Unraveling the Patient Experience, One Form Letter At a Time

Recently, my wife and I welcomed our son into the world. From admission to discharge, we had a very pleasant experience amid some trying circumstances. Her care team explained every facet of her care, provided a plethora of printed educational resources, and ensured that we were prepared for parenthood when we left the hospital. They even offered advice to skirt the rules about room service so Dad could pretend to be Mom and get a meal delivered at no extra charge. (Hint: Order food that you’d expect a brand-new mother recovering from birth to be eating.)

Then my wife got a letter from the hospital a few days later. I tore it open, expecting a bill, a request for a donation or – in my sleep-deprived naivete – perhaps a congratulatory letter.

“Our records indicate that you were recently a patient…” the letter began. The hospital was asking my wife to fill out a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

For the uninitiated, HCAHPS surveys help hospitals retrospectively track the patient experience. Survey results in hand, the Centers for Medicare & Medicaid Services (CMS) ranks hospitals based on care quality and experience metrics, assesses financial incentives to high achievers and penalties to laggards, and (theoretically) increases transparency about overall care quality.

That’s all well and good. I mean, paper-based surveys are passé, and retrospective assessments are inherently inaccurate and biased, relying solely on what a patient remembers days (if not weeks) after the fact. Back in 2018, I wrote a report for Chilmark Research about the emerging market for point-of-care patient surveys and why they’re in a much better position to meet hospitals’ patient experience reporting needs.

Still, paper-based mail surveys help hospitals cast a wide net. (They were nice enough to send a prepaid envelope to mail it back, too.) Plus, old habits die hard in healthcare, so paper surveys aren’t going away – especially if folks aren’t going to answer phone calls from unrecognized numbers. And, let’s be real, those who have just given birth aren’t exactly well-positioned to answer a few questions on an iPad amid check-ins with the anesthesiologist, the obstetrician, the lactation consultant, the nurse collecting vital signs, and the friends and family members sending a flurry of text messages.

So I wasn’t irked to get a HCAHPS survey in the mail. I get it. It’s how the world turns.

It was the cold tone that got to me.

Good friend Jen Horonjeff recently wrote about why healthcare often gets empathy wrong. Jen was diagnosed with juvenile diabetes at a young age. She has spent most of her life hearing otherwise well-intentioned people say they “know what she means” because they once tore an ACL or sprained an ankle. “[I]n that moment it felt that they were not interested in what I was going through,” she writes about those attempting to equate an acute injury that has healed to a chronic, debilitating autoimmune disease.

A form letter for a patient who spent five days in the hospital – admitted for a labor induction after an onsite obstetrics appointment, only to have a C section roughly 17 hours later, and then staying to recover for four days – shows no interest in what that patient went through. It shows interest solely in accomplishing the business objective of getting another completed survey in the mail.

When it comes to patient experience, healthcare often talks out of both sides of its mouth. In the moment, it’s possible to receive world-class care from practitioners clearly and genuinely devoted to their craft, holding your hand and handing you a tissue and running to get those little packs of graham crackers so you’re not taking pain medication on an empty stomach.

After the fact, it’s paper-pushing. It’s a faceless administrative task. I’d go so far as to say that it’s worse than accounts payable, since at least no one’s expecting cheerful language on a bill.

But “Our records indicate that you were a patient…?” For a request to fill out a patient experience survey for a woman who just had her first child? Or anyone who spent days recovering from an unplanned surgery? Or anyone who suddenly felt their life change due to a procedure or diagnosis?

The bar’s so low that it’s resting on the floor. Do better. Stop sending form letters and start putting forth a hint of effort.

Until then, don’t expect too many surveys to come back, even if the postage is paid.

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UPDATE #1: In a discussion of this post in LinkedIn, Dr. Adrienne Boissy, the Chief Experience Officer at the Cleveland Clinic, pointed out that the language in the form letter is required for HCAHPS correspondence. So that puts it on CMS, and not the hospital, for being so cold.

In my mind, I see this as an opportunity to be seized. Prior to discharge, most patients have a conversation with a nurse – especially after delivering a child. Why not take a moment to let them know the survey is coming?

“You’re going to get a letter in the mail with a request to fill out a survey. It’s going to say, ‘Our records indicate that you were a patient.’ We know it’s impersonal. Government regulations, am I right? Anyway, we hope you can give it a look when you’re ready. Your feedback helps us provide better care, and it helps patients like you know which hospitals provide the best experience.”

UPDATE #2: The hospital sent us another survey…