Patient as Customer model of healthcare

[GardenDove]

Our hospital has in the last couple of years initiated a number of changes. One of them is that in much of our correspondence from upper management the patients are refered to as 'customers'.

What do you all think? Should we think of our patients as customers? Somehow it has a capitalistic ring to it that I don't like. Ours in a small community hospital, btw, funded by county taxes, in addition to revenue collected from patients. We are also a critical access hospital and this also brings in additional revenue.

[incublissRN, BSN, RN]

When patients have unrealistic expectations, we need to educate them as to what can be expected and what we can and cannot do for them.

Remember that any model is just that--a model--and within that framework, we have a lot of options.

I do try to educate my patients, but most of the time I feel like they believe the idiot box more than what comes out of my mouth. And I'm not going to change their view of nursing or their expectations in one hospitalization most likely, but I give it a try anyways.

Nurses have been trained NOT to tell people what they do, to ensure patient confidentiality and to keep the patient from worrying more about the nurses' needs ("I didn't call because I knew how busy you are," says the patient from the floor). Yet there are diplomatic ways to say what you do. I hear far more often things like "do I really have to call you if I need to get up to the bathroom?" than I hear unreasonable demands from patients.

Right, I try not to look too rushed or busy to meet my patients needs. When my patient is asking for a glass of water and my other patient next door is short of breath I have priorities and I politely explain that in words they will understand. Some days I feel like I hear far more unreasonable demands from my patients, maybe it is just a difference in patient populations. Plus, it does occur in spurts.

That would work like the docs do--we'd have priveleges at a certain hospital or group of hospitals along with use of its equipment, supplies, and services. Nurses would form agencies or workgroups, and instead of working for the hospital, nurses would work for the agency. Hospitals would contract out for nursing services, just as they do for Radiology, and each of us would either be in independent practice or work with a group of nurses, according to our specialty.

Something like that. But if docs and PT's and Radiologists can do it, why can't we? If they can deliver timely, appropriate, ethical care and still make money, why can't we?

I have to at least ask.

I was thinking along the lines of doctors bring patients to hospitals and order services...I didn't know how we would be able to bill since we obviously can't do that. But if we did all work for agencies and had privileges at hospitals then hospitals would have to bill patients for our services, point well taken.

[bagladyrn, RN]

One aspect of "patient as customer" that really disturbs me is that the "retail" model generally leans toward the "big money" customer getting the best and extra service - after all that's where the profit is! This thinking in hospitals is what leads to "VIP" patients and floors, and extending services to some patients and not others. Personally, I find this repugnant and refuse to participate - won't work in a VIP setting and no manager has ever made the mistake of telling me to treat some pt. "extra special" more than once.

Nope - I take care of patients to the best of my ability and my level of caring is not based on their ability or method of payment. This is part of the reason I am finding myself picking more and more contracts in non-profit hospitals rather than the corporate chains.

[UM Review RN, ASN, RN]

One aspect of "patient as customer" that really disturbs me is that the "retail" model generally leans toward the "big money" customer getting the best and extra service - after all that's where the profit is! This thinking in hospitals is what leads to "VIP" patients and floors, and extending services to some patients and not others. Personally, I find this repugnant and refuse to participate - won't work in a VIP setting and no manager has ever made the mistake of telling me to treat some pt. "extra special" more than once.

Nope - I take care of patients to the best of my ability and my level of caring is not based on their ability or method of payment. This is part of the reason I am finding myself picking more and more contracts in non-profit hospitals rather than the corporate chains.

But VIPs have always been able to afford private duty nurses, private rooms, and all the comforts. Was I supposed to refuse to care for the mother of an important bigwig in our state just because she was rich and the homeless drug addict down the hall in the semi-private was not?

I refused neither, and I also give the best care to all. I have had patients who tried to "tip" me (literally) hundreds of dollars and I have not once taken any of it, in order to prove that we don't give preferential treatment.

I've had homeless people who've cried when I did simple things for them like getting them an extra pillow or propping up or washing their feet.

I don't care if you call it customer service or good nursing care, it's really just a matter of semantics to me. But they really both encompass the same principles, IMO.

[bagladyrn, RN]

But VIPs have always been able to afford private duty nurses, private rooms, and all the comforts. Was I supposed to refuse to care for the mother of an important bigwig in our state just because she was rich and the homeless drug addict down the hall in the semi-private was not?

I refused neither, and I also give the best care to all. I have had patients who tried to "tip" me (literally) hundreds of dollars and I have not once taken any of it, in order to prove that we don't give preferential treatment.

I've had homeless people who've cried when I did simple things for them like getting them an extra pillow or propping up or washing their feet.

I don't care if you call it customer service or good nursing care, it's really just a matter of semantics to me. But they really both encompass the same principles, IMO.

