Keywords

Background

Satisfaction is the fulfillment of one’s wishes, expectations, or needs, or the pleasure derived from this. It can be viewed as a measure of how happy a person is with a given situation, which is often difficult to gauge during daily interactions with people. This is even more difficult to decipher as a surgeon interacting with a patient, perhaps one you are meeting for the first time. Many of us have been surprised to hear that a patient complained about their care after we interacted with them seemingly without incident. Therefore, a number of standardized tools have been developed to examine how satisfied patients are with their care. The data obtained can be harnessed to change our practice and shore up deficiencies to improve patient care and satisfaction .

Patient satisfaction is a quantitative measure of how patient experience as they progress through the care process compares with their expectations. This differs from other commonly used metrics. Patient-reported outcome measures (PROMs) are any report of the status of a patients’ health condition or health behavior that comes directly from a patient without interpretation by a clinician. This includes tools that measure health-related quality of life and symptoms. Patient-centered care is described as safe, effective, timely, efficient, and equitable care. Patient experience encompasses the cumulative evaluation of the patient with the healthcare system and providers; with particular focus on relationships, trust, and peace of mind.

History of Patient Satisfaction

In 1999, the Institute of Medicine published “To Err is Human: Building a Safer Health System,” which described thousands of deaths due to medical errors in the United States [1]. While the healthcare quality improvement movement started years earlier, the safety of medical care was not publicly scrutinized until the publication of this report. Healthcare organizations , insurers, government organizations, and accrediting groups responded with interventions to improve safety and quality of care in the United States, which included a focus on involving patients in their care. In 2002, the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) joined forces to develop the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey [2]. The main objectives of the HCAHPS survey were to allow consumers to objectively compare hospitals, motivate hospitals to improve quality of care, and increase transparency through public reporting of survey results. The psychometric properties of the survey were validated and the HCAHPS survey was endorsed by the National Quality Forum (NQF) in 2005.

Hospital has placed added focus on improving HCAHPS scores as patient satisfaction is now tied to Medicare reimbursement. HCAHPS scores fulfill the Patient and Caregiver Experience of Care/Care Coordination domain that comprises 25% of the Total Performance Score in the CMS Hospital Value-Based Purchasing program. Importantly, patient feedback can lead to improvements in care delivery and better outcomes. Patients who are satisfied with their care will return themselves and recommend the hospital or physician to friends and family. Patients can now reach a large number of people very quickly using social media and online platforms and, as a result, they are increasingly being considered as customers.

Measurement Tools

The HCAHPS survey, like other standardized patient satisfaction questionnaires, attempts to quantify subjective opinion based on evaluation at multiple patient touch points [3]. The survey consists of 32 questions administered to a random sample of adult patients discharged from medical, surgical, or obstetric services. The survey includes global questions about overall rating of the hospital and willingness to recommend the hospital on a scale of 0–10. The remainder of the questions, each with 4 multiple choice answers, asks about interactions and communications with physicians and nurses, ease of access such as appointment scheduling, responsiveness of hospital staff, pain management , communication about medicines, discharge instructions, and environmental factors such as cleanliness of the facility. Each question like “During this hospital stay, how often did doctors listen carefully to you” has these possible responses: never, sometimes, usually, and always. “Top box” scores indicate the percentage of patients who chose the most favorable answer for each question. For the “doctors listen carefully to you” question above, the “top box” score would be the percentage of patients who responded “always.” The results of the survey are adjusted based on patient case mix and are reported quarterly by CMS. The Hospital Compare website (www.medicare.gov/hospitalcompare) administered by CMS, publicly reports hospital-specific scores and compares scores across hospitals [4].

