Five Evidence-Based Ways to Increase Patient Satisfaction

Ask any doctor for their opinion on patient satisfaction, and you’re likely to hear an impressively heated response. Doctors, in general, want their patients to be happy and to get better, but this does not necessarily equate to a love for the modern concept of patient satisfaction. While this may seem paradoxical, in many cases, physicians are simply concerned that some of the things that make patients happy might actually make them less healthy. One recent landmark study, for instance, found higher rates of hospitalization and death among patients who were more satisfied, even after controlling for health status.[1]

Other studies have found the opposite, though, showing better health outcomes in patients with higher satisfaction.[2] Since, all else being equal, doctors would prefer their patients to be satisfied, it would be useful to have an explanation that reconciled these disparate conclusions. How can patient satisfaction be healthy in one case and dangerous in another? Perhaps the simplest possible theory is that not all patient-satisfying behaviors are created equal. Unnecessary imaging for low back pain and antibiotics for respiratory illness, for example, have been shown to be excellent at increasing patient satisfaction, but they also unfortunately increase iatrogenic harm and cost.[1] Empathic communication, on the other hand, engenders higher satisfaction while also improving clinical outcomes in diseases ranging from diabetes to the common cold.[3]

With this possible reality in mind, here are five evidence-based things you can do to increase patient satisfaction that don’t seem likely to decrease patient health. Primum non nocere, and awayyy we go:

1) Get Creative With the Wait

People hate waiting. Patients hate waiting. You have probably already optimized your patient wait times as much as you can, so maybe you think there’s nothing else you can do. But there might be!

It turns out that most of what people actually hate is feeling like they’re waiting or, worse, feeling like they’re waiting longer than they expected to. This is a subtle but critical difference, and you can capitalize on it to make your patients happier without having to take on the nearly impossible task of changing actual wait times.

In one study, actual wait time to see a physician (PWT) did not predict patient satisfaction, but the wait time being longer or shorter than expected had a huge impact:[4]

Expectation of Wait Time Determines Satisfaction

So what can you do to decrease perceived wait time? There’s not as much good evidence on this, but there is some decent guidance. One study, for instance, found satisfaction to more than double when the waiting room was viewed as “comfortable and pleasant” by patients with the same perceived length of wait.[5]

Research and thinking from outside of medicine may also be useful, and a set of business guidelines from 30 years ago is often cited on this topic:[6]

  • Unoccupied wait times feel longer than occupied wait times
    Give your patients valuable things to do when waiting. Make the waiting space attractive and pleasant, despite how much we seem to love a good sepia-tone dystopia in medical design.
  • Preprocess waits feel longer than in-process waits
    Get patients moving through check-in flows and other steps of their visit, even as they wait to get to you.
  • Anxiety makes waits seem longer
    See if you can find ways to identify patients with urgent concerns and provide reassurance, if possible, while they’re still waiting.
  • Uncertain waits are longer than known, finite waits
    GIVE SOME GUIDANCE ON EXPECTED WAIT TIME. UPDATE AS NECESSARY.
  • Unexplained waits are longer than explained waits
    Something going wrong in clinic? Keep the waiting room updated. See the point above this one.
  • Unfair waits are longer than equitable waits
    Sometimes we triage, depending on medical environment. Find a way to explain wait differences that seem unfair.
  • The more valuable the service, the longer people will wait
    Provide tons of value when you do finally see the patient. Research suggests that great visits make up for bad waits (more on this later).
  • Solo waits are longer than group waits
    Encourage patients to bring friends or family to visits; decreased wait time perceptions will be a side benefit.

Then, after their wait is finally over, make sure that you…

2) Spend Time With Patients

I hear you; don’t groan yet! Of course we would all spend more time with patients if we could, so how is this useful advice? Because perception of visit time, just like wait time, is different than actual time.

In one study, patients were more likely to rate their visit at the highest satisfaction level as perceived visit length increased:[7]

Satisfaction and Perceived Visit Time

The researchers did not report whether this effect was independent of actual visit length, which is unfortunate, but they did note that there was only fair to moderate agreement (kappa 0.41) between actual times and patients’ estimates, so it is possible that the entire effect depends on perception.

In support of the importance of perception, the same authors also found that a patient’s expectation of visit length predicted their satisfaction:

Satisfaction and Expected vs Perceived Visit Length

If patients were expecting a visit to be shorter than it actually ended up feeling, they were pleased. Similarly, if they thought it was going to be longer than it was, they were less likely to be happy. Understanding your patients’ expectations of a visit will help you set and then exceed them, producing tons of satisfaction without requiring you to change the impossible (available minutes in the day).

Bonus power-up tip: Longer perceived visits make up for bad wait times!
This is the greatest. Decent evidence shows that patients who perceive their visits to be longer are likely to be satisfied even when they have abominable wait times:[8]

Mean Provider Ratings by Waiting Time and Visit Time

In that graph, patients with short wait times were generally happy no matter what, but things started to get ugly as wait times crept up. The magic, though, is that happiness could still be salvaged if the visit was perceived to be longer (and probably “better” in general).

