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The Kano Model
The Kano Model provides a useful tool for studying different levels of patient expectations (23).
This model is useful to examine the voice of the customer in the relationship between satisfaction and quality, and it is relevant for hospital encounters. According to the model, patients will have a basic set of subconscious expectations about their care that will be taken for granted. These expectations are so routine and expected that patients don’t recognize them as comparative quality factors, but they will be shocked if they are absent. For example, patients assume that physicians are basically competent, and that hospitals are capable of providing safe, courteous, lifesaving medical care (25). Although these expectations are in the patient’s subconscious, if they are not met, the patient will be dissatisfied. Providing this level of basic quality isn’t necessarily enough to create satisfied patients.
There is a normal level of service that patients consciously consider, they have to do with the anticipated issues of hospital care related to access, wait times, scheduling, and billing. The model shows that satisfaction increases as more of these expectations are met and that patients will be dissatisfied if these quality expectations are not met. Patients use comparisons of these expectations to recognize differences among competitors and to make choices.
The latent quality curve lies entirely in the satisfaction region and represents supraconscious, unexpected quality items that patients didn’t know they wanted and result in a delightful surprise when present. In this experience, patients receive more than they had expected, often as the result of innovation that can raise patient expectations and provide a significant competitive advantage. The data from hospitals show that this is achieved primarily through the patient’s perception of personalized, customized service, provided by caring and concerned clinicians (26).
There is a tremendous opportunity in hospital care to modify patient expectations through education and to create high levels of patient satisfaction. Hospitals that are successful in this endeavor will have a significant competitive advantage. Hospital patients have a whole list of issues about which they have expectations: the smoothness of the admission and discharge process, accuracy and clarity of billing statements, courtesy of hospital employees, response time for calls and requests, the level of technology available in the hospital, nurse competency, taste and temperature of the food, and price. Most of these issues are not directly related to clinical care and certainly not under the control or influence of the hospitalist. What are the expectations that patients have for their clinical care by hospitalists, and how can we give it to them?
The Hospitalist as a Caring and Concerned Clinician
A useful model to define the hospitalist’s role in patient satisfaction is that of a caring and concerned clinician. This caring and concern for patients is exemplified by attentiveness, dignity and respect, effective information transfer, and shared decision making (23).
The outcome service chain for hospitals begins with the patient’s perception of caring and concerned clinicians who demonstrate these attributes of attentiveness, dignity and respect, effective information transfer, and shared decision making. This leads to the degree of patient satisfaction and loyalty that results in patients who will return to the hospital, seek related business, and refer additional business. This drives market share and financial success for hospitals (9).
The characteristics of the caring and concerned clinician begin with attentiveness. This is the practice of establishing a person-to-person connection with patients and involves attending to them as unique individuals and not just in their role as patients. The constant interruptions that occur in physician/patient encounters, control issues, discontinuity of care, and the often overwhelming complexity of a patient’s illness can be obstacles to the perception of attentiveness that result in patients feeling connected with the clinician. Some effective tools for attentiveness are demonstrating curiosity about the patient as a person, using open-ended questions to gather clinical data, orienting patients to the process of care, and actively eliciting a patient’s agenda for their care and then summarizing their concerns.