Carl Denham was hospitalized at Rowan Regional Medical Center in North Carolina in December. Denham, seen with his daughter Benicia, said his second visit to the hospital was much better than his first one two years before.

Carl Denham was hospitalized at Rowan Regional Medical Center in North Carolina in December. Denham, seen with his daughter Benicia, said his second visit to the hospital was much better than his first one two years before.

Michael Tomsic/WFAE

Lillie Robinson came to Rowan Medical Center for surgery on her left foot. She expected to be in and out in a day, returning weeks later to the Salisbury, N.C., hospital for her surgeon to operate on the other foot.

But that's not how things turned out. "When I got here I found out he was doing both," she said. "We didn't realize that until they started medicating me for the procedure." Robinson signed a consent form and the operation went fine, but she was in the hospital far longer than she'd expected to be.

"I wasn't prepared for that," she said.

Disappointed patients such as Robinson are a persistent problem for Rowan, a hospital with some of the lowest levels of patient satisfaction in the country. In surveys sent to patients after they leave, Rowan's patients are less likely than those at most hospitals to say that they always received help promptly and that their pain was controlled well. Rowan's patients say they would recommend the hospital far less often than patients elsewhere.

Feedback from patients like Robinson matters to Rowan and to hospitals across the country. Since Medicare began requiring hospitals to collect information about patient satisfaction and report it to the government in 2007, these patient surveys have grown in influence. For the past three years, the federal government has considered survey results when setting pay levels for hospitals. Some private insurers do as well.

In April, the government will begin boiling down patient feedback into a five-star rating. Federal officials say they hope that will make it easier for consumers to digest the information now available on Medicare's Hospital Compare website. The hospital industry says judging a hospital on a one-to-five scale is too simplistic.

Nationally, hospitals have improved in all the areas the surveys track, including how clean and quiet their rooms are and how well doctors and nurses communicate . But hundreds of hospitals have not made headway in boosting their ratings, federal records show.

"For the most part, the organizations that are doing really wonderfully now were doing well five years ago," said Deirdre Mylod, an executive for Press Ganey, a company that conducts the surveys for many hospitals. "The high performers tend to continue to be the high performers and the low performers tend to be low performers."

Some hospitals have made great gains. The University of Missouri Health System created a live simulation center at its medical school in Columbia to help doctors learn to communicate better with patients. The simulations use paid actors. Instead of having to diagnose the patient, doctors must respond to nonmedical issues, such as a feuding teenager and mother or a patient angry that he was not given information about his condition quickly enough.

"My scenario was I was late to the appointment and the patient's husband was upset," said Kristin Hahn-Cover, a physician at Missouri's University Hospital. In 2013, the most recent year that the government has provided data for, 78 percent of patients at University Hospital said doctors always communicated well, a 10 percentage-point jump from 2007. Other scores rose even more.

Nudging up scores has been a frustrating endeavor elsewhere, such as at Novant Health, a nonprofit hospital system that runs Rowan Medical Center and 13 other hospitals in North Carolina, South Carolina and Virginia. While some Novant hospitals have excellent patient reviews, Rowan's scores have remained stubbornly low since Novant took over the hospital in 2008.

Last fall, Rowan's president, Dari Caldwell, replaced the physician group that ran the emergency room because the doctors had not reduced wait times. ER waits are down to half an hour, a spokeswoman said. Doctors and nurses also are being coached on their bedside manner, like being advised not to stare at their computer when a patient is talking.

Rowan's nurses now spend 70 percent of their time with patients, swinging by every hour. Even the president makes rounds once a day. The hospital has made lots of small improvements to provide a warmer environment, such as putting white poster boards in each room where nurses can list a few personal details about their patients.

"I can go in there and say 'Oh, you have three dogs' or 'You have a grandchild, that's great, great,'" said Jennifer Payne, a nurse manager. "And they can talk for hours about that."

Patient perceptions have been tough to change at Rowan Regional Medical Center in Salisbury, N.C.

Patient perceptions have been tough to change at Rowan Regional Medical Center in Salisbury, N.C.

Joanna Serah/Wikimedia

Payne said she pores over patient comments and surveys, passing around the good ones and tackling complaints. "We're very driven by what these patients say," she said. "Everything I do is based around how these patients come back [in comments in the surveys] and say, 'Hey, is this working?' or 'This isn't working.'"

Rowan executives fear scores may not be going up because patients still harbor bad memories from previous hospitalizations.

"I was treated like a dog," Carl Denham, 76, said about a stay two years ago. He said the hospital was doing loud construction work that kept him awake, and it took nurses all day to deliver an oxygen tank his doctor ordered.

