed to produce—intentional and unintentional. Having worked in the long-term care field for 30 years and having served as a Baldrige examiner for seven, I am inspired by the existence of such powerful frameworks for improvement.

    Now our long-term care leaders must take up these tools and apply them. Who better to do so than those who know intimately the complexity and challenges facing this sector? If they do not, others—with less commitment and connection to preserving and enhancing the health and well-being of our seniors—are sure to impose changes on us that will be neither of our design nor of our choosing.

  4. Fanfare for Baldrige in Health Care

    June 17, 2015 by BPIR.com Limited


    Originally posted on Blogrige by Dawn Bailey

    In January 2015, the 2015–2016 Baldrige Excellence Framework (Health Care)—which contains the Health Care Criteria for Performance Excellence, core values and concepts, and scoring guidelines—will be released. The Baldrige Program is grateful that there has already been much written about the value of using this Criteria for improvement.

    “Baldrige hospitals are . . . more likely to be cited for marked performance improvement over a five-year span,” writes Deborah Bowen, president and CEO of the American College of Healthcare Executives and Baldrige Fellow. In “Using Baldrige Criteria as a Tool for Hospitals’ Performance Improvement,” Bowen writes that thousands of hospitals, clinics, and health care systems have turned to the Health Care Criteria “with its established framework for improvement and innovation that builds on core values and concepts, including: patient-focused excellence; organizational and personal learning; agility; and focus on results and creating value. . . . It is clear the Baldrige framework can be useful in enhancing systemic performance and achieving better results. . . . A key component is the importance of sharing best practices and learning from those who have achieved systematic results.”

    Bowen adds, “Boards also can encourage their organizations to learn from others and adopt performance improvement processes using such resources as the Baldrige Health Care Criteria for Performance Excellence, because there is still much work to be done to improve the outcomes of health care for patients, families, and our communities.”

    In “What About Lousy Hospitals?,” John Griffith, professor emeritus, Department of Health Management and Policy, School of Public Health, The University of Michigan, writes, “Hospitals seeking excellence are pursuing various paths, but the best documented and most comprehensive is the ‘Baldrige journey.’ . . . Baldrige recipients and Magnet hospitals claim that they are ‘great places to get care’ because they are ‘great places to give care.’ Both document low workforce turnover and vacancy rates. . . . Hospitals such as AtlantiCare in Atlantic City, Henry Ford in Detroit, Sharp in San Diego, and North Mississippi in Tupelo all work in challenging economic environments. They are all Baldrige winners. Maybe the ‘lousy’ hospitals should study the public responses and start the Baldrige journey? It takes as little as three years to move from lousy to respectable or better.”

    In “Correlation Between Baldrige Award Recipients and 100 Top Hospitals Winners,” Truven Health’s Jean Chenoweth, senior vice president, Performance Improvement and 100 Top Hospitals, writes, “Once again, the selection of St. David’s HealthCare and Hill Country Memorial as 2014 Malcolm Baldrige Award winners and performance on the 100 Top Hospitals® National Balanced Scorecard overlap . . . a significant statistical association between use of Baldrige best management practices and highly balanced performance excellence. . . . This is all very good news for measurement of the impact of leadership in hard data.”

    As for any organization, its best testimonials come from its customers. Thankfully, the two 2014 Baldrige Award winners in health care have embraced the Baldrige spirit of improvement and sharing. In “Baldrige Awards are Just the Icing on the Cake for 2014 Winners,” both Hill Country Memorial and St. David’s HealthCare write that participating in the Baldrige Award process brought them improvement:

    “We never got on this journey to win—though that’s amazing and we’re super-excited—it was to improve,” says Debbye Dooley, executive director of business intelligence for Hill Country Memorial.

    C. David Huffstutler, president and CEO for St. David’s HealthCare, adds, “Obviously, our organization, our employees, our physicians are delighted. It’s something we’ve been working toward for a long time. . . . Though we have said from the beginning, while it would be nice to win the award, it really has been about the Baldrige process, and using it as a performance improvement tool.”