As long as both of those patients are getting the good care, that's as it should be. I just object to being told - this couple gets the post delivery special meal because they have private insurance, the one with medicaid doesn't.(NOt a big thing in and of itself, but indicative of an attitude). Or the patient on medicaid being unable to have an epidural unless she paid cash up front for it, while the private insurance pt. got hers as soon as she walked in the door. I've watched nurses fall all over themselves to cater to the famous patient while others were getting at best minimal care. This is what I feel that the "patient as customer" can lead to.

[talaxandra]

One of my 'customers' said "You should be called the patience and we should be called the nursed."

[maryloufu]

I work hard to make sure my patients have the 'creature comforts' as one seasoned nurse put it in a post to new nurses. I go above and beyond what they ask in most cases. BUT I will often have a patient who thinks I am a sonic carhop who's main purpose is to bring them food and drink. I had a patient the other day who kept 'ordering' drinks and food with her call light. When she was having a medical issue (SOB- she was brought in for exacerbation of COPD) I really didnt even want to go in there- (and since her O2 sat was 95 and she was yelling at someone on the phone I was not too worried about her) This woman had eaten 4 box lunches on the night shift and was getting gripey with me because there were none to be had on the day shift (She ate 100% of both meals that day and also had some snacks). Most patients are not like this and will delight in personal attention afforded them- I am asking you seasoned nurses= when it comes to a point when a line is crossed- (Like when a patient is ordering drinks for guests in the room. I mean come on!) How can I tactfully refuse to play hostess? I have trouble with not being nice and sweet, but giving one patient all of the box lunches is a poor allocation of resources.:trout:

[lorster]

I find when you use terms like client or customer you lessen the reality of the situation! I will always call my patients 'patients' because they are there to be treated in a very serious way for their well being, not like going to a restaurant or store!

Here is another thing...why not actually take a survey on performance of staff related to the condition...not how quickly a towel was brought in, how fast someone came to show them how to turn the TV volume down, or if a nurse was available every 15 minutes to bring new ice!!! And okay...if you are going to base it all on these issues...why not actually improve the situation by adding nurses or nursing aides instead of complaining to the nurses there to do even more! Obviously we can't do much more!

When did it become a customer service deal that asks too much from nurses and nurse aides as is versus quality care for the patient on their treatments and conditions (customer service is important, but not the number one deal to me...quality and safe care for the patient condition is!).

YOu go to the hospital to be treated for a condition...not to badger a nurse and get disgruntled when your Low Fat Latte isn't there in 5 minutes or less!

Boy, I think we all work at the same facility. Patient (customer..sorry) surveys really do seem to focus on the promptness of services such as how fast the nurse came back with juice and water. I don't know if they really know what we do in regards to following up on a problem found on a physical assessment. I personally don't seem to hear praise when I've moved on a critical problem but I hear about complaints. I have been criticizing the "5 star hotel" status that our hospital is trying to attain. They are now offering bottled water when we have some of the best water in the world and patients have come to expect it. We provide very good care here and I'm proud to be a staff member but it seems the better you do, the more that is expected each time the patient comes in and pretty soon, you just cannot keep up with the expectations of the hospital or patients. I feel that this is becoming an issue when it comes to nurse burnout. I have an issue with patients that walk into the ER and by the time they get to the floor, they won't even lift a kleenix out of the box. A patient asked one of our nurses the other day if she would pick his nose. I'm currently nearing burnout and taking a job at another facility in hopes that things are better but sounds like it is the same everywhere.

[burn out]

The biggest problem is that nursing is not a charge item on the patiens bill. Nurses are paid in most hospitals from room/board charges or from lab charges. If we were able to charge for every time we took a vital sign or served a meal or snack, adm pain med there would be no way any insurance could handle to cost..if we charged the patient directly maybe they wouldn't be so demanding. As long as nursing is seen as a freebie by patient then we will continue to be treated as servants. If nurses were so important why arent we billed for their services. When was the last time you received all the care a nurse gave her patients outside of the hospital and didn't have to pay for it?

[nurse4theplanet, RN]

Here is my problem with the "customer" model.

The term customer has historically been used in retail/food service, where the customer gets to make all the decisions. They call the shots. They get a list/menu/aisle of choices or seek out a certain good or specific service for which their is a known desired outcome...and wallah...either the standard is met or they receive something comparable. In general, the customer knows what they need/want, and knows the standard to expect.

In healthcare, especially hospitals, most patients are coming to us because they don't know what they need. They don't know what's wrong with them and are relying upon the knowledge of the doctors and nurses to figure that out. Therefore, if they don't know what it is they are seeking, they certainly don't know what to expect, how long to stay, what should be ordered, how long the wait time for their results will be, what restrictions will be placed on them (diet, smoking, visitors), how often the nurse will be in and out (interrupting their sleep, their phone conversations, their visits), etc. They also do not take into consideration that if the nurse doesn't answer their call light immediately to bring them more ice chips, that it may not be that the nurse is lazy but that she has a pt coding down the hall at the moment.

