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Why Your Voice Counts: $1 Billion in Hospital Payments Tied to Patient Satisfaction

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San Francisco General Hospital has installed "yacker trackers" around some nursing stations to reduce nighttime noise, part of the hospital’s enhanced effort to improve patients’ experience. (Photo: San Francisco General Hospital)
San Francisco General Hospital has installed "yacker trackers" around some nursing stations to reduce nighttime noise, part of the hospital’s enhanced effort to improve patients’ experience. Red is "too loud;" yellow is "noisy;" green is "perfect." (Photo: San Francisco General Hospital)

By Chris Richard

To try to improve patients’ rest, San Francisco General Hospital has installed devices resembling traffic signals near some nursing stations. Called “yacker trackers,” they monitor the volume of conversation and other work-related noise around the stations. When sound is at an acceptable level, the light shows green, turning yellow as the noise increases. When it’s too loud, the light turns red.

The admonitions might get on the nerves of hospital staffers who think they’re capable of regulating how loudly they talk without electronic oversight, but there’s evidence the yacker trackers do keep the racket down – and help patients rest better.

“Some staff members think this is a reinforcement that is welcome, and others may feel this is reinforcement that isn’t really necessary,” said Baljeet Sangha, San Francisco General’s “chief experience officer.”

“The answer is to go back to the metrics. They show these reminders do work.”


In some areas where the trackers were installed, patient satisfaction over nighttime noise doubled between April and June, Sangha said.

Under the Affordable Care Act the federal government is starting to link a hospital's payments to how well they treat patients, and hospitals are responding by creating new customer-satisfaction positions like Sangha’s, changing security procedures, and even timing how long people must spend in computerized telephone call-routing systems before speaking to a human being.

The federal health law links about $1 billion in Medicare reimbursement payments nationwide to how hospitals score on the federal Centers for Medicare & Medicaid Services’ “Hospital Consumer Assessment of Healthcare Providers and Systems” survey, or HCAHPS.

First instituted in 2006 as a comparison tool to help people choose a hospital, HCAHPS is now being used as one tool to set Medicare reimbursement rates.

The survey’s 32 questions range from “Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?” to “During this hospital stay, how often was the area around your room quiet at night?”

Officials at the Centers for Medicare & Medicaid Services (CMS) say the answers to such questions demonstrably affect medical outcomes. For example, if nurses communicate clearly, patients are more likely to know how to assist in their own healing. And they tend to heal faster if they get enough rest.

Tony Padilla, patient affairs director at the Ronald Reagan UCLA Medical Center, said the CMS surveys are changing how nurses conduct their hourly rounds.

“They’re regularly asking, not just, ‘How can I help you?’ or do ‘Do you need something?’ but, ‘Do you have any pain and can we address the pain?’ and ‘Are things within reach?’ We don’t want people getting up out of bed and falling.”

In the most recent surveys statewide, about half of patients reported that the area around their room was always quiet at night. Three quarters of patients in California said their nurses always communicated well. Slightly fewer said their room and bathroom were always clean.

Statewide responses across California in all three areas were below the national average.

In response to such concerns, Foothill Presbyterian Hospital in Glendora has launched a new cleanliness campaign, regularly setting patient rooms for overhaul under the “Room a Day” program.

This isn’t just ordinary housekeeping. It’s a 78-item checklist that ranges from waxing floors to tightening plumbing connections to disassembling ceiling ducts to replace air filters. Three Foothill departments join in the work, and a supervisor may add instructions for additional corrections.

According to Patrick Kegin, chief patient experience officer at Citrus Valley Health Partners – a Southern California consortium that includes Foothill Presbyterian and three other medical centers – the meticulous overhauls are about more than cleanliness. They’re about a state of mind.

“If you go to a group of well-meaning staff members who are working in a system that has broken processes and you ask them to start being kinder and more deliberate with the patients, they’re going to say, ‘You know what you can do for me? Fix this place. Let’s make this place cleaner,’” Kegin said.

“We need to establish hospital environments that work. If we do that, it benefits the patients.”

On top of the federal surveys, competition for patients plays a role in the adoption of policies aimed at increasing satisfaction among health care consumers. Last February, Los Angeles County Department of Health Services director Mitchell Katz embarked on a program to make the medical centers that serve some of the county’s poorest, most violent neighborhoods more welcoming.

He announced a plan to remove metal detectors at all Health Services facilities, except at the three county emergency rooms, by July.

But the detectors had been set up following a 1993 shooting at Los Angeles County-USC Medical Center in East Los Angeles that left three doctors wounded. Word of Katz’ plan stirred outrage among Health Services employees, and Service Employees International Local 721, which represents Medical Center nurses, told Katz his proposal was subject to negotiation over workplace safety.

Sabrina Griffin, a union steward, said the dispute remains unresolved.

Anish Mahajan, the health system’s director of system planning, said officials still plan to remove the detectors eventually and are in discussions with labor groups.

Meanwhile, Mahajan said, county hospitals have moved forward with a new, computerized, multi-lingual telephone system that has dramatically cut the time patients must spend on hold while seeking information about their medical conditions.

He said another computerized system has enabled the county system to address another source of patient discontent, long waits to see specialists.

Bridget Duffy, chief medical officer at Vocera Communications and a consultant to hospitals across the country on patient satisfaction, stressed that establishing systems to take better account of patients’ needs means following sound medical practice.

She said emergency room doctors in one Florida hospital admitted to her that they’d devised a special code for admissions designed to avoid patient complaints, even when the admission wasn’t otherwise warranted. The doctors told her that they came up with the scheme after administrators at their hospital started recording negative patient surveys in their personnel files, Duffy said.

“When administrators are punitive with patient satisfaction data, they breed that kind of thing,” she said. “I think that’s bad medicine and I don’t think that’s the norm.”


The standard Duffy hopes for is something closer to the “code lavender” instituted at Lucile Packard Children’s Hospital at Stanford. The name is based on the standard hospital “code blue” summoning an emergency resuscitation team. With code lavender, the focus is on delivering spiritual resuscitation when a patient suffers a severe trauma, Duffy said. Pastoral, bioethics and holistic nursing staff members gather to offer immediate and ongoing support, she said.

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