Competing Objectives
Patient Satisfaction and the (Re)Making of Healthcare Service Workers
Tim Sundeen is a research analyst for the labor union SEIU-UHW. This is the second blog post in our Labor Day series, Dispatches from the Field, which takes a workers’ perspective on the way technology is reshaping work.
Collecting and managing data has become critical to the business and practice of healthcare. Having experienced this development through interactions with doctors and nurses — filling out iPad surveys before each appointment, devoting significant appointment time to updating my electronic health record — I wanted to understand how the focus on patient data has affected allied health workers, technicians, assistants, and clerical staff who constitute support staff for doctors, dentists, and nurses engaging in direct patient care. As a researcher for a large labor union in California that represents many of these workers, I arranged a focus group with 20 labor leaders employed at a hospital in one of our bargaining units to get a sense of how they experienced data-centric technologies and practices. For many of the participants in the session, data gathered from the patients themselves through a patient experience assessment has had a significant impact on their work environment.
In recent years, patient satisfaction has become an increasingly prominent metric for evaluating hospital performance. Patient feedback on their hospital experience is gathered through the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS). HCAHPS was first implemented in October 2006, and the first results were made public in March 2008. Although hospitals are not mandated to participate in the assessment, there are numerous incentives to do so. Since 2010, scoring well on the HCAHPS has been linked to Medicare reimbursement rates, as a provision of the Affordable Care Act (ACA). Since 2012, HCAHPS has constituted 30% of a hospital quality measure used to identify high performing hospitals to receive funds under the ACA’s value-based purchasing program.
Institutional sensitivity to the “patient experience” side of care can be disruptive for workers.
Supporters of these evaluation tools point to evidence of high patient satisfaction correlated with pro-health practices, such as greater adherence to treatment plans and willingness to continue using health services, as well as some objective outcomes like higher quality process of care and lower hospital readmission rates. Notably, patient satisfaction is also intertwined with the pursuit of patient-centered care, and the corresponding conviction that the “professionalism” of the care provider encompasses competencies beyond technical competency, such as good communication, empathy, compassion, and a positive attitude.
Consequently, there seems to have been very little pushback against the idea that patient perspectives as consumers are worth collecting or that healthcare providers should change their practices in response to patient feedback. However, institutional sensitivity to the “patient experience” side of care can be disruptive for workers, who must sometimes negotiate irreconcilable objectives, and may find that patient-centered behaviors shape their professional identities in ways that emphasize interpersonal skills while downplaying the value of technical competence.
Focus group participants were largely critical about the use of patient satisfaction surveys. Some of their comments reflected predictable conflicts with management — the belief that satisfaction scores were being surreptitiously used in performance evaluations, or the frustration that they were being used as the basis of critiques by supervisors who had little knowledge of how workers managed their job requirements. A couple of participants also complained about the unfairness of being evaluated in a collective, where scores could be dragged down by one bad actor. Some workers challenged the underlying rationale for collecting patient perspectives in the first place, which veered into critical assessments of the patients themselves.
In sum, workers expressed that centering the patient experience interfered with their ability to do their jobs. This response is understandable because the satisfaction data — and management’s response to that data — set conflicting goals for the workers. On the one hand, workers were expected to personalize their interactions with patients by engaging in conversation, smiling, maintaining eye contact, and producing other friendly gestures designed to show that workers were paying attention to the individual needs and circumstances of the patients. However, workers were simultaneously required to ensure that patients be processed from intake to their appointments as quickly as possible — the “assembly line” as one worker put it — which seemed incompatible with patient-supportive behavior. Worker frustrations with these competing objectives spilled over into annoyance with patients who would not reciprocate eye contact because they were looking at their phones or who had to have instructions repeated to them because they were not paying attention to the workers. At a more fundamental level, some workers bristled at the notion that patient engagement should be part of their job description.
The inclusion of patient engagement as an aspect, and potentially a measure, of job performance reinforces a service-oriented perspective on healthcare work that has racial and class dimensions. One of the interesting findings in the study of “professionalism” in the field of radiography was that some faculty perceived that “self-effacement,” or “suppression of personal inclinations that were unrelated to or in conflict with work duties” were really important to how one should present oneself in the field. This is similar to how many allied health workers — which include skilled workers like technicians but also other administrative support staff in hospitals — have experienced practicum requirements in their course of study, where they were required to dress properly, cover tattoos, control hair, and minimize jewelry while at their placements sites. In California, where allied health jobs are disproportionately staffed by people of color, these admonishments always seemed to contain an uncomfortable subtext, as if students of color exhibited innate race and class-based behaviors that needed to be tamed before they could step into the hospital. This bias undermines a major selling point of these types of technologies as neutral evaluations of performance and professional conduct.
To paraphrase one outspoken X-Ray technician, he didn’t go to school in a demanding, high-skilled profession to learn how to smile at people.
The prioritization of patient satisfaction adds another component to the mix, where disciplining worker affect supports a construction of worker professionalism built around deference associated with stereotypes of service work, while downplaying their medical knowledge and technical competence. Measures of quality risk being reduced to the aspects of work that are interfacing with and intelligible to patients. To paraphrase one outspoken X-Ray technician, he didn’t go to school in a demanding, high-skilled profession to learn how to smile at people.
Tim Sundeen has a Ph.D. in Anthropology from UCLA. He works as a research analyst for SEIU-UHW, a labor union that represents 95,000 healthcare workers in California.