Yes, the patient is a paying for a service. But the term customer seems to carry with it the expectation of being able to have the final say, to make demands, and have all those demands met at any expense. It is designed to make the 'customer' feel as if they are the authority and have ultimate control. And that is not the type of environment that a hospital should foster.

While the underlying concept is good (please your pts, try to meet their needs, and do it with a smile, be friendly, etc.)...it can become excessive.

Pt's come in for anything from a nosebleed to a emergency CABG...and they all leave with the same 4 question survey. Generic questions like, "Overall, how would you rate this hospital 1-4?". If they survived the emergency CABG in the first place, that's saying a lot isn't it? But God forbid one call light went unanswered or their meal tray was missing silverware. The basis for the customer service improvements is so skewed that I don't want to even get myself going about it.

Anyway, that's my rant! I treat all my pts with dignity, courtesy, and respect and my priority is to keep them stable and improve their conditions first, then I will worry about the nit picky customer service improvements if I have nothing better to do.

[UM Review RN, ASN, RN]

Here is my problem with the "customer" model.

The term customer has historically been used in retail/food service, where the customer gets to make all the decisions. They call the shots. They get a list/menu/aisle of choices or seek out a certain good or specific service for which their is a known desired outcome...and wallah...either the standard is met or they receive something comparable. In general, the customer knows what they need/want, and knows the standard to expect.

In healthcare, especially hospitals, most patients are coming to us because they don't know what they need. They don't know what's wrong with them and are relying upon the knowledge of the doctors and nurses to figure that out. Therefore, if they don't know what it is they are seeking, they certainly don't know what to expect, how long to stay, what should be ordered, how long the wait time for their results will be, what restrictions will be placed on them (diet, smoking, visitors), how often the nurse will be in and out (interrupting their sleep, their phone conversations, their visits), etc. They also do not take into consideration that if the nurse doesn't answer their call light immediately to bring them more ice chips, that it may not be that the nurse is lazy but that she has a pt coding down the hall at the moment.

Yes, the patient is a paying for a service. But the term customer seems to carry with it the expectation of being able to have the final say, to make demands, and have all those demands met at any expense. It is designed to make the 'customer' feel as if they are the authority and have ultimate control. And that is not the type of environment that a hospital should foster.

While the underlying concept is good (please your pts, try to meet their needs, and do it with a smile, be friendly, etc.)...it can become excessive.

Pt's come in for anything from a nosebleed to a emergency CABG...and they all leave with the same 4 question survey. Generic questions like, "Overall, how would you rate this hospital 1-4?". If they survived the emergency CABG in the first place, that's saying a lot isn't it? But God forbid one call light went unanswered or their meal tray was missing silverware. The basis for the customer service improvements is so skewed that I don't want to even get myself going about it.

Anyway, that's my rant! I treat all my pts with dignity, courtesy, and respect and my priority is to keep them stable and improve their conditions first, then I will worry about the nit picky customer service improvements if I have nothing better to do.

I understand what you're saying, but really, the term "customer" is as much of a semantics issue for patients as it is for nurses.

You, the nurse, are a customer because you are in a business relationship with the hospital. So is the doctor. So is the patient/customer.

The patient does have an indicator of quality care--personal comfort. Am I comfortable with the staff, the surroundings, with the amenities? Did they hurt me? Did they care if they hurt me? Obviously, if someone doesn't care if I'm comfortable, I won't get that extra pillow, which will make me wonder what other uncomfortable things will happen to me while I am there.

Now instead of relaxing and trusting my caregivers, I'm uncomfortable, I'm anxious, I'm scared into silence.

Is that the kind of patient you want?

Nothing conveys concern like taking care of the "little nitpicky things" like giving someone a toothbrush and a wash basin to wash up with, or an extra pillow, or a midnight snack before going NPO. If a patient/customer is not clear about what is expected during the hospital stay, we can always show them the little blurb underneath the "Patient Rights" that describes "Patient Responsibilities." Yes, patients have clearly stated responsibilities too.

Yes, there is a line. Yes, there are patients who ask too much of us. There are also patients who ask too little.

It comes with the territory.

But we need to remember that doing all those "nitpicky things" are part of good nursing care. When we resent doing those things for patients, it says a lot about what we've allowed ourselves to become as nurses.

The whole "customer service model" is really based on Nursing 101:

If I'm sick, I want someone to act like they care about me.

