When quality trumps service, patients lose out

The Ontario government deserves applause for tackling global funding for hospitals. “Global budgets provide[d] little incentive for hospitals to focus on efficiency, innovation, improving access, coordinating care across facilities and sectors or improving quality.”

In 2012, the Ontario Ministry of Health announced its commitment to patient-based funding. It promised to deliver patients:

• Shorter wait times and better access to care in their communities
• More services, where they are needed
• Better quality care with less variation between hospitals

Deb Matthews, Minister of Health and Long-Term Care, said

“Our current funding model for hospitals is out of date and doesn’t reflect the needs of the communities they serve. As part of our Action Plan we are implementing a system that funds hospitals to increase services where needed, deliver quality care more efficiently and serve more patients.”

Patient-based funding promised to “breathe new life into hospitals” and move hospitals “into the 21st century”. Some described it as a “financial ray of sunshine”. Health System Funding Reform (HSFR) promised a new era in healthcare.

But rather than a revolutionary funding mechanism, Ontario hospitals got Quality Based Procedures (QBPs):  “standardized clinical pathways based on best clinical evidence”.

The trouble with QBPs is that by focusing on standardizing clinical pathways, they ignore other important dimensions of quality, namely customer experience. QBPs do not incent improved customer experience.

Focusing only on clinical pathways is like Starbucks’ coffee scientists obsessing over the quality of coffee beans, the temperature of espresso steam, and the precise way to make latte foam, but then ignoring all the other components of good customer service: friendly staff, clean stores, pleasant music, etc. The quality of Starbucks coffee is only one part of its success. Customers walk past other coffee shops to Starbucks for more than just high quality coffee. People return to Starbucks for great customer service and an enjoyable experience. Customers leave knowing Starbucks wanted them there.

No one argues for low-quality care. Improving quality beats staring at budgets. But QBPs miss a key dimension of quality: patient experience.

Unfortunately, QBPs do not reward hospitals for good patient experience, such as being respectful of patients’ time and providing friendly service. QBPs reward hospitals only for providing clinical quality as defined by QBPs.

QBPs focus on product, not patients; coffee, not customers.

Standardizing care pathways is probably a good thing. But once hospitals standardize, will patients get great customer service? Will QBPs motivate hospitals to serve patients like Starbucks works to earn customer devotion and trust? Or will hospitals continue as they are today, trying to do things as cheaply as possible and within budget? I suspect hospitals know they won’t get more and more money for providing more services. They will find a tipping point of maximal efficiency and stop. Just like they did with global funding.

We must debate motivation, not structure. If healthcare is a rowboat, standardized care pathways address leaks. They keep the boat afloat, but they don’t get us anywhere. They don’t help us view patients as valued customers, they won’t shorten wait times, and they don’t encourage innovation. Quality will plateau, limited by budgets.

We need our system to reward hospitals for putting patients first. We need true patient-based funding. So far, finance reform has only motivated hospitals to see certain patients as more risky, and costly, than before. It remains to be seen if finance reform in Ontario will live up to its promises in the future.

The comments section is closed.

  • Kim Fraser says:

    Love the leaky rowboat metaphor! I was having a discussion on quality indicators the other day particularly about what we measure; and while these indicators may be important to us–working in the system–very few were likely important to the client. It is about time we listen to what clients, patients, families tell us what matters and put some focus there. With all of the counting, reporting, searching for information, etc we are loosing site of what matters. One of my favorite sayings is– not everything we can count matters, and what matters cannot always be counted.

    • D. John Hooper says:

      Kim, referring to patients as clients is a huge mistake. They are not clients and we as health care professionals are not vendors.

      The physician-patient relationship is nothing like the vendor-client relationship. Clients want to be there to buy something. Patients just want to be well and would rather not spend time on the ward, in the OR or waiting in the ED.

      Using the term “client” reduces the plight of the patient to nothing more than window shopping. It also implies that the customer is always right, which in many cases is not true in patient care (demanding antibiotics for viral URTI, MRI for tension headache etc)

      That business term has no place in medicine and should be abandoned!