So how can you make visits seem longer and more generally valuable for your patients? Well, you could make them actually longer, or you could…

3) Sit Down

This one’s easy, and you might have heard it before. When asked, patients say that they want their doctor to be seated when possible: one study observed a 52% patient preference for this versus only 8% for standing (40% didn’t care either way).[9]

Furthermore, when this preference for seated posture is tested in a controlled way, it turns out that it likely is real. In an emergency medicine study, patients perceived physician encounters to be nearly 25% longer when their doctor was sitting instead of standing.[10] Other studies have reinforced this finding, while also observing that seated physicians are typically perceived to be more compassionate than their standing colleagues, as well as better at listening carefully and explaining things.[9,11,12]

Direct measures of satisfaction in posture studies are not as clear, but given that patient perception of visit length appears clearly linked to satisfaction, and seated posture seems like a slam dunk to increase perceived visit length, the dots mostly connect themselves. Anyway, wouldn’t you rather sit down from time to time? The evidence basically demands that you do it.

Interestingly, some of the posture researchers were also extremely thorough documenters (or realized too late that they didn’t have enough figures for their paper):[11]

Chair Used in Posture Study

Definitely a vital Figure 1. Now, before you take that compassionate and evidence-based seat, make sure to…

4) Dress Like a Boss

How you look affects many things in life, and it’s likely that patient satisfaction is on that list. To be fair, there is some conflicting evidence on this topic, so don’t throw your hospital wardrobe out just yet. In general, what we know is that patients will tell you that they favor doctors who are dressed the part (white coats, no jeans, etc.), and this finding has been reproduced many times, both in studies that directly surveyed patients on their preferences and in those that were obviously geared to investigate physician appearance (e.g., patient judgments were based solely on photographs).[13,14]

Things get murkier, however, when you control physician appearance and then measure patient satisfaction in actual care settings. One emergency department study found no difference between scrubs and formal attire, for instance, but a post-hoc analysis on the same data revealed a significant positive effect for wearing a white coat.[15] In an obstetrics and gynecology clinic, no satisfaction difference was found when comparing business clothing with casual attire or scrubs, but the “casual” category was still fairly formal (e.g., no jeans allowed, and some doctors were wearing white coats).[16]

Perhaps the best summation of this topic comes from a recent review of clothing for healthcare personnel, which concluded that “patients express preferences for certain types of attire, with most studies indicating a predilection for formal attire, including a white coat, but these partialities had a limited overall impact on patient satisfaction and confidence in practitioners.”[17] So you might be able to dress down a bit without sacrificing satisfaction, but with that said, here is the number of studies that support you wearing 10-year-old jeans and a battered fleece jacket during patient care: zero. Dressing the part, within reason, is a definite easy victory.

For visceral impact, here’s an actual picture of a doctor in “casual” dress from one of the survey studies, with patients preferring this ~40 times less than when he was wearing “professional” attire:[13]

Casual Doctor

Don’t be that guy. Instead, dress like you mean it and…

5) Be an Expert Communicator

You don’t always have control over the course of a patient’s disease or their eventual outcome, but the way you build the doctor-patient relationship can have an important impact on how satisfied that patient is with your care and how they feel about their illness. There are endless possible ways to communicate well or poorly with a given patient, of course, but studies have identified several concrete communication topics that seem to reliably affect patient perception of care:[18]

  • Unmet expectations
    It’s not just expectations that are important but also whether they are met. Try to identify why exactly your patient has come to see you, and then do your best to meet those needs. If you spot a gap between expectation and likely reality, find a tactful way to address it and hopefully recalibrate your patient’s goals (or a way to connect them with care that can meet their expectations).
  • Likely length of symptoms
    If it is possible to give responsible guidance on likely symptom course, you should definitely do so. The natural history of bronchitis or a kidney stone may be old news to you, but your patients will derive a huge mental benefit from being given a clear timeline on such things. We all like tracking numbers on our packages so that we know when to expect them; help your patients know when to expect the arrival of their first symptom-free day.
  • Explanation of symptoms
    Your patients are coming to you for relief, yes, but they are also coming for answers. Don’t underestimate the positive effect you can have simply by explaining what is happening (and what isn’t!) If you can explain to your patient why their cough is likely to be a self-limited virus and not a bacterial pneumonia, you might have already provided a good deal of what they wanted when they walked in your door.

Unfortunately, much of the work on the role of communication in patient satisfaction relies on surveys instead of controlled experimentation, so it is difficult to say precisely which practices best establish a good doctor-patient relationship. For what it’s worth, many studies have identified likely roles for a variety of behaviors, including giving patients ample time for questions, utilizing shared decision-making, conveying a positive attitude, and using normal human nonverbal communication strategies (eye contact, handshakes, appropriate humor).[19,20] If these findings are unsurprising, maybe that’s because it’s obvious that communication is critical to human satisfaction in every arena, and we can’t afford to ignore that when the white coats go on.

