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This article discusses challenges for measurement of the patient experience, such as lack of consistent terminology and multiple contributing factors, by reviewing a brief selection of selected literature to help readers appreciate the complexity of measurement. Citation: Berkowitz, B. Key Words : Patient experience, patient satisfaction, pay for performance, quality care; Triple Aim, nursing practice, healthcare, measurement of quality performance, health systems, quality improvement.

Were it not for the mandate to report on the metrics of the patient experience, we may have continued to value the concept but avoided the challenge of precision and definition around the term.

Leading in Health Care Organizations: Improving Safety, Satisfaction and Financial Performance

Measurement and understanding of the patient, caregiver, and family experience of healthcare provides the opportunity for reflection and improvement of nursing care and patient outcomes. The concept of patient experience, however, is surprisingly complex. Instead, as noted in a brief from the National Quality Forum, nursing leaders have put patient experience first on their list of organizational and patient care priorities National Quality Forum, Over time there has been a regulatory and clinical care response to the concept of patient satisfaction and patient experience. We often measure patient satisfaction but the satisfaction score is based on many factors that a patient experiences before, during, and after an episode of care, along with characteristics of the care environment.

Nurses, the primary caregivers in all health promoting environments, including hospitals, clinics, and community settings, have responded in various ways to regulatory and clinical mandates. The purpose of this article is to describe the concept of patient experience and its impact on patient satisfaction within the contextual framework of payment systems for quality and the challenges of measurement, such as lack of consistent terminology and multiple contributing factors.

A brief review of selected literature can help readers to appreciate how these challenges may contribute to the complexity of measurement. For example, the CMS Quality Strategy identified six priorities that include: making care safer; ensuring individuals and families are engaged as partners in their care; promoting effective communication and coordination of care; promoting prevention; working with communities to promote healthy living; and making quality care more affordable.

To incentivize health systems to implement these goals, CMS created ways to reward innovation related to how these strategies are implemented across health systems. Each of the six priority areas within the CMS Quality Strategy is an opportunity to engage patients, caregivers, and families, thereby bringing the experience of care into the quality equation. The Affordable Care Act Office of the Legislative Counsel, called for provisions that would improve outcomes of healthcare through a series of requirements designed to assure quality reporting for such processes as effective case management, care coordination, chronic disease management, and others.

Thus began a major focus on the development of measurement sets designed to collect and report on the quality of evidence-based clinical care within healthcare institutions. Not only would the system measure quality, it was designed to eventually reimburse services based on quality outcomes. As the provisions of the ACA have become integrated into regulation within health system reform and into care environments themselves, more specific measures for concept of patient experience have been developed.

As the provisions of the ACA Office of the Legislative Counsel, have become integrated into regulation within health system reform and into care environments themselves, more specific measures for the concept of patient experience have been developed. The set of measures for ACOs to capture patient experience includes: timely care, provider communication, provider rating, access to specialty care, health promotion and education, shared decision-making, health status, courteous staff, care coordination, between visit communication, medication adherence education, and good use of patient resources CMS Center for Medicare, The National Quality Forum has included measures specific for patient experience with psychiatric care as well.

As noted, since the Affordable Care Act became law in , considerable activity by healthcare leaders has taken place to develop ways to measure quality outcomes. Equal effort has been underway within healthcare systems to address the delivery of quality care. The establishment and utilization of systems to reimburse providers and institutions based on quality performance is also well underway. Quality, efficiency, and affordability of healthcare have become the conceptual umbrella for a system that will pay for the provision of healthcare based on the quality of patient care.

One of the precursors to health system reform involving metrics associated with improving care was the development of specific aims to guide the work of quality. Berwick et al. Without a focus on all three at the system level, outcomes may be less than desirable. They described a system in balance as goals are pursued with a focus on ethics, equity across populations, and specific strategies to assure that the pursuit of one aim in isolation would not adversely impact the other aims.

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We might imagine how initiatives within a healthcare setting could have an unsettling impact on patient experience if, for example, cost cutting measures reduced the ratio of nurses to patients. Equally variable and complex is the experience that an individual has with the healthcare they receive. Much of the literature that describes how patients view their healthcare experience has focused on patient satisfaction.

The next section will briefly describe selected literature to illustrate challenges related to terminology and measuring the complexity of the patient experience and patient satisfaction with care.


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The literature reports studies that use both terms, but rarely defines either patient satisfaction or patient experience. Perhaps this is because each term seems to be defined by the factors used to measure it. This section describes selected research that demonstrates the interchangeability and variability of terminology, illustrating the lack of conceptual clarity that can challenge accurate measurement.

The purpose of HCAHPS is to standardize the collection of data to measure patient perspectives on hospital care through a survey instrument. These factors are organized into nine topical areas: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, and transition of care. A number of studies whose purpose was to understand the response of patients to their hospital experiences utilized the HCAHPS survey to collect data.