      • Shawn Whatley says:

        Thanks John (I hope this isn’t a repeat…first reply evaporated on me…)

        I agree that analogies aren’t perfect; they try to highlight one aspect, one feature. The post tries to refocus finance reform to include patient experience at the centre of debate on quality. We all agree that healthcare should provide the best evidence, technology, and training available.

        What we provide is entirely different from how we provide it. Patient experience needs to be an integral part of quality; we need to include ‘how’ with ‘what’.

        We all find demands for narcotics, unnecessary tests, and useless antibiotics frustrating and tiresome. But MOST patients present for help out of genuine concern, yet we make far too many of them feel like they are undeserving and should have sought care somewhere else. The system has no incentives for providers to treat patients like we actually wanted to see them; wanted them there.

        We need to put patients first. Let’s work together to find creative ways to make patients feel valued in the same way that other service industries do.

        Thanks again for taking the time to comment!

        Best Regards,


      • Pamela Velos says:

        Curious as to where you get the idea patients feel they are undeserving and should have gone somewhere else for care? Could it be the 4-6 hour waits in the ED before being seen?

        “• Shorter wait times and better access to care in their communities
        • More services, where they are needed
        • Better quality care with less variation between hospitals”

        How about the MOH and Deb Matthews delivering on the above commitment to improve the customer experience? This would require real change – increase the number of frontline workers and the resources they need to do their jobs and, decrease the number of bureaucrats and very well paid healthcare executives and consultants. This would go a long way to improving customer service

      • Kim Fraser says:

        The use of the term client is widely used in health care beyond the physician-patient dyad around the world. I disagree that it reduces the plight of the client. However, I do agree with the use of the term vendor with respect to health care professionals. It is problematic in many health care scenarios in particular where services are provided rather than medical supplies per se.

    • Shawn Whatley says:

      Thanks Kim!

      Brilliant saying, “Not everything we can count…” I will definitely Tweet that (and credit you, of course).

      We have a long way to go after decades of a provider-and-cost-focussed system. There is hope, though. Small changes to the things we measure and reward could translate into major changes for patient experience.

      Thanks again!


  • D. John Hooper says:

    Dr. Whatley, you appear misinformed.

    Look to the USA and the problems ERPs are having with Press-Ganey surveys.

    A patient is not a customer. The difference is quite clear: a customer wants to buy a product that a vendor is selling, whereas a patient would rather not need to obtain medical services (otherwise there’s a psychiatric diagnosis for that). The latter is essentially a forced relationship out of grave necessity.

    I am all for making sure patients are well taken care of, but they are certainly not the ones with the expertise to dictate what is appropriate care. Unfortunately, many believe in a “more is better” approach and will ding the physicians if they do not cede to their demands.

    To improve the patient experience, physicians must be more demanding of administration. We can start by freeing up the money that’s being wasted on hiring new “vice-presidents” for newly-crafted departments who don’t lead, don’t listen, and serve no purpose but to be paid.

  • Voytek Roszuk says:

    Interesting article. Patient experience is an important component of quality but it is just that, a piece of a quality puzzle. Patient experience is not all that easy to gauge in a health care setting and I would rather not have it included in the initial QBP process than to have it included inappropriately. Also, not sure I would agree with a Starbucks analogy. As I walk into a local Starbucks I expect to get what I want at a price that I’m willing to pay. As I walk into my doctor’s office I hope I get what I need and not have to worry about the cost. I think we’ll have our set of issues with QBP (for one thing, I’m not entirely certain about the Q) and I don’t know if I would want to complicate it further with adding patient satisfaction component to it. Interesting topic though. Thanks Shawn.