  5. The Problem With Satisfied Patients

    May 27, 2015 by BPIR.com Limited

    Originally posted on the Aatlantic by Alexandra Robbins

    When healthcare is at its best, hospitals are four-star hotels, and nurses, personal butlers at the ready—at least, that’s how many hospitals seem to interpret a government mandate.

    When Department of Health and Human Services administrators decided to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores, they likely figured that transparency and accountability would improve healthcare. The Centers for Medicare and Medicaid Services (CMS) officials wrote, rather reasonably, “Delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.” They probably had no idea that their methods could end up indirectly harming patients.

    Beginning in October 2012, the Affordable Care Act implemented a policy withholding 1 percent of total Medicare reimbursements—approximately $850 million—from hospitals (that percentage will double in 2017). Each year, only hospitals with high patient-satisfaction scores and a measure of certain basic care standards will earn that money back, and the top performers will receive bonus money from the pool.

    Patient-satisfaction surveys have their place. But the potential cost of the subjective scores are leading hospitals to steer focus away from patient health, messing with the highest stakes possible: people’s lives.

    The vast majority of the thirty-two-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”

    This question is misleading because it doesn’t specify whether the help was medically necessary. Patients have complained on the survey, which in previous incarnations included comments sections, about everything from “My roommate was dying all night and his breathing was very noisy” to “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.” An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery). “Many patients have unrealistic expectations for their care and their outcomes,” the nurse said.

    In fact, a national study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years.

    Joshua Fenton, a University of California, Davis, professor who conducted the study, said these results could reflect that doctors who are reimbursed according to patient satisfaction scores may be less inclined to talk patients out of treatments they request or to raise concerns about smoking, substance abuse, or mental-health issues. By attempting to satisfy patients, healthcare providers unintentionally might not be looking out for their best interests. New York Times columnist Theresa Brown observed, “Focusing on what patients want—a certain test, a specific drug—may mean they get less of what they actually need. In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should.”

    As a Missouri clinical instructor told me, “Patients can be very satisfied and dead an hour later. Sometimes hearing bad news is not going to result in a satisfied patient, yet the patient could be a well-informed, prepared patient.”

    * * *

    How far will a hospital go to satisfy a patient? Recently, some have rushed to purchase extra amenities such as valet parking, live music, custom-order room-service meals, and flat-screen televisions. Some are offering VIP lounges to patients in their “loyalty programs.”

    And because almost every question on the survey involves nurses, some hospitals are forcing them to undergo unnecessary nonmedical training and spend extra time on superfluous steps. Perhaps hospitals’ most egregious way of skewing care to the survey is the widespread practice of scripting nurses’ patient interactions. Some administrators are ordering nurses to use particular phrases and to gush effusively to patients about both their hospital and their fellow nurses, and then evaluating them on how well they comply. An entire industry has sprouted, encouraging hospitals to waste precious dollars on expensive consultants claiming to provide scripts or other resources that boost satisfaction scores. Some institutions have even hired actors to rehearse the scripts with nurses.

    In Massachusetts, a medical/surgical nurse told The Boston Globe that the scripting made her feel like a “Stepford nurse,” and wondered whether patients would notice that their nurses used identical phrasing. She’s right to be concerned. Great nurses are warm, funny, personal, or genuine—and requiring memorized scripts places a needless obstacle in their path.

    The concept of “patient experience” has mischaracterized patients as customers and nurses as automatons. Some hospital job postings advertise that they are looking for nurses with “good customer-service skills” as their first qualification. University of Toledo Medical Center evaluates staff members on “customer satisfaction.”

    By treating patients like customers, as the nurse Amy Bozeman pointed out in a Scrubs magazine article, hospitals succumb to the ingrained cultural notion that the customer is always right. “Now we are told as nurses that our patients are customers, and that we need to provide excellent service so they will maintain loyalty to our hospitals,” Bozeman wrote. “The patient is NOT always right. They just don’t have the knowledge and training.” Some hospitals have hired “customer-service representatives,” but empowering these nonmedical employees to pander to patients’ whims can backfire. Comfort is not always the same thing as healthcare. As Bozeman suggested, when representatives give warm blankets to feverish patients or complimentary milkshakes to patients who are not supposed to eat, and nurses take them away, patients are not going to give high marks to the nurses.

