Making the Grade
More hospitals turn to patient satisfaction surveys, using them as "report cards" to identify strengths and weaknesses—and implement improvements in health care

By John Leighty
December 22, 2003

Keni Horiuchi, MSN, RN, is the leader of a pain management team whose quick interventions at the bedside helped boost patient satisfaction rates at North Bay Healthcare System in Fairfield, Calif.

Patient satisfaction data pinpointed pain management as an area for improvement at the nonprofit health system, and the nursing team started by Horiuchi five years ago has helped the hospital achieve dramatically better results.

"Pain management is very important. It affects the entire patient experience," said Horiuchi, a clinical nurse specialist in oncology.

The pain team now consists of five specially trained nurses who can be called to the bedside for rapid intervention and 20 to 30 more RNs are scheduled to go through the program soon, Horiuchi said.

"These are nurses who can advocate for the patient and recommend what needs to be done," Horiuchi said. "They can assess a problem and call the doctor with what's going on."

Horiuchi said a common question on patient satisfactions surveys is: Were you asked about pain? "Patients now answer 'yes,' but it wasn't always that way."

The health system, which includes two hospitals and a hospice, scored high marks in the 2003 Patients' Evaluation of Performance in California (PEP-C) project, the largest publicly reported and most comprehensive hospital patient survey of its kind in the nation. Even with high scores, the survey offers clues as to where improvements can be made, according to Kathy Richerson, MS, RN, vice president of patient care and chief nursing officer.

North Bay was one of 181 California hospitals that volunteered to participate in the PEP-C survey, Richerson said, because the methodology used by National Research Corp./Picker provides scores that can reveal problem areas. "The NRC survey shows where we can place our efforts to affect patient satisfaction the most," she said.

The pain management program included an educational outreach to the system's 400 nurses, Richerson said, and resulted in effective changes that went beyond just providing drugs and medications. For example, changes were made in how care was documented to show what therapies were most effective. A noise reduction program also was implemented.

"The high scores in PEP-C show real evidence that the time put in was worthwhile," Richerson said.

The PEP-C survey, Richerson said, also enables participants to compare results and to take part in conference calls to discuss overall outcomes and trends and to share solutions with other hospitals. Data from the survey also are shared with nurses during recruitment and orientation because patient satisfaction is a key indicator of a quality working environment, she said.

Marsha Nelson, RN, helped develop and launch PEP-C. The California survey results, she said, provide nurses with insight to a hospital's culture, morale and how employees are treated.

"Studies show a direct correlation between employee satisfaction and patient satisfaction," said Nelson, vice president of the California Institute for Health Systems Performance.

"[Fewer] problems with care make a hospital a more favorable place to work."

Measure for measure

Nationally, several health care consulting groups rate hospitals on patient satisfaction measures and other quality of care issues, including patient safety and clinical outcomes. Many hospitals hire the consulting firms to do a private survey to see how they match up against certain benchmarks as well as other facilities.

For example, Stanford Hospital and Clinics in Palo Alto, Calif., recently adopted the patient satisfaction tools of Lincoln, Neb.-based NRC/Picker in an effort to use patient feedback to improve operations and service.

Stanford Hospital has been conducting patient satisfaction surveys for years-but the NRC/Picker approach is a better, more scientific way to obtain that information, said Nick Gaich, vice president of material management and customer service.

"Our old survey was basically a rating tool-it told you if you were bad or good, but it didn't tell you why," Gaich said. "Now, we're asking our patients about specific activities and behaviors we can measure and act on."

Instead of asking patients to rate the hospital's service as "excellent," "good," "fair" or "poor," the Picker survey asks about specific behaviors, such as "How many minutes did you usually wait before your call button was answered?" "Did a doctor or nurse tell you accurately how you would feel after the surgery?" or "Did staff talk in front of you as if you weren't there?"

One section of the survey focuses on physicians, with questions such as "Did you have confidence in the doctors treating you?" and "When you had important questions to ask a doctor, did you get answers you could understand?"

Strength in numbers

At Huntington Hospital in Southern California, Press Ganey Associates of South Bend, Ind., provides the "report card" on patient satisfaction.

Press Ganey also did a survey of 906,902 patients in 34 states that showed the nursing shortage has an effect on patient satisfaction. The study, released in May, said the higher the ratio between working registered nurses and residents in any given state, the higher the rate of patient satisfaction with the quality of nursing care.

Bonny Ciribassi, RN, said Huntington Hospital has used the Press Ganey surveys to focus on specific issues revolving around patient satisfaction. The hospital took part in the 2003 PEP-C survey as a means of comparing results and earned the highest mark of three stars.

"PEP-C was really a validation tool and told us pretty much the same thing as the Press Ganey surveys," said Ciribassi, vice president of patient care services at Huntington. "It validated what we already know about patient care and was a good validation for the staff as well."

