Not just another satisfaction survey

A survey asks patients what they didn't like about their hospital stays, and gets some interesting answers.

Patient satisfaction surveys have become a standard, and often required, aspect of hospitalist practice. But recently a group of internists decided to look at the opposite side of the issue—patient dissatisfaction.

They used post-discharge telephone interviews with patients who had been treated at Yale-New Haven Hospital in Connecticut to elicit reports of dissatisfying experiences during hospitalization. The researchers combed through almost 1,000 responses to the question, “If there was one thing we could have done to improve your experience in the hospital, what would it have been?”

Photo courtesy of Leora I Horwitz
Photo courtesy of Leora I. Horwitz.

In results published in the November/December 2010 Journal of Hospital Medicine, they categorized the suggestions for improvement into six domains: ineptitude (7.7%), disrespect (6.1%), waits (15.8%), ineffective communication (7.4%), lack of environmental control (15.6%), and substandard amenities (6.9%). The report also offered some examples of specific comments, ranging from “In that ICU they should put a TV on the ceiling” to “I didn't know if I was going to have surgery or go home.”

The findings could pinpoint needed changes not only at the Yale hospital, but also others, according to lead author Alicia V. Lee, MD, co-author Leora I. Horwitz, ACP Member, and colleagues. Dr. Horwitz, an assistant professor of medicine at Yale University, recently spoke to ACP Hospitalist about the study and its implications for hospitalist practice.

Q: How did this project get started?

A: We go to the trouble of calling just about every patient after they go home from the hospital and we ask them a bunch of questions about whether they had a follow-up appointment or whether they got their medications. But at this hospital, we also ask them what went really well and if there are particular people that they want to praise, and we also ask them what we could do better. We noticed that we were getting really different comments. We started to wonder, “Is dissatisfaction really a different concept from satisfaction?” We send out the Press-Ganey surveys, and we get comments back, but they weren't really asking about the things that people were complaining about. We started to wonder a little bit, ‘What are we missing by only asking our standard satisfaction questions?’

Q: What did you find?

A: We took a random sampling of 10% of all the negative comments we got over a year and we looked to see what was in them. Some of them were, in a sense, opposite of the [standard survey's] satisfaction questions. There were lots of comments about waits; that's a satisfaction question.

But some of them were just totally different domains. A lot of people commented on communication failures between their doctors. Satisfaction questions ask about communication between the doctors and the patients. We found that patients could tell when their doctors weren't communicating with each other. Lots of people have tried to measure communication between doctors, but nobody's ever really asked the patients. So we discovered that there were things that we were trying to measure that we hadn't thought about asking patients about, that in fact they had quite a bit of insight into.

Q: Did the problems raised by the patients vary in severity?

A: Absolutely. People were complaining about the TV channels and the food, and other people were complaining that they almost got taken away for the wrong surgery—a huge range. And I do want to make one important point clear: We only took the negative comments for the study, but there were lots of positive comments, in fact, more positive comments than negative comments. These same people also [said] lots of positive things, which is to our point that satisfaction and dissatisfaction are not opposite. People can be simultaneously satisfied and dissatisfied. By no means was everybody responding that they were upset. I want to make that clear because this should not be a poor reflection on the hospital. I was really impressed that the hospital [administration] was confident and self-aware enough to really want to look at this set of negative comments, even though the majority was very positive.

Q: Do you think other hospitals should do this kind of surveying?

A: Hospitals do ask these questions, but because they ask them on phone calls in an open-ended fashion, it's actually very hard to categorize them in a useful fashion. Everybody responds individually to the comments. If somebody complains about x nurse, that nurse will get a follow-up.

But to think about it more broadly takes more systematic work. We spent a lot of time categorizing [responses]; that's not really that practical on a day-to-day basis for hospitals across the country. One thing that we were suggesting, as a result of the paper, is that there are things that could be added in a more structured and standardized way to the typical satisfaction questions that might capture some of these [issues].

Although many of these areas are captured in the HCAPS and other surveys, some of them are not. The concept of disrespectful treatment is really not captured in HCAPS very well; the concept of communication among providers is really not captured in HCAPS. We make the point in the paper that most of these patient satisfaction surveys were developed without patient input. HCAPS actually was developed with patient input, but most of the others were not.

Q: Could other hospitals modify their surveys based on your findings?

A: You never know how generalizable things are. My suspicion, looking at the kinds of categories that we came up with, is that most hospitals would find very similar results, but of course I don't know that for sure.

Q: What changes could be made in response to your results?

A: For each category, we made some suggestions in our paper, and there are many others that could be made. Some areas [quality improvement leaders] just haven't thought about at all, but some of them are areas we focus on, like it's important to treat people with respect and dignity. How is it that people are still commenting that we don't?

I'll give you a funny example. As an institution, we bought computers on wheels a couple of years ago. They were labeled COWs. People would stand in the hallway and say, “Oh, what's going on with the COW?” Or, “Where's the COW?” Patients were hearing this in their rooms and feeling very insulted that people were calling them cows. We started to get a bunch of complaints. We changed it so now we call them WOWs— workstations on wheels. We were not being disrespectful to patients, but things can be misinterpreted in all kinds of ways. Until you ask people or find out what they're thinking, you might not know that.

Q: Are there particular issues that are under the control of hospitalists?

A: My personal research area is in communication and handoff, and for me, what was dramatic about this study is that patients were really able to tell the quality of communication between and among their doctors. That's something that we, especially hospitalists, need to focus on, because hospitalists often cause that discontinuity between the primary care doctor and the hospital. Yet at the same time, [hospitalists] are in a position to really coordinate care within and outside the hospital. This is something that hospitalists have always thought of as a particular domain for them—coordination and communication—and it's something that our patients are pointing out we're not doing that well yet.