    More disturbing, several health systems are now using patient satisfaction scores (likely from hospitals’ individual surveys) as a factor in calculating nurses’ and doctors’ pay or annual bonuses. These health systems are ignoring the possibility that health providers, like hospitals, could have fantastic patient satisfaction scores yet higher numbers of dead patients, or the opposite.

    * * *

    On the nursing blog Emergiblog, one nurse reported that at a hospital that switched its meal service to microwaved meals, food-service administrators openly attributed low patient scores to nurses’ failure to present and describe the food adequately. It is both noteworthy and unsurprising that the hospital’s response was to tell the nurses to “make the food sound better” rather than to actually make the food better.

    This applies to scripting, too: It does not improve healthcare, but makes it sound better. The University of Toledo Medical Center (UTMC) launched an entire program based on patient satisfaction, iCARE University, which mandated patient satisfaction course work and training for every university student and employee. “Service Excellence Officer” Ioan Duca told a publication sponsored by Press Ganey, a company that administers the surveys for hospitals, “I am really focused on creating a church-like environment here. We want a total cultural transformation. I want that Disney-like experience, the Ritz Carlton experience.”

    But hospitals, too, can offer poor care and still get high patient-satisfaction ratings, and an alarming number of them do. I examined Medicare’s provider data for thousands of hospitals—the data on every hospital in the country that the agency makes publicly available. I found the hospitals that perform worse than the national average in three or more categories measuring patient outcome. These are hospitals, in other words, where a higher number of patients than average will die, be unexpectedly readmitted to the hospital, or suffer serious complications. And yet two-thirds of those poorly performing hospitals scored higher than the national average on the key HCAHPS question; their patients reported that “YES, [they] would definitely recommend the hospital.”

    UTMC is a good example of how an emphasis on patient satisfaction does not make for better care. At the time of this writing, according to government data on hospitals’ rates of readmissions, complications, and deaths, UTMC appeared to be among the worst performers in the state, if not the country. UTMC has higher than average rates of serious blood clots after surgery, accidental cuts and tears from medical treatment, collapsed lungs due to medical treatment, complications for hip/knee replacement patients, and, more generally, “serious complications.” In addition, UTMC made headlines in 2013 when, during a transplant operation, hospital staff threw away a perfect-match kidney that a patient was donating to his sister.

    Many hospitals seem to be highly focused on pixie-dusted sleight of hand because they believe they can trick patients into thinking they got better care. The emphasis on these trappings can ultimately cost hospitals money and patients their health, because the smoke and mirrors serve to distract from the real problem, which CMS does not address: Patient surveys won’t drastically and directly improve healthcare.

    But research has shown that hiring more nurses, and treating them well, can accomplish just that. It turns out that nurses are the key to patient satisfaction after all—but not in the way that hospitals have interpreted.

    A Health Affairs study comparing patient-satisfaction scores with HCAHPS surveys of almost 100,000 nurses showed that a better nurse work environment was associated with higher scores on every patient-satisfaction survey question. And University of Pennsylvania professor Linda Aiken found that higher staffing of registered nurses has been linked to fewer patient deaths and improved quality of health. Failure-to-rescue rates drop. Patients are less likely to die or to get readmitted to the hospital. Their hospital stay is shorter and their likelihood of being the victim of a fatigue-related error is lower. When hospitals improve nurse working conditions, rather than tricking patients into believing they’re getting better care, the quality of care really does get better.

    Instead, hospitals are responding to the current surveys and weighting system by focusing on smiles over substance, hiring actors instead of nurses, and catering to patients’ wishes rather than their needs. Then again, perhaps it’s no wonder that companies are airbrushing healthcare with a “Disney-like experience,” a glossy veneer. One of the leading consulting companies now advising hospitals on “building a culture of healthcare excellence” is, oddly enough, the Walt Disney Company.