The terms patient satisfaction and perceptions of the hospital experience are multidimensional terms and, in a sense, are characterized by the items in the HCAHPS survey such as communication with nurses and the responsiveness of staff. Two examples of this type of research are studies developed by a team of researchers who have explored factors in acute care settings that are associated with patient satisfaction. Kahn, Iannuzzi, Stassen, Bankey, and Gestring studied patients in trauma and acute care surgery settings to investigate predictors of patient satisfaction as measured by the HCAHPS survey.

Their findings indicated that patient perception of interactions with the healthcare team strongly predicted patient satisfaction. Other factors associated with satisfaction included speedy responsiveness of staff, the hospital environment, and pain control. Similar findings were reported by Iannuzzi et al.

In this study, clinical complications in particular were associated with patient satisfaction scores, and although a number of other factors were associated with patient satisfaction, provider communication was the strongest predictor of high satisfaction. Results showed that physician-patient communication during the preoperative experience was predictive of satisfaction.

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Patient satisfaction contributing to patient experience. They described the situation of patients weighing the service received against their expectation. If the service exceeds expectations, they judge quality to be high; the reverse is true if the care is below expectations.

All of these dynamics impact how satisfied patients are with their experience of what they encounter in healthcare. Their satisfaction may or may not actually be related to whether they received quality care or whether they had good clinical outcomes. Patient satisfaction and reimbursement. Johnston expressed concerns about the utilization of patient satisfaction scores to judge the performance of physicians or its use as a metric for reimbursing physicians for care. Johnston described an encounter with a patient receiving palliative care where the patient and the physician had different approaches and expectations about facing end of life.

These differences led to a less than satisfactory experience on the part of the patient, even though the physician used an evidence-based approach. The experience of this patient was very different from his expectation and equally distressing for the physician. Neither were very satisfied. Johnston also suggested that linking patient satisfaction to physician payment creates a dilemma for the provider who knows that a particular treatment may not lead to a satisfied patient or family. The opposite view was reported by Riskind, Fossey, and Brill based on their belief that patient satisfaction, while time consuming, can have a positive effect on the success of a medical practice.

Their premise was that increased patient satisfaction, and the ability to measure those results, created a climate where providers began to understand that a successful medical practice was influenced by how satisfied their patients were. Benchmarking patient satisfaction goals to physician accountability enabled this practice to directly educate providers on the correlation among higher patient satisfaction and profitability, increased market share, employee and physician productivity, retention, and reduction of malpractice lawsuits. Evaluate patient experience to determine patient satisfaction.

The list of criticisms included such ideas as:. Price et al. Experiences that providers and patients have during a healthcare encounter seem to capture not just the clinical aspects of care, but many other non-clinical aspects that further illustrate the complexity of measurement of these concepts. What are those conditions within a healthcare encounter, particularly within a hospital environment, that may impact the patient experience and, therefore, his or her satisfaction? Examples of these may include: predictors of patient satisfaction, patient perception, and health related failures; the relationship between nurse burnout and patient satisfaction; and patient safety perceptions and patient satisfaction.

Each of these conditions is discussed briefly below in the context of selected research studies. Predictors of patient satisfaction, patient perception and health related failures. Jackson, Chamberlin, and Kroenke examined the predictors of patient satisfaction in a general medical clinic. The authors utilized a satisfaction survey with eight predictors of satisfaction. At subsequent intervals, the patients completed a different questionnaire with one overall satisfaction question.

The authors found a high correlation between the overall satisfaction scores and their responses to the eight specific satisfaction questions. Specific satisfaction items that correlated positively with the overall satisfaction score included functional status, unmet expectations, provider-patient communication in this study the providers were all physicians , and symptom outcomes.


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  8. Specific satisfaction items that correlated positively with the overall satisfaction score included functional status, unmet expectations, provider-patient communication A study by Gadalean, Cheptea, and Constantin examined factors that had the potential to impact patient satisfaction scores. This international study examined 39 factors related to satisfaction or dissatisfaction. The sample was patients within an intensive care unit in a National Cancer Center in Romania.

    Factors that positively impacted satisfaction scores included: proper treatment; compassionate treatment; clear explanations about treatment; no pain; demonstration of proper concern; adequate contact with family; prompt resolution of requests; rest; quality and quantity of food; and properly addressing the patient.

    However, the only factors significantly related to satisfaction scores included compassionate treatment and prompt resolution of requests. Factors significant for dissatisfaction included facilities and accommodations; lack of privacy; room temperature; medical staff not present; nurse attention focused on devices rather than patients; no explanation about treatments; regarding patience as objects; noise; and lack of sleep. The study also examined patient factors such as education level and diagnosis. The authors reviewed events that caused significantly poor outcomes in each of the triple aim categories.

