Tuesday, November 15, 2016

Doctor PatientPatient experience is an important indicator in assessing hospital and clinic performance. Altarum has been involved in the design, administration, and analysis of several patient experience surveys, particularly within the military health system. Understanding the implications of the data generated from these surveys can do much more than tell us whether patients were pleased with the magazine selection in the clinic waiting room...

Why does patient satisfaction matter?

Because it is strongly correlated with quality of care and better patient outcomes. A growing body of evidence suggests a link between patient experience and quality and safety of health care.1–3 In their 2010 examination of the relationship between Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and technical measures of quality and safety, Isaac et al. (2010) found that patients’ overall hospital rating and willingness to recommend the hospital had “strong relationships with technical performance in all medical conditions and surgical care.” Similarly, Anhang Price, and colleagues (2014) found that improved patient satisfaction is associated with increased levels of adherence to recommended prevention and treatment processes, improved clinical outcomes, better patient safety within hospitals, and lowered need for health care utilization. Studies have found significant links between patients’ ratings of their clinical experience and surgical outcomes4,5, patient safety measures6, and mortality5. Other studies have found associations between patient satisfaction and staff cultural competency7 and levels of patient staffing3,8. Thus, the experiences that patients report carry significant weight, as they can serve as an indicator of the actual quality of the care they receive. 

What do we know about patient satisfaction data?

Different cohorts tend to respond differently to patient satisfaction surveys. Specifically, studies have found that age, income, gender, geographic location, and race all have an impact on how patients report on their health care experiences. 9–12 For example, older populations (65 to 80 years old) have a tendency to report higher ratings of patient satisfaction. 13 Our recent work found a similar phenomenon—there was a significant difference between the patient satisfaction scores of our oldest patients when compared to those of our youngest. The reasons for these variations have not been determined, although several possible explanations have been proposed: older individuals may be less critical of medical services because they have lived through decades of health system improvements, and thus appreciate recent innovations. Or, they may have developed stronger relationships with their doctors over time, leading to higher provider ratings. It is also possible that the older medical model, in which the emphasis is on the physician’s authority to diagnose and treat, rather than work with the patient as a partner in his/her own health care, leads older individuals to have different expectations of how their providers should communicate with them, and subsequently affects how they report their patient experiences. While patients come from a variety of backgrounds, and each experiences the health care system in their own unique ways, the quality of those experiences as a collective are still correlated to measures of the quality of a health care system.

What matters most to patients?

Quality of communication with doctors is key to patient satisfaction. Both the literature and our own research show that whether or not patients report positive health care experiences is most frequently driven by how their providers communicate with them. “Communication” can pertain to bedside manner (“Is the provider polite?” “Is the nurse friendly?”) or accessibility (“Is the physician available?” “Am I able to speak with my doctor when I need to?”). Measuring communication can be accomplished using a range of questionnaire items, from the tone the provider uses with the patient (“Is it respectful?”) to the amount of time providers spend talking to patients about issues, treatment, etc.

The second most frequent driver of patient experience (again found in the literature and in our own work at Altarum) is access to care, particularly with waiting times—both in terms of how long patients have to wait before they can get an appointment, and how long they have to wait at the time of the appointment to actually see a provider. Other key drivers of patient satisfaction identified in recent Altarum studies include patient-centeredness of care and cleanliness of the facilities.

Understanding drivers of patient experience and patient satisfaction provides researchers with a picture of what patients believe is most important with regard to the health care they receive.

What do providers believe is most important in providing care? 

Several studies suggest that providers and patients have different beliefs about what is critical in the health care experience. While both providers and patients believe improved health outcomes are important, research indicates that providers’ emphasis tends to be on providing services that are timely and efficient, whereas patients report wanting to feel cared for and involved in their health care process. 14,15 In a recent study of the factors associated with differences between patients’ stated reasons for outpatient visits and physicians’ priorities at those same visits, the question “How well do physician and patient visit priorities align?” was examined. 16 The findings indicate a significant lack of alignment between physician and patient visit priorities; physicians focused on balancing patient concerns with chronic disease management, health promotion, and disease prevention while patients focused on their personal health, and how physicians communicated with them. 16

What are the takeaways?

