Press Ganey questionnaires do not reflect ‘immeasurables’ in medicine

Quality ratings for physicians are becomingly increasingly important as measures of performance and determinants of reimbursement. One measure gaining traction for physician rating is the Press Ganey score.

This system uses a patient questionnaire to evaluate satisfaction with the physician visit experience and some large medical group practices are using Press Ganey scores to determine base pay and bonuses. Is this type of scoring evaluation accurate and valuable? This is a question worth examining as it pertains to dermatology.

Following a dermatology visit, the patient is encouraged to go online and complete the Press Ganey questionnaire. This questionnaire evaluates everything from the dermatologist, to the office staff, to the promptness of the visit, to the length of time spent with the patient, to the cleanliness and attractiveness of the office.

I would argue that this is not a good measure of performance because not all patients are capable of going online and completing the questionnaire. Older patients who are not adept at navigating the Internet are probably not going to complete the electronic questionnaire, thus skewing the responder population. Further, I think patients who are neutral or satisfied with the visit probably will not take the time to do the rating, while dissatisfied patients are more motivated to voice their dislikes. This definitely alters the survey outcome.

Specialty challenges

Patient dissatisfaction takes on a different meaning in dermatology than other medical specialties because we provide both insurance covered and uncovered services. The patient who comes in requesting removal of a benign seborrheic keratosis for appearance purposes may give the dermatologist a poor rating when they are told this is an uncovered procedure requiring an out-of-pocket expenditure.

Providing cosmetic services also creates another challenge when the patient claims, despite extensive explanation, that the tube of filler did not remove every wrinkle on her face. How do the surveys capture the difference between the dermatologist who was following insurance guidelines and quality? How can the challenging patient who has unrealistic expectations that could not be quelled be separated from the true skill of the dermatologist?

I would contend that surveys are only as accurate as the perceptions of the individual completing the questionnaire. I would also argue that many of the questions have little to do with skill and more to do with nonquality related measures. While the cleanliness of the office is important, I am not sure that chic chairs and gallery quality artwork reflect on physician skill.

I also am not sure that waiting time is a reflection of medical quality. Many excellent dermatologists are not as prompt because they rise to meet the needs of the patient at the time of the visit. Is a physician who only addresses one problem per visit to stay on time better that the physician who spends a few extra needed minutes with a distraught patient in crisis? Is the office wait time really under the control of the physician given the unpredictably of patient needs?

Consumers versus patients

Satisfaction questionnaires work well for situations where the consumer is in control. For example, in the office supply store, the consumer can spend as much time or as little time desired picking out a new pen. The store staff can direct the consumer to the aisle where the pens are located, but all other aspects of the purchase are in the consumer’s hands.

This is not the case in the dermatologist’s office. The patient did not come in to buy a melanoma from the dermatologist. They are purchasing treatment for something they did not want.

Those trying to control medicine are applying business principles to an area where business simply does not work. Disease is not cost-effective and the emotions of the moment are not properly timed.

Press Ganey scores are interesting, but may not reflect the immeasurables in medicine that are important in treatment success. As dermatologists, we must recognize that this approach to quality care is fraught with disaster.