    • Shawn Whatley says:

      Good thoughts, Voytek! Thanks for sharing them. I’m suggesting that patients, as taxpayers, should be viewed by hospitals and providers in such a way that hospitals and providers go out of their way to address the patients’ experience. As medicare providers, we tend to hold an attitude that great patient service is nice, but not necessary. Unless the system gets designed to motivate behaviours that put patient service first, we will never treat patients as well as they deserve.

  • Scott Kapoor says:

    The problem with focusing on customer experience is we may continue and emphasize what patients want, not what they need. I had a recent experience in the hospital, where a patient’s family member demanded that their relative be admitted to hospital, even though there was no clinical and personal support indication to do so. I had another patient who demanded a CT scan, when it was not indicated and would have caused more harm than good. We all know of cases where the clinical information does match the surprising positive result of the test, and therefore, validates doing the test. But these cases were gross misuse of resources where there was a clear non-indication. These demands increase utilization, which is something physicians, government and hospitals can control, but have been unwilling to do for various political reasons. That admission to hospital can be done and that CT scan can be done, but not on the taxpayer dime. The measure of patient experience is HOW these demands were handled, but the temptation will be strong to acquiesce to patient demands rather than reject tests not clinically indicated. In a fast fee-for-service environment, it would be quicker to do the test or admit, rather than spend the time discussing, or later deal with a complaint. In summary, focusing on patient experience will increase unnecessary utilization of taxpayer resources. Patient experience can be tended to, but the non-clinically indicated tests or admissions for the people who speak the loudest should not be borne by taxpayers. But government will dare not touch the issue of paying for certain tests, as it may their own political future.

    • Shawn Whatley says:

      Thanks so much for commenting, Scott.

      No question, we all find it frustrating when patients insist on getting things we don’t feel are necessary in the emergency department. Their insistence has many layers: fear of missing something, fear because something was missed before, insecurity, or old-fashioned entitlement (to mention a few).

      I’m certain that all service industries get demands they cannot meet from people they find tough to handle. How do they manage? Do they send them away? What if they can’t give them what’s being demanded? We assume that great service happens easily in commercial settings because customers just have to spend more to be happy. I think it’s the opposite. I suspect patients are more predisposed to be grateful for medical care, and yet, we don’t seem to regard great patient service very highly as a system.

      We have too much emphasis on dictating what patients need, instead of focussing on meeting patients’ felt needs.

      Thanks again!

  • Sue Robins says:

    Interesting analogy! Funding incentives are crucial, and as a family rep, from the system perspective, I’d love to see transparency in the sharing of patient experience results from individual hospitals, and incentives for patient engagement through the strong encouragement of Patient/Family Councils at the local hospital level (there are many councils already set up in the pediatric health world in Canada).

    Locally, a patient-centred care approach should be taught starting at our university’s health faculties, be embedded in hospital hiring and evaluation processes, and be offered at orientation for ALL staff (not just clinicians) – ironically, including the folks who serve Starbucks coffee in our hospitals’ lobbies…

    %featured%As a lay-person, I never understood why our health care system is funded based on how sick people are, rather than by keeping them well.%featured%

    • Shawn Whatley says:

      Thanks for commenting, Sue! I agree, we need training to support a renewed focus on patient experience. Patient satisfaction surveys are public, but there’s opportunity to engage the public much more in designing health services.

  • Leslee Thompson, President & CEO KGH says:

    Bravo! Well said and I agree completely however this does not apply only to hospitals. %featured%Hospitals are but one stop ( albeit an expensive one) in people’s interaction with the health care system. Patient based funding was designed to have money follow the patient across the continuum of care. Now that the financial building blocks of funding reform are being put in place, we have to build out the quality and patient experience dimensions in a deliberate and transparent way.%featured% The voices and perspectives of patients, as well as clinicians and managers need to come together to help shape this next stage of funding reform a positive and productive way. The Ministry can not do this alone.



Shawn Whatley


Shawn Whatley is an emergency physician at a large, suburban emergency medicine program. He blogs about improving patient experience at http://shawnwhatley.com/.   He does not speak for any organizations he works for currently or in the past.

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