Communicate, Educate, and Empower Personnel

Findings on patient satisfaction and experience can serve as an indicator of whether or not a health system is efficiently and adequately addressing the needs of its patients. How can systems integrate patient satisfaction into their quality improvement initiatives? Step one is to foster understanding of the link between patients’ perceptions and the actual quality of their care, and then effectively communicate that interrelatedness to stakeholders. This means finding ways to effectively convey the importance of that connection to administrators, board members, and health care providers. For an institution to improve its performance, people at every level must understand the value of a positive patient experience. This includes all hospital and clinic staff including providers, administrators, office staff, and facilities staff.  While everyone has a role in this, providers have the most direct influence on the experience. When they understand that patient satisfaction data can serve, if not as a proxy, then at least as an indicator, of the quality of care, and are informed of the strengths and deficits their patients perceive, it will influence their focus on the quality of engagement with patients.  

Evaluate, Measure, and Assess Performance

Another important step is to look at the patient satisfaction scores over time and identify areas of success and areas that need improvement. Formalized strategies aimed at assessing the factors that contributed to improvements (and declines) is imperative for the development of effective processes within and across services. Comprehensive, deep-diving evaluation would aid in activities and policies that influence patient satisfaction. The employment of qualitative methods such as key informant interviews with leadership, staff, and patients; focused surveys; and quality improvement symposia can all provide and disseminate information on effective strategies, as well as system challenges. We recommend methods focused on deepening the understanding of personnel and team dynamics, program champions, and measures of success.



1.           Anhang Price R, Elliott MN, Zaslavsky AM, et al. Examining the Role of Patient Experience Surveys in Measuring Health Care Quality. Med care Res Rev. 2014;71:1-33.

2.           Isaac T, Zaslavsky AM, Cleary PD, Landon BE. The relationship between patients’ perception of care and measures of hospital quality and safety. Health Serv Res. 2010;45(4):1024-1040.

3.           Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ Perception of Hospital Care in the United States. N Engl J Med. 2008;359(18):1921-1931.

4.           Sacks GD, Lawson EH, Dawes AJ, et al. Relationship Between Hospital Performance on a Patient Satisfaction Survey and Surgical Quality. JAMA Surg. 2015;150(9):858-864. doi:10.1001/jamasurg.2015.1108.

5.           Tsai TC, Orav EJ, Jha AK. Patient satisfaction and quality of surgical care in US hospitals. Ann Surg. 2015;261(1):2-8.

6.           Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring relationships between patient safety culture and patients’ assessments  of hospital care. J Patient Saf. 2012;8(3):131-139.

7.           Weech-Maldonado R, Elliott M, Pradhan R, Schiller C, Hall A, Hays RD. Can hospital cultural competency reduce disparities in patient experiences with care? Med Care. 2012;50 Suppl:S48-55.

8.           Al-Amin M, Makarem SC. The Effects of Hospital-Level Factors on Patients’ Ratings of Physician Communication. J Healthc Manag. 2016;61(1):28-41.

9.           Morgan MW, Salzman JG, LeFevere RC, Thomas AJ, Isenberger KM. Demographic, Operational, and Healthcare Utilization Factors Associated with Emergency Department Patient Satisfaction. West J Emerg Med. 2015;16(4):516-526.

10.         Elliott MN, Lehrman WG, Beckett MK, Goldstein E, Hambarsoomian K, Giordano LA. Gender Differences in Patients’ Perceptions of Inpatient Care. Health Serv Res. 2012;47(4):1482-1501.

11.         Elliott MN, Zaslavsky AM, Goldstein E, et al. Effects of survey mode, patient mix, and nonresponse on CAHPS hospital survey scores. Health Serv Res. 2009;44(2 Pt 1):501-518.

12.         Goldstein E, Elliott MN, Lehrman WG, Hambarsoomian K, Giordano LA. Racial/Ethnic Differences in Patients’ Perceptions of Inpatient Care Using the HCAHPS Survey. Med Care Res Rev. 2010;67(1):74-92.

13.         Jaipaul CK, Rosenthal GE. Are Older Patients More Satisfied With Hospital Care Than Younger Patients? J Gen Intern Med. 2003;18(1):23-30.

14.         Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol. 2002;186(5 Suppl Nature):S160-72.

15.         Lang M, Uttaro T, Caine E, Carpinello S, Felton C. Implementing Routine Suicide Risk Screening for Psychiatric Outpatients With Serious Mental Disorders: I. Qualitative Results. Arch Suicide Res. 2009;13(2):160-168.

16.         Tomsik PE, Witt AM, Raddock ML, et al. How well do physician and patient visit priorities align? J Fam Pract. 2014;63(8):E8-E13.


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