Customer satisfaction versus patient safety: have we lost our way?

The maturing science of the causes and consequences of boarding of admitted patients demonstrates unequivocally the dangers the patient may face when entering a crowded emergency department (ED). 1 Even the demonstration of increased mortality rates associated with crowding 2,3 has not compelled the hospital industry as a whole to implement policies and procedures to ameliorate crowding. However, a Trojan horse, patient satisfaction scores, might provide a call to action where literature of greater desperation has failed. It is in this spirit that Garson et al 4 examine patient preferences for boarding locations when hospitals are at full capacity. Specific details of the study are crucial to understanding the seemingly modest results. First, 90% of the patients included in the survey were boarded in rooms in the ED, rather than an ED hallway. Second, no patients at this institution are actually boarded in hallways on inpatient units. Thus, few patients in the survey had firsthand experience of “in-hallway boarding” to make their choice more meaningful. Despite this, a modest preference for inpatient boarding still existed. In this study, 36% of patients had no preference, and those expressing a preference favored inpatient versus ED hallway placement at a preference split of 60%/40%. Were the right questions being asked? The patients received no context for the question. Survey results are heavily influenced by the presence or absence of contextual information. For instance, the question “Would you object to a 5% tax increase?” might get a very different response than “Would you object to a 5% tax increase if, in return, your family received a free education, free health care, a free retirement fund, a free house, and a free car?” Our experience with patient preference is quite different. 5