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Risk management: Using patient surveys to manage patients

Article-Risk management: Using patient surveys to manage patients

Loveland, Colo. Analysis of low-score patient satisfaction data can act as a predictor for a physician or department’s risk of a malpractice claim, according to Fullam et al. A multistrategy approach designed to improve communication on individual and departmental levels is described.

Poor communications. A surgeon’s tone of voice. Patient complaints. All of these have been found to be associated with a higher risk of medical malpractice lawsuits, according to a review of the literature presented in Fullam et al’s recent study published in Medical Care. Other researched correlated factors include the “negligent physician” label, physician gender, patient volume, specific specialties (including orthopedic surgery, neurosurgery, and obstetrics/gynecology) and past malpractice claims.

Whatever the cause, however, there is an average two-year (24.2 months) lag time between the date of the incident and the notice of intent to file a suit. This period, suggests Fullam et al, could be useful from a prevention perspective if efficient prelitigation indicators of risk could be identified.

“You don’t want to start thinking about [litigation risk] when you get the call from an attorney, but you do want to think about the patient experience and begin to manage it,” says Francis Fullam, MA, senior director of marketing research in strategic planning, senior director for patient relations and a faculty member at Rush University Medical Center in Chicago.

Predicting Risk

Mr. Fullam’s recent research sought to identify how common patient satisfaction indicators might identify potential malpractice litigation risks. Fullam et al cite previous work by Hickson and associates, which found that unsolicited patient complaints, whether delivered via telephone, mail or email, are positively correlated with malpractice claims. And although the goal is to prevent incidents of patient dissatisfaction, unsolicited complaints can help to identify healthcare providers at greater risk of malpractice claims. 

What might be useful as well in prevention are patient satisfaction surveys. Fullam et al’s research suggests “that analysis of low-score patient satisfaction data may be an efficient source of actionable information concerning litigation risks within specific physician practices.”

Using eight years of risk management data from a large academic medical center, the team applied three methodologies (two conventional methods and one innovative technique) to analyze the information. In so doing, they sought to determine which, if any, estimators could predict whether an attending physician was named in a lawsuit in a given year.

The two conventional methodologies revealed no significant predictive value, but the innovative technique — the minimum satisfaction score — was found to be a significant predictor. “We found that as the minimum response moves one category lower (eg, from ‘very good’ to ‘good,’ from ‘good’ to ‘fair’), the risk of implication was estimated to increase by 21.7 percent.”

Managing Expectations

“I believe there are better informed and more serious efforts [underway] to control or get a better handle on risk management and lawsuits,” says Mr. Fullam. The research indicates that interventions should be directed to both departments and individual physicians. The trends, Mr. Fullam notes, are to better communicate to physicians what their patients are saying about them.

“In most cases, it’s really quite positive, but it can be beneficial to call out instances where the patient experience has not met the expectation. We can provide feedback to the physicians in terms of the best way to react to that feedback,” says Mr. Fullam.

Fortunately, most physicians are seasoned professionals with careers built on patient interaction, and Mr. Fullam suggests that cosmetic surgeons may be particularly aware of the importance of this relationship.

“[Cosmetic surgeons] completely understand that outcome is dependent upon the expectation of patients, and many times the outcome is visible to the patient. I believe cosmetic surgeons are generally good at engaging the patient and setting expectations early on,” says Mr. Fullam.

Key to managing patient expectations is communication. “You really have to work with patients to understand where they are beginning from and what their expectations are, and you should always stay in touch with them on that—so they have a reasonable view of what the outcome will be,” says Mr. Fullam.

This means the physician must listen to the patient and make the patient feel as though he or she has been heard. “The general literature shows people are not suing for bad clinical outcomes but usually over communication issues,” says Mr. Fullam.

Communicating Better

More research is needed to better understand ways to reduce the risk of litigation through communication. Mr. Fullam would like to see his results replicated by other researchers. In this study, the team acknowledges one of the limitations is the fact that the data is collected from a single institution.

Other research should examine a multistrategy approach involving three steps:

First, hospitals should require training on effective patient communication for physicians applying for admitting privileges and provide this training for all physicians who request it. Second, physicians whose own feedback from unsolicited patient comments (e.g., calls, letters, e-mails) and solicited comments (i.e., patient surveys) suggest higher risk should be required to participate in communication improvement programs. Third, hospitals should hold routine department-level training on the specific physician-patient communication issues for the departments at higher risk for lawsuits. This should involve all physicians, regardless of lawsuit.

Patient surveys therefore hold the potential for use as a tool to manage malpractice risk. As they are standardized and become more prevalent within healthcare organizations, they enable greater data mining on the part of hospitals and researchers.

Mr. Fullam doesn’t think a single ideal patient survey exists but feels there are a number of existing surveys that work. In the paper, the team suggests expanded use of the federally mandated “Consumer Assessment of Healthcare Providers and Systems” Hospital Survey, which looks at the experience of inpatients. This has become the “de facto source” of patient feedback for individual physicians. An outpatient version in development could do the same for that segment of care. Custom in-house surveys fill in the gaps left by these national efforts.

According to Fullam et al, there are a number of programs designed to improve physician-patient communication and an expanding body of research examining their efficacy. Results are expected to help shape these efforts and perhaps help to reduce the risk of malpractice litigation. “Coupling risk assessment tools with empirically proven physician-patient communication programs holds the promise of significantly reducing occurrence of lawsuits and a better bond between patients and their physicians,” writes Fullam et al. So hospitals may be able to avoid that call from the attorney by thinking about the patient experience and managing it right away.


Fullam F, Garman, AN, Johnson TJ. The use of patient satisfaction surveys and alternative coding procedures to predict malpractice risk. Med Care. 2009;47:553–559.

For the full study, visit Medical Care

For a national survey, check out Consumer Assessment of Healthcare Providers and Systems Hospital Survey

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