Patient voices can be captured by other mechanisms including patient councils and representatives, consumer apps, social media , and online reviews or patient communities. Popular social media and online outlets include: Facebook , LinkedIn, YouTube, Twitter , Instagram , Angie’s List, Yelp!, SnapChat, as well as various blogs and websites. Hospitals and physicians are using social media more commonly to increase brand awareness and loyalty and to educate patients and the community. A consistent social media presence with valuable information and reputable followers reinforces to patients that their provider is an expert in the field and helps providers build a positive reputation. Many patients use the internet and social media to find hospitals and providers. Researchers have examined patient postings on social media groups to evaluate patient satisfaction with specific procedures. The use of online tools has the potential to improve communication between patients and their doctors and improve access to, and satisfaction with, care. While teenagers and 20-year-olds have historically made up the majority of social media communities, today your 80-year-old bladder cancer patient is likely engaging on social media , which can be an important venue to share information, engage patients, and perhaps improve patient satisfaction .

What Correlates with High Satisfaction?

As patient satisfaction is studied more, we are learning about how institutional, process measures, and provider characteristics influence satisfaction scores [2]. Figure 8.1 summarizes many factors that have been found to be associated with high patient satisfaction . An institutional culture of safety encourages reporting patient safety events and focuses on providing safe, quality care by high performing teams. Patient satisfaction has been shown to correlate with a focus on safety, staffing, teamwork, organizational learning, timely communication of errors, and nonpunitive response to error.

Fig. 8.1
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Predictors of patient satisfaction

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Provider characteristics, interpersonal skills, and care team collaboration that is evident to the patient and family can all influence patient satisfaction . Patient satisfaction is enhanced when patients and their families feel that all health team members treat them with dignity and respect, make them a priority, and listen to their concerns. Both physician and nursing burnout has been found to be inversely associated with satisfaction scores, highlighting the need to care for our staff in order to optimize patient care. When patients and families feel there is a caring team of physicians and staff who are communicating and working well together to provide patient-centered care, they are more likely to be satisfied.

Process and quality measures have been studied in relation to patient satisfaction , specifically the Hospital Quality Alliance (HQA) measures and the Healthcare Effectiveness Data and Information Set (HEDIS). HQA measures evaluate compliance with best practices for acute myocardial infarction, heart failure, and pneumonia. HEDIS measures monitor primary and secondary prevention and mental health care. Multiple studies have identified a positive correlation between HQA disease-specific process measures and patient satisfaction scores on the HCAHPS survey. A study of the HEDIS measures found higher patient satisfaction in numerous domains correlated with HEDIS process measure compliance.

While HCAHPS survey results have been extensively studied, less is known about predictors of satisfaction in the surgical patient population. An evaluation of >370,000 patients undergoing a major extirpative cancer surgery [5] found modest, but statistically significant correlations between high satisfaction on the HCAHPS survey and low complication rates (p < 0.001), readmissions (p < 0.001), and mortality (p < 0.001). A study of adult surgical patients requiring an overnight admission at a single academic institution [6] found that 72% of patients provided “top box” scores for overall physician satisfaction based on the Consumer Assessment of Healthcare Providers and Systems Surgical Care (S-CAHPS) survey, which focuses on patient satisfaction with surgeons, anesthesiologists, surgical staff, and surgical care. Independent predictors of “top box” responses on the S-CAHPS survey included preoperative communication (OR 6.8, 95% CI 2.9–16.1) and day of surgery attentiveness (OR 5.4, 95% CI 2.2–13.4). A study of >46,000 surgical patients with genitourinary cancer [7] did not find an association between high satisfaction on the HCAHPS survey and death, disposition status, medical complications, or surgical complications. The authors did note that patients satisfaction was decreased with prolonged hospital stay (OR 0.77, 95% CI 0.64–0.92) and nursing-sensitive complications (OR 0.85, 95% CI 0.72–0.99), which included venous thromboembolism, mobility-related events, and sepsis. More work is needed to better delineate what influences patient satisfaction for patients undergoing surgery.

How to Improve Satisfaction Scores

The white paper by the Institute for Healthcare Improvement (IHI) on Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care is an excellent resource for administrators, physicians, and staff seeking to learn more about how to improve patient satisfaction [8]. Providers should be open to receiving patient satisfaction information in a variety of forms and should not write off certain sources, as any information about what patients think is helpful. This may include HCAHPS data, other standardized surveys, online patient reviews, patient reported outcomes , or patient comments on social media .

Patients put their trust in their surgeons at an incredibly vulnerable time and, therefore, they are looking for compassionate care that addresses their physical and emotional needs. Patients present with a wide variation in healthcare literacy, however, even the most educated patients may have trouble processing and synthesizing information during a stressful time. Flexible teaching techniques and tools (visual aids, analogies, handouts, videos, web links) should be utilized to adapt to how individual patients learn best. Physicians come to the clinic visit with an “agenda”—we want to obtain information, examine the patient, and present our surgical plan. While patients may have a different set of expectations. Therefore, physicians need to listen to patient (and family) concerns and expectations to fully engage in a clinical care relationship based on shared understanding and decision-making. When physicians are not attentive or are constantly interrupting a patient, the patient does not feel listened to. Consequently, trust is not built and the critical personal connection with the patient cannot be established creating an obstacle to optimal care. Conversely, when patients and families are treated with respect and empathy, they will trust the healthcare team and be more engaged in their own care. Patients and families can be engaged in their own care with shared decision-making, being encouraged to ask questions and participate as much as they would like in their own care, thereby collaborating to develop common goals and treatment plans. Improving satisfaction isn’t about being nice or giving patients everything they want, it is about taking the time to listen, communicate, and partner with patients and families for the best outcomes. Therefore, avoiding topics such as weight loss or smoking cessation or prescribing unnecessary medications such as antibiotics or pain medications, in an effort to please patient is not only ill-advised, it is unethical. Physicians have a duty to discuss sensitive matters respectfully with their patients using clear language and teaching aids to ensure understanding. For example, if weight loss is important to reduce surgical complications, take time to explain that. Physicians can specifically explain why a lifestyle modification is important for the patient’s surgical care. For example, excessive abdominal weight pushes on the diaphragm leaving less room for the lung to expand and leading to greater risk of postoperative atelectasis and pneumonia. Be realistic when giving specific expectations to patients and be encouraging of their effort while avoiding the tendency to show disappointment when they are unable to reach goals such as weight loss or smoking cessation.

Communication is especially important for surgical patients who need to adequately understand the risks and benefits of a surgical procedure as part of the informed consent process and to have appropriate expectations of the potential outcomes. Some specific examples where communication and shared decision-making is key in urologic surgery include setting expectations for patients with incontinence secondary to pelvic floor weakness, deciding when to obtain and how to act on PSA results, and discussing the risk associated with specific procedures such as risk of incontinence and erectile dysfunction after prostatectomy. Medical errors should be immediately disclosed and apologized for, because patients deserve honesty from the surgeon in whom they placed their trust. In addition to having clear, open communication with patients, physicians need to communicate well with the entire health care team. Patients may tell a medical student, resident, MA, or RN things they don’t want to “bother” their surgeon with. If you have a good relationship with your clinical team and make it clear that you want to hear their thoughts, you may learn information from your team that patients are hesitant to share with you. Patients can tell when care is well coordinated, thus it is important to do your part to ensure that by referring to your discussions with other team members, mentioning what a consultant told the patients or what a night nurse had written in his or her report. Patients and families cannot tell if your anastomosis was sewn perfectly, but they can tell if your communication with the cardiology consultant is poor or if nursing staff does not know the plan for the day. When HCFA began reporting hospital mortality data more than two decades ago hospitals with clearly higher mortalities saw no significant decrease in their patient volumes, suggesting that patients, in general, make their decisions based on personal values of the service they receive not the objective technical quality of care. It is very important to establish a connection when examining a patient by making eye contact, calling them by name, expressing kindness with words and gestures, and considering the whole person not just their illness. Attention to their privacy, dignity, and responding appropriately to their concerns are crucial to ensuring a good patient experience.