I don't need a medical degree to figure out who gives a darn and who doesn't. The nurse that gets me that extra pillow or who takes the time to teach me that water will only make my stomach more bloated and cause me to vomit and later buy an NG tube, is showing me who cares about what happens to me.

[nurse4theplanet, RN]

I understand what you're saying, but really, the term "customer" is as much of a semantics issue for patients as it is for nurses.

You, the nurse, are a customer because you are in a business relationship with the hospital. So is the doctor. So is the patient/customer.

The patient does have an indicator of quality care--personal comfort. Am I comfortable with the staff, the surroundings, with the amenities? Did they hurt me? Did they care if they hurt me? Obviously, if someone doesn't care if I'm comfortable, I won't get that extra pillow, which will make me wonder what other uncomfortable things will happen to me while I am there.

Now instead of relaxing and trusting my caregivers, I'm uncomfortable, I'm anxious, I'm scared into silence.

Is that the kind of patient you want?

Nothing conveys concern like taking care of the "little nitpicky things" like giving someone a toothbrush and a wash basin to wash up with, or an extra pillow, or a midnight snack before going NPO. If a patient/customer is not clear about what is expected during the hospital stay, we can always show them the little blurb underneath the "Patient Rights" that describes "Patient Responsibilities." Yes, patients have clearly stated responsibilities too.

Yes, there is a line. Yes, there are patients who ask too much of us. There are also patients who ask too little.

It comes with the territory.

But we need to remember that doing all those "nitpicky things" are part of good nursing care. When we resent doing those things for patients, it says a lot about what we've allowed ourselves to become as nurses.

The whole "customer service model" is really based on Nursing 101:

If I'm sick, I want someone to act like they care about me.

I don't need a medical degree to figure out who gives a darn and who doesn't. The nurse that gets me that extra pillow or who takes the time to teach me that water will only make my stomach more bloated and cause me to vomit and later buy an NG tube, is showing me who cares about what happens to me.

I never said that I did not believe in making the patient comfortable and relieving their anxiety about their care. The most important part of the nurse patient relationship is establishing trust and rapport. However, management is taking the idea of "the patient is a customer and the customer is always right" too far.

They are developing a skewed, one sided method of evaluating customer satisfaction that is severely flawed because the typical customer (a lay person with no medical training) does not necessarily have the knowledge base to appropriately evaluate the true extent to which the staff tried to meet their needs.

Here is what I mean by 'nit picky'...

Okay, our hospital's Service First Campaign requires the employee to walk with any 'customer' (pt, family member, or visitor) whenever they need to find their way to an area in the hospital. Instead of pointing down the hall or giving directions, they want you to say "Let me take you there myself", or even better, walk around and find someone else who can (yeah right!). Great idea in theory, right? It's a decent, respectable thing to do. If you violate this rule, its grounds to be written up. That is how strongly they are pushing this customer service campaign!

So...if I am taking a specimen down to the lab. I got two unstable ICU patients upstairs and I get asked by at least 5 different groups of people, "How do I get to the cafeteria? Gift Shop? Rm ###?" If I stop and walk each person to their destination...I'd never get back to my patients? But all it takes is for one person in any of those 5 groups to write my name down on a Customer Satisfaction card (the hospital advertises it's customer service campaign and these cards are EVERYWHERE) and I get written up! If I do follow the Service First BS then my patients suffer.

That's what I mean by nit picky! That's the extreme that it is being taken to in some instances.

"Customer Complaints" are very one sided and based on that person's impression of the given situation, not necessarily reality. If I pass you quickly in the hall or do not hold the elevator, it is not because I am unfriendly...it is because I am running for emergency supplies. If I don't bring you your ice chips within 5 minutes after you ask for them, it's because my other patient is crashing and I am frantically trying to get an order for a pressor or I'm paging respiratory. But you as the 'customer' do not understand these things because you typically do not know what it is like to be a nurse. It would be helpful if my EMPLOYER would not drill the idea into the 'customers' head that every single need will be met at any expense and then understaff and overload me. Then when you evaluate customer satisfaction, factor this into your equation!

[UM Review RN, ASN, RN]

management is taking the idea of "the patient is a customer and the customer is always right" too far.

Thanks for the clarification. I agree, in the cases you cite, it does border on the ridiculous.

I cannot imagine being written up for not escorting people! I certainly am helpful and I will assist someone if they appear to need it, but not during an emergency.

I would politely excuse myself from that duty and say, "I'd show you the way myself, but I'm dealing with an emergency right now."

In fact, if I got written up for that, I'd have to turn in an incident report to Risk Management and let them and management duke out which priority is more important.

During an emergent situation, our hospital elevators even have little signs posted informing visitors/family/staff that they might be asked to vacate the elevator for the patient emergency.

So not all hospitals following this model are throwing the baby out with the bath water, thank god.