    They provided examples of six clinical care and or health related failures that negatively impacted the quality of care, the patient experience, and the cost of the care. These events included unplanned hospital readmission within 30 days, nursing home admission, inappropriate initiation of hemodialysis, wrong-site surgery, intentional injury or maltreatment of a child, and overly invasive treatment of a preference-sensitive condition. The authors developed an approach to identifying populations by risk of experiencing these failures and taking a preventive approach to avoiding the outcomes.

    For example, patient satisfaction was negatively impacted by the loss of independence as the result of a nursing home admission, or invasive treatment Lewis et al. Nurse burnout and patient satisfaction. This study was conducted during a time when a national nurse shortage was raising concerns about nurse burnout and stressed nurse work environments. The authors used cross-sectional surveys of nurses and patients across 20 urban U. They reported that patients cared for by nurses who were in a work environment with adequate staffing, good administrative support, and positive relations between physicians and nurses reported higher satisfaction with their care.

    Safety and patient satisfaction. The authors studied these relationships across three hospitals in acute care in-patient environments. One of their interests was the role that patients themselves play in improving patient safety and that patient perception and understanding of safety may influence better safety outcomes. Health Resources and Services Administration projects that Tennessee will only be able to meet half of the demand for registered nurses by next year.

    Data released from the National Council of State Boards of Nursing provides a sobering reminder of the looming challenges for meeting nursing workforce demands. According to the data, the average age of registered nurses in was 51, and half of all nurses practicing today are older than This data supports the finding by the NSI Nursing Solutions survey that indicated a breaking retirement wave, and it might also help explain why national nursing turnover is increasing to its highest levels in recent history.

    We are pleased with these operating results, which demonstrate that, against serious headwinds for all hospitals in the nation, Ballad Health is taking the right steps to ensure patient safety, demonstrably higher quality and stable financial performance — all of which are necessary and important. In partnership with physicians and clinical staff, Ballad Health has seen a focused effort on quality improvement significantly benefit patients. Specific examples include:. Investments by Ballad Health also are beginning to generate benefits for the region. These savings have not only benefitted federal taxpayers; evidence shows area employers are benefitting from partnering with Ballad Health.

    Amit Vashist, chief clinical officer of Ballad Health. We strive to be a zero-harm, top-decile institution, and so far, the work of our unique clinical council in partnership with our administrative leadership is showing promise. Clay Runnels, chief physician executive of Ballad Health. Since the closing of the merger, Ballad Health has recruited more than new physicians and advanced practice providers to serve the region. Successes include the recruitment of cardiology in rural Wytheville and Norton, Virginia; nephrology in Abingdon, Virginia; and urology in Kingsport.

    Throughout the region, Ballad Health has also recruited neurology, orthopedics, pain management, hospitalists, psychiatry and other needed specialties. These opportunities will expand as payment models move further toward increased sharing of risk between the payers and Ballad Health. By focusing on reducing unnecessary duplication in cost, we can be stronger financially as we continue to see a decline in inpatient utilization.

    These improvements are in spite of challenges, both reflective of what all providers are facing and some that are unique to Ballad Health and the region. Lower lengths of stay, reduced rates of hospital-acquired conditions, reduced readmissions and better integration with physicians have helped reduce the cost of care and helped Ballad Health achieve success with the new value-based purchasing environment.

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    Just a few examples of capital spending in the year included:. Skip to main content. Search form Search. Ballad Health reports annual results: high-ranking hospitals in quality, strong financial performance and significant investment in region. You are here Home About Us News Ballad Health reports annual results: high-ranking hospitals in quality, strong financial performance and significant investment in region Ballad Health reports annual results: high-ranking hospitals in quality, strong financial performance and significant investment in region. Thursday, August 15, In its first full fiscal year of operation, Ballad Health surpasses expected results in quality, invests entire FY18 operating income in nursing wage increases Ballad Health today announced quality, investment and financial results from its first full fiscal year of operation as a combined system.

    Ballad Health has organized a nursing leadership council and nursing advisory committee to advise leadership on steps and initiatives that can be taken to help improve nursing retention, satisfaction and recruitment. Many of the steps being taken by Ballad Health are the results of this feedback. Based on feedback from nursing staff, Ballad Health has implemented an updated and more robust clinical nursing ladder program.

    This program is a best-practice model designed to provide less experienced nurses with mentorship and growth opportunity to expand their skills. As they achieve milestones, they can earn increased pay and responsibility. Like most health systems, Ballad Health seeks to reduce the number of contract, or traveler, nurses. This is intended to help improve quality of care and nursing satisfaction.

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    Ballad Health has worked with physicians and payers to reduce the number of lower acuity admissions. As outlined in this release, Ballad Health has reduced the number of low-acuity admissions by more than 5, this year. By avoiding these admissions, Ballad Health has been successful in reducing demand for nurses.