Second bonus power-up tip: Good communication also improves health outcomes and reduces lawsuits!
You thought we were done, but this is too good not to mention. Being an expert communicator with your patients will make them more satisfied, yes, but the evidence also suggests that it will make them healthier. And you’ll get sued less. Maybe we’re simply measuring the placebo effect, but meta-analysis of studies on the doctor-patient relationship has indicated that its quality has a small but statistically significant effect on healthcare outcomes.[21] Individual studies on the topic are interesting, too: one showed reductions in symptom length and severity among patients with the common cold when they felt their clinician was maximally empathetic.[19]

As for lawsuits, a large study found that 75% of patient complaints were related to “communication” problems rather than “care” issues, noting also a 6% increase in complaint rate for each 1-point drop in satisfaction score (on a scale of 5).[22] The same authors then correlated satisfaction scores to eventual risk management cases and found that each 1-point decrement in satisfaction was also associated with a 5% increase in the probability of a risk management episode. Do you want to find out how much bad communication it takes to drop a few points of satisfaction? Probably not. Here’s a simple bar graph of risk management episodes among the top third, middle third, and bottom third of physicians by patient satisfaction score:

Risk Management Episodes by Patient Satisfaction


So there you have it: five evidence-based ways to increase patient satisfaction that aren’t likely to decrease patient health. Let us know if you put any of these to work and notice any differences, or if you’re already using some of them successfully!


References:

  1. Fenton, J. J., Jerant, A. F., Bertakis, K. D. & Franks, P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch. Intern. Med. 172, 405–411 (2012).
  2. Glickman, S. W. et al. Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction. Circ. Cardiovasc. Qual. Outcomes 3, 188–195 (2010).
  3. Finset, A. 50 years of research on the effect of physician communication behavior on health outcomes. Patient Educ. Couns. 96, 1–2 (2014).
  4. Thompson, D. A., Yarnold, P. R., Williams, D. R. & Adams, S. L. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann. Emerg. Med. 28, 657–665 (1996).
  5. Leddy, K. M., Kaldenberg, D. O. & Becker, B. W. Timeliness in Ambulatory Care Treatment: An Examination of Patient Satisfaction and Wait Times in Medical Practices and Outpatient Test and Treatment Facilities. J. Ambul. Care Manage. 26, 138 (2003).
  6. Maister, D. H. The psychology of waiting lines. (www.davidmaister.com, 1985).
  7. Lin, C. T. et al. Is patients’ perception of time spent with the physician a determinant of ambulatory patient satisfaction? Arch. Intern. Med. 161, 1437–1442 (2001).
  8. Camacho, F., Anderson, R., Safrit, A., Jones, A. S. & Hoffmann, P. The relationship between patient’s perceived waiting time and office-based practice satisfaction. N. C. Med. J. 67, 409–413 (2006).
  9. Bruera, E. et al. A randomized, controlled trial of physician postures when breaking bad news to cancer patients. Palliat. Med. 21, 501–505 (2007).
  10. Johnson, R. L., Sadosty, A. T., Weaver, A. L. & Goyal, D. G. To sit or not to sit? Ann. Emerg. Med. 51, 188–93, 193.e1–2 (2008).
  11. Merel, S. E., McKinney, C. M., Ufkes, P., Kwan, A. C. & White, A. A. Sitting at patients’ bedsides may improve patients’ perceptions of physician communication skills. J. Hosp. Med. (2016). doi:10.1002/jhm.2634
  12. Swayden, K. J. et al. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Educ. Couns. 86, 166–171 (2012).
  13. Rehman, S. U., Nietert, P. J., Cope, D. W. & Kilpatrick, A. O. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am. J. Med. 118, 1279–1286 (2005).
  14. Lill, M. M. & Wilkinson, T. J. Judging a book by its cover: descriptive survey of patients’ preferences for doctors’ appearance and mode of address. BMJ 331, 1524–1527 (2005).
  15. Baevsky, R. H., Fisher, A. L., Smithline, H. A. & Salzberg, M. R. The influence of physician attire on patient satisfaction. Acad. Emerg. Med. 5, 82–84 (1998).
  16. Fischer, R. L., Hansen, C. E., Hunter, R. L. & Veloski, J. J. Does physician attire influence patient satisfaction in an outpatient obstetrics and gynecology setting? Am. J. Obstet. Gynecol. 196, 186.e1–5 (2007).
  17. Bearman, G. et al. Healthcare personnel attire in non-operating-room settings. Infect. Control Hosp. Epidemiol. 35, 107–121 (2014).
  18. Jackson, J. L., Chamberlin, J. & Kroenke, K. Predictors of patient satisfaction. Soc. Sci. Med. 52, 609–620 (2001).
  19. Rakel, D. et al. Perception of empathy in the therapeutic encounter: effects on the common cold. Patient Educ. Couns. 85, 390–397 (2011).
  20. Zachariae, R. et al. Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease. Br. J. Cancer 88, 658–665 (2003).
  21. Kelley, J. M., Kraft-Todd, G., Schapira, L., Kossowsky, J. & Riess, H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One 9, e94207 (2014).
  22. Stelfox, H. T., Gandhi, T. K., Orav, E. J. & Gustafson, M. L. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am. J. Med. 118, 1126–1133 (2005).

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