Admitted again in Rowan in December, Denham said that visit was different. "It is fantastic from what it used to be if you want my opinion," he said as he lay in his hospital bed a few days after he came back. "I've been both ways and the way it is now, it is great. No waiting and the doctors are all pleasant. I never thought I'd see it like this." He said he would give the hospital top marks.

His daughter Benicia said that in the last visit she had to nag the nurses to get her dad his medication. This time, it has not been an issue. "It's like a totally different hospital," she said. "I had to say, 'Did I come to Rowan Regional?'"

Despite the unexpected operation on both feet, Robinson also said nurses have been attentive to her pain. "They do the best they can," she said. "At times it gets so bad I'm crying because it's overwhelming to me."

But "the best they can" is not good enough for Medicare. In determining how much to pay hospitals, the government only gives credit when patients says they "always" got the care they wanted during their stay, such as their pain was "always" well-controlled. If a patient says that level of care was "usually" provided, it does not count at all. Likewise, the surveys ask patients to rank their stays on a scale of 0 to 10; Medicare only pays attention to how many patients award the hospital a 9 or 10.

"Sometimes what we see and hear from our patients doesn't show up on their surveys," Caldwell said.

Copyright 2015 Kaiser Health News. To see more, visit



Hospitals can no longer afford unhappy customers because bad patient reviews can mean lower pay from the federal government, which is why when the long waits at Rowan Medical Center's emergency room weren't getting any shorter, the hospital replaced all the doctors in charge. Jordan Rau visited the hospital in Salisbury, N.C., which is trying to make its patients happier.

JORDAN RAU, BYLINE: Rowan Medical Center has some of the worst patient reviews in the country. Experiences like the one Lillie Robinson had don't help.

LILLIE ROBINSON: When I came in Wednesday for my surgery, I thought I was just having one foot done. And when I got here, I found out that he was doing both. I signed the consent, but even the nurse in pre-op, she didn't realize that he had wrote it for both until the anesthesiologist came in and started asking questions. And that's when she read further down into the paperwork and she said, yeah honey, it is for both.

RAU: Instead of being in and out the same day, she's got to lie in a hospital bed for weeks, just watching TV and in pain.

ROBINSON: They do the best they can. At times, it gets so bad I'm crying because it's overwhelming to me.

RAU: But the best they can isn't good enough for Medicare. The federal government only gives credit when a patient says an aspect of their hospital stay, like pain control, was always good - usually doesn't count. Novant Health runs Rowan and is looking everywhere for improvements. Jill Rabon is the head of guest services.

JILL RABON: For example, down in our emergency department, we recently have added murals for a positive distraction is what we say because a lot of times people will have extended waits down in the emergency department and there wasn't anything to for them to do besides read magazines, you know, and that causes unnecessary anxiety and stress as they're waiting.

RAU: Rowan has also asked some of its patients for ideas.

RABON: And they said, well, you know, it'd be better if you moved the chairs here so that we could see the mural better.

RAU: Once patients are admitted, there are more substantial changes. Nurses swing by each room every hour, and even the hospital president makes rounds once a day. Doctors and nurses are being coached on their bedside manner, like not staring at their computer when a patient is talking. Nurse Jennifer Payne especially likes the poster boards on the walls, where nurses write a few personal details about their patients.

JENNIFER PAYNE: I can go in there and say, oh, you have three dogs and you have a grandchild. That's a great, great - and they can talk for hours about that.

RAU: The hospital says this is all working. ER waits are down to half an hour and the nurses are spending 70 percent of their time with patients. But Rowan's satisfaction scores aren't going up. The hospital says that may be because bad memories linger.

CARL DENHAM: I was treated like a dog.

RAU: Carl Denham is 76, and like a lot of people in Salisbury, he's been coming here since he was a kid. He says his last visit, about two years ago, was dreadful.

DENHAM: At 5 o'clock in the morning, they come in doing construction work, knocking the walls out. The doctor ordered the oxygen, you know? Well, they kept me just sitting out all day long with the oxygen.

RAU: He says this time has been very different, starting with the ER.

DENHAM: It's fantastic from what it used to be if you want my opinion. I've been both ways, and the way it is now it's great. No waiting and there's doctors and they're all pleasant. I never thought I'd see it like this.

RAU: But Rowan can't figure out why patients aren't so enthusiastic when they fill out their surveys a few weeks later. Rowan scores poorly on questions like was it noisy at night, and how well did your doctors and nurses communicate. This year, Rowan's losing $29,000 for Medicare. That's not a huge amount, but if Rowan doesn't get better, next year it could be a lot more. For NPR News, I'm Jordan Rau.

MONTAGNE: And Jordan Rau is with our partner Kaiser Health News. Visit NPR's Shots blog to find out how your local hospital rates. It's NPR News. Transcript provided by NPR, Copyright NPR.

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