One problem the Press Ganey surveys revealed was solved by a task force that included nurses and involved improving patient flow in the emergency department. Waiting times were shortened and procedures were revised to get blood tests back more quickly to patients. Also, better communication with patients on how long they might have to wait for an X-ray or other tests was established.

"We did a lot of customer service training, including role playing for certain situations. It really brought up our scores dramatically in the patient satisfaction surveys," Ciribassi said. "Nursing satisfaction also went up when we did the redesign around patient flow because we concentrated on many of the things nurses found frustrating. We've since improved patient flow throughout the hospital."

Hospitals now taking part in patient satisfaction surveys will be better prepared to meet a standardized approach to obtaining data for a national survey being launched by the federal government in 2004. The results will be publicly reported by the federal Centers for Medicare & Medicaid Services, which decided Nov. 4 to make the survey voluntary rather than mandatory. Still, about 3,000 hospitals say they'll participate in the ratings, and indications show that hospitals' Medicare funding may be linked to these performance measures.

Michael Hays, president and CEO of NRC/Picker, said the issue isn't whether the government survey is mandatory or voluntary. "The important thing is the percentage of hospitals that step up to the plate and get involved in public reporting," Hays said.

Patient satisfaction scores, Hays said, don't necessarily correlate to hospitals that achieve Magnet status or are put on the Top 100 lists because a lot of those ratings are based on clinical outcome measures. Consumers need the information that patients provide on their hospital experiences.

Rick Blizzard, managing research director with the Gallup Organization, said future surveys would benefit from looking at the link between patient measures and clinical outcomes, but added that the stumbling block is the confidentiality of patient records. "This creates a significant barrier to useful research in this area," Blizzard said.

At the Cleveland Clinic, nursing units display color-coded charts that show how they're performing on patient satisfaction measures. Green signifies that certain targets are met, while red is a caution flag that shows improvements are needed.

Customer service

Such attention to patient satisfaction and other quality care measures won the hospital system Magnet status in June, and also got the clinic a "Consumer's Choice" award. It was also in the "top five" category for U.S. News & World Report's 100 Best Hospitals in America.

"Listening to the voice of the patient is a strong motivator in moving us forward," said Linda Lewicki, Ph.D., RN, senior nurse researcher for the Cleveland Clinic. Lewicki said the NRC/Picker patient satisfaction surveys allow the clinic to compare itself to national benchmarks and compare units within the hospital. Nursing questions have been the key factor in identifying weaknesses and strengthening the patient care program, she said.

"We also looked at nursing satisfaction and the results have helped us to invest in the nursing staff," Lewicki said.

For example, an equipment technician role was added so nurses wouldn't have to leave the bedside to track down equipment. More admission nurses were added to some units that were facing heavier volume, and transportation people were added to assist and escort patients being discharged.

"We also have an MD/RN partnership in every unit where nurses and physicians discuss interdisciplinary approaches to care," Lewicki said. "We're giving nurses what they need in terms of resources and this is coming from the data from patient satisfaction questions."

The launch of a mandatory hospital "report card" by the government next year will be just another indicator to the public of how well the hospital is doing, Lewicki said.

Blizzard said hospital satisfaction surveys such as PEP-C often miss some important questions, particularly when it comes to engaging employees into the health care mission. He sees staff surveys as an important element in the overall process of improving the way patients view their hospitals.

"The key to inpatient satisfaction is the relationships between patients or patients' family members and hospital employees," Blizzard said. "Employees must be engaged to make these relationships successful, but they must also be supported by efficient hospital processes that enable them to succeed."

Gallup research contains five key items in its 12-question employee engagement survey that have a strong influence over hospital inpatient satisfaction scores, he said. The response of nurses has particular significance because of their high contact with patients.

The items include:

• Having the materials and equipment to do the job right.
• Having the opportunity to do the best work possible every day.
• Having a mission or purpose that makes the job feel important.
• Having other employees committed to doing quality work.
• Being given opportunities to learn and grow.

"Everybody is concerned about improving the quality of care," Blizzard said. "The question is: Do you want to improve blindly and choose the squeaky wheel approach, usually responding to patient complaints, or use some objective measurement system that provides valid information on where to focus on improvements for the best results?"

Regardless of what survey method a hospital uses to measure patient satisfaction, the results can trigger improvements that will contribute to higher quality care, a contented workforce and competitive marketing. The mandated national patient satisfaction survey is coming at a time when consumers are taking a close look at how hospitals are listening and responding to patient needs.

Richerson at North Bay sees the national survey as a way to heighten the public's awareness when selecting a hospital while acting as a catalyst for needed changes.

"Patient satisfaction surveys provide good information and knowledge to help hospitals improve," she said. "With the information going public, hospitals don't want to be put in a negative light."

Contact John Leighty at johnsan@aol.com