Good communication with the care team can also improve employee satisfaction and thereby improve patient satisfaction . Having satisfied nurses improves patient satisfaction scores. Creating a healthy work environment for staff enables the recruitment and retention of staff with values that will ensure patient-centered, high-quality care . As a physician, you can influence working conditions and create joy in the workplace by making sure staff have the resources and skill they need to provide quality care , acknowledging good work and successes, and rewarding staff who go above and beyond for patients.

Patients want to know they will receive high quality, reliable care. This includes the ability to schedule appointments in a timely manner, staff that are available and responsive, and limited wait times for appointments, getting questions answered, and obtaining results. The hospital environment should also support healing with accessible parking or valet services and quiet comfortable patient waiting and care areas. A supportive environment decreases stress and improves the overall patient experience, which leads to greater patient satisfaction as it is impossible to separate patient satisfaction from other elements of care. Patients and families are looking at all aspect of care from the hospital environment, ease of use, perceived quality of care, and the relationships with the healthcare team, and among members of that team. As demonstrated in Fig. 8.2, service is only as good as the weakest link in the chain; therefore, physicians need to pay close attention to supporting and training all team members. They should aim to hire competent people who are willing to learn and can follow agreed upon standards. Exam rooms need to be clean with comfortable furniture to seat patients and accommodate family members or friends.

Fig. 8.2
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Patient satisfaction is intertwined with other elements of care

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Future of Patient Satisfaction

In addition to measuring and responding to patient satisfaction , healthcare organizations and physicians will need to evaluate drivers of patient satisfaction including patient-centered care, employee engagement, patient education , reliability, and coordination of care. Hospitals can learn from high performing industries such as aviation, manufacturing, construction, and finance to improve patient safety and reliability. They can also learn how to optimize patient experience from service industry leaders such as Disney, where the pervasive culture is focused on the guest experience.

While incorporating patient satisfaction scores into hospital reimbursement schema has placed an added emphasis on patient satisfaction , other measures of patient-centered care such as PROMs are likely to play an important role in the future. PROMs measure procedure-specific outcomes that are important to patients and providers, as opposed to overall satisfaction measure used in other surveys. Therefore, PROMs provide a more granular view of the patient’s physical, emotional, and psychosocial responses to treatment. New regulation and demands by patient and payers are likely to increased transparency in reporting of all outcomes allowing consumers to compare hospitals and leading to more focus by providers and hospitals on efforts improve outcomes and patient experience.

In order to make a measurable difference in patient satisfaction , the organization and providers have to genuinely want to provide high-quality, patient-centered care. If the focus is solely on raising satisfaction scores or reimbursement, it will be difficult to change the institutional culture and patient satisfaction scores. The most reliable way to produce highly satisfied patients and families is with a pervasive culture of quality and safety, sincere efforts to engage patients and families, and providing the care in an environment that we would want for our own family. The majority of adults are now using social media and this is not limited to the young, as a third of seniors are now using Facebook . There are ample venues to share experiences at this time from Twitter to Yelp! to SnapChat to blogs and Facebook posts. While these tools may not have a direct relationship with objective data of care quality, or even with the results of standard surveys such as HCAHPS, hospitals and physicians are paying greater attention to online postings and seeking help from media experts to monitor and respond to patient comments. Soon the days of post discharge surveys will be in the distant past and patients will be able to express their opinions on ongoing basis using handheld devices, apps, or computers to provide feedback to physicians and their team. Physicians will receive the data in real time, giving them the opportunity to respond to patient concerns as they arise. The collective timely feedback from patients in a hospital, if appropriately monitored, can be a very useful barometer to gauge how well a given unit is doing in meeting patients’ needs and where help needs to be dispatched to attend to any deficiency. This will no doubt allow for greater participation of patients and their family in their care and should further improve patient satisfaction with the care they receive.

  • Ways to improve patient satisfaction

    • Compassionate care

    • Culture of patient-centered care

    • Clear, open communication

    • Shared decision-making

    • Team work amongst multi-disciplinary team

    • Supportive